58 Unpublished MSS.
59 Brit. Med. Journal, Dec., 1877.
60 Nouveau Dict. Méd., vol. xxviii., art. "Thoracentesis."
61 Loc. cit.
We cannot always estimate accurately the quantity of fluid by the displacement of the heart and other organs. The retractile energy of the lung is a very important factor in producing this result. A very large effusion, associated with a very powerful lung, will produce but slight displacements, while small effusions, when the lung of the affected side has lost its elasticity, will cause relatively great displacements (Garland). If there be no adhesions present, the letter S curve of flatness becomes a sign of the greatest value. It marks accurately the height of the effusion. Knowing this, as well as the position of the heart and diaphragm, and the capacity of the chest, we can estimate the quantity of fluid in the pleural cavity. If in left pleurisies the heart be so pressed out of position that its apex beats to the right of sternum it is very diagnostic. With these signs, whether accompanied by dyspnoea or not, we must regard thoracentesis as imperatively called for. The presence of the febrile movement is not a counter-indication under these circumstances. The presence of a basic murmur, caused by the heart or aorta displacement, is an urgent indication for surgical interference.
There are attacks of fainting and syncope, suffocative paroxysms, with irregular and painful palpitations of the heart, with sometimes alarming threatenings of asphyxia—especially in pleurisy of the left side. These symptoms are probably due to the twisting of the inferior cava as it passes through the quadrilateral foramen of the diaphragm. The danger is necessarily increased by long continuance of the effusion. Prompt surgical treatment is indicated when we detect evidences of embarrassed circulation in the opposite lung, with a blowing quality of respiration and subcrepitant and oedemic râles.
In all cases of double pleurisy, where the total amount is sufficient to fill one whole cavity, we ought not to postpone operating. Even when the effusion is not very large, if there are other diseases of the respiratory or circulatory systems to cause grave complications, and danger of increased impairment of their functions, thoracentesis is rendered necessary. That these conditions justify thoracentesis we believe no one who has any practical experience will question. But two conditions exist where there is considerable difference of opinion in regard to the propriety of operating: 1st, during the febrile stage, and, 2d, where moderate effusion remains unabsorbed.
In regard to the first of these, many authorities, even among the most enthusiastic advocates of the operation, have contended that unless there is imminent danger to life from the excessive collection of fluid, it should not be withdrawn, as it would at once re-form, and additional inflammatory action might be excited by surgical treatment. Castiaux,62 however, strongly advocates the view that the operation by aspiration will hasten the cure of acute pleurisy and prevent the formation of the fibrinous deposits and bands which to a greater or less degree, even in moderate effusions, impair the expansion of the lungs. He relates 37 cases, almost all of which were operated upon by himself. He was successful in all of them, and the patients suffered no inconvenience or discomfort in consequence. In most of his cases the pulse and body-temperature fell (perhaps the same day, certainly the next morning), and even became normal after the operation, and the patients improved rapidly. He aspirated as soon as he detected the presence of fluid by exploratory punctures, believing that from the moment we have at our disposition sure means of relief which are harmless, it is useless to leave to nature the duty of removal—useless to leave to untrustworthy medication the relief which we can promptly give. He operated at the height of the first or inflammatory stage of the disease. He assigned as reasons for operating that he thereby relieved the lung of the compression which impairs expansion; that he removed a liquid rich in fibrin and capable of increasing the thickness of the neo-membranes; that by restoring the power to dilate he further prevented the lung from being compressed by the false membranes. These membranes cannot become organized unless they are separated by fluid. He states that he removed the fluid as completely as possible. As soon as the cavity was emptied respiration was made easy and the patient was relieved. Auscultation showed, by the vesicular murmur, that the lung had resumed its place without difficulty from top to bottom. The effusion returned, only in a few cases, with high temperature and frequent pulse, but another operation effectually arrested them. The pleurisy was cut short and puncture was considered the means of aborting the disease. The duration of the disease treated by this means was much shorter. Thus the patients were not forced to retain for months the liquid and false membranes in their chest. He states emphatically that there never supervened any accident, and especially that he never witnessed as a result the transformation of the serosity into pus, although it might appear theoretically likely to occur, as the serous membranes, already inflamed, ought to be more sensitive to injury.
62 Thèse de Paris, 1873.
This testimony is very strong. Moutard-Martin operated upon 12 patients with fibro-serous effusions where they had existed less than ten days, and where there was more or less of fever. Out of this number, 8 had no reproduction whatever of fluid, and in 4 there was only a slight re-formation, and there was no degeneration into purulent fluid in any of them. In the other cases operated upon, where the effusions dated from twenty to sixty days, the fluid was almost always reproduced, though ordinarily to a moderate extent. He urges the prompt withdrawal of the fluid as the most successful method, especially if there is reason to suspect the formation of false membranes.