212 Loc. cit.
213 Rev. des Sci. Méd., 1880.
TREATMENT.—If the quantity is excessive, local applications and ergot ought to be employed to arrest the flow. If the dyspnoea and oppression are great, it is best to draw off at least some of the fluid. If the quantity be not large enough to embarrass respiration, we must expect nature to absorb it, or by local inflammation to encyst it. Lacaze214 reports a case where a fistula was established, and the case was cured. Dieulafoy gives another case where six punctures were made, and no less than 6 liters, in all, were withdrawn. He injected afterward a solution of 4 grammes of sulphate of zinc to 400 grammes of water, and the patient was cured. In the first stage of the disease we use palliatives—morphia hypodermically, bromides, and chloral—if indicated. During febrile symptoms of acute cases we refrain from withdrawal of fluid unless it is excessive. The question of thoracentesis has been discussed in regard to simple pleurisies. The same rules apply, a fortiori, when the nature of the fluid is hemorrhagic. Ordinarily, the abundance of fluid, and the dyspnoea which results therefrom, indicate the operation. We prefer not to draw off the fluid completely—only enough to relieve the embarrassment of respiration—because we destroy the equilibrium of pressure on one side against the neo-membranes and the compressed lungs on the other. Congestion of the lung may thus be produced with albuminoid expectoration. Moutard-Martin (R.) coincides with Dieulafoy in limiting the amount to be withdrawn to one liter. Of course the fluid is slowly aspirated. After part of the fluid is withdrawn, what remains is absorbed, remains stationary, or increases in quantity. We repeat the operation, and slowly draw off greater quantities of fluid if it returns; especially in cancerous cases, where the effusion is often very large, the operation gives great relief. It is rarely large enough in tubercular cases to justify thoracentesis.
214 Thèse de Paris, 1851.
Tubercular Pleurisy.
Tubercular pleurisy may be acute or chronic. It may occur during the course of ordinary tubercular disease of the lung, by extension of the disease from the lung to its serous covering, or it may proceed from tubercular deposit on the pleura independently of any previous disease of the lung. Acute tubercular pleurisy may be dry and situated at the summit of the chest, or may be what is called accidental pleurisy. Dry pleurisy is almost constant in tuberculosis of the lung. Its existence is, in itself, a powerful presumption of pulmonary phthisis, especially when it is situated at the apex. In tuberculosis pleuritic inflammation is lighted up by slight and scarcely appreciable causes. Its commencement is insidious, with little or no pain or fever: indeed, it is with subacute symptoms that the disease slowly advances. The first intimation the patient has of the disease is the impairment of his breathing-power by the presence of fluid. The fluid is not generally in large quantities, and is serous or sero-fibrinous, and sometimes sero-purulent. Latent pleurisy of the older writers was frequently tuberculous in its origin. This form of tuberculosis may precede or follow the deposit of tubercles in the lung-tissue. The tubercles may be deposited to a slight extent in the tissue of the lung, and their presence is shown by an irritating cough only when the pleurisy approaches insidiously. The tubercular granulations over the visceral pleura are extended to the parietal surface also, and notably to the circumference of the fibrous leaflet of the diaphragm—an especial point of elevation for the secondary products.
This disposition of tubercular lesions of the pleura is one of the most striking examples of what is called infection from contiguity, and is a powerful proof of the infective property of tubercular products which from an initial nucleus is propagated from point to point. Acute tuberculosis of the pleura is one of the most common manifestations of acute phthisis. It more frequently causes acute than subacute pleurisy. Chronic tuberculosis almost always produces purulent pleural effusions. It is much more common in infants than in adults, and is sometimes met with in children from three to ten years of age (Barthez et Rilliet215). Tubercles may be developed in the intra- or extra-serous membrane. Among old people the tubercle sometimes appears first in the recent false membranes produced by pleuritis (as associated with caseous pneumonia, or genuine tuberculous processes in the lungs), or in connection with tubercles of other organs (Fraentzel216). The advance of this disease is habitually slow, or at least not accelerated by the development of other tubercular diseases. The diagnosis is often accompanied with great difficulties, for the disease may be confounded with chronic or with purulent pleurisy, especially if these are developed in a tuberculous subject. In both cases we have hectic, night-sweats, emaciation, etc. Thoracentesis alone can give definite results when the effusion is in considerable quantity. When suppurative pleurisy supervenes in tuberculous subjects, the prognosis is very grave. Should the pus be sufficient in quantity to embarrass respiration, it can be drawn off cautiously by aspiration. The open method of drainage and free incisions should not be used, for experience has shown that they injure instead of benefiting the patients.
215 Mal. des Enfants.
216 Ziemssen's Cyc., vol. iv.
Hydrothorax.