R. Townsend295 wrote an elaborate paper in 1833 on empyema, in which he applied the principles of physical diagnosis. He cites numerous cases of thoracentesis, and speaks of the operation as easy of execution, productive of little pain to the patient, generally followed by immediate relief, and as having been in numerous instances crowned with complete success. Robert Law296 (1834) speaks discouragingly of the operation in consequence of the "unavoidable admission of air into the inflamed cavity." He considered the operation of tapping the chest more likely to be successful in chronic than in acute pleurisy.
295 Cyclop. Prac. Med., vol. ii., 1833, London.
296 Ibid., vol. iii., 1834.
In 1835, Faure297 read his paper on thoracentesis before the Academy of Medicine of Paris, which attracted a great deal of attention. Contradictory opinions were given by prominent members as to the value of the operation. The debate was prolonged, and no definite conclusion was reached. Laennec, although he had recommended the operation in excessive effusions and in chronic cases, was yet timid, and his advice had not the overwhelming influence that it should have had. Becker of Berlin in 1834 wrote his paper on chronic pleurisy, in which he also laid down the principles of diagnosis by means of auscultation and percussion. He detailed 5 cases which he had operated upon. To Thomas Davies is due the credit of having in 1835 recommended the use of the exploring-groove needle to ascertain the nature of the pleuritic effusions, but Powell claims that Sir Benj. Brodie first suggested it. Ringer first recommended the use of the hypodermic syringe for that purpose. Stokes298 insisted upon the evils attending paracentesis, among which he mentions the converting of serous into purulent effusions.
297 Bullétin de l'Académie de Médecine, 1838, tome i. p. 62.
298 Dis. of Chest, Dublin.
Watson's lectures on practice, delivered in 1836–37, show that while he was much interested in the operation, the necessity of which he discusses with his characteristic ability, yet his conservatism led him to put prominently forward the dangers and evils connected with it. According to these two prominent English practitioners, only imminent peril to life justified the operation. Guérin299 in 1841 applied his subcutaneous method of operation to empyema. He drew fluids from the chest by a suction-pump applied to a canula, using a curved trocar and canula to prevent injury to the lung.300
299 Essai sur la Méthode Sous-cutanée, Paris, 1841.
300 Drawings of the trocar and canula, with the aspirators, are shown in Jacob and Bongeré, Med. operatoire.
Reybard in 1837 took up Dupuytren's suggestion, and used gold-beater's skin as a valvular means of excluding air at the mouth of the canula; this is now known as Reybard's canula apparatus, and was the one used and highly recommended by Trousseau. Stanski in 1839 invented an apparatus for drawing off air from the chest, working on the principle of aspiration. Bowditch states301 that while in Paris from 1832 to 1835 he never saw a case of pleurisy in Louis's, Chomel's, Andral's, or Trousseau's wards where thoracotomy was performed or even suggested. Medical opinion was either indifferent or in actual opposition at that time. H. I. Bowditch of Boston relates302 that he saw 2 cases of effusion in the pleural cavity in 1839, in which he proposed thoracentesis, but the surgeons would not operate: both of these patients died. He was convinced at the time that their lives might have been saved. Schuh of Vienna published his work on the Influence of Auscultation and Percussion on Practical Surgery, in which he boldly maintained that paracentesis was a radical cure in cases of chronic thoracic effusion, no matter how originating. This work had a great influence in advancing the popularity of the operation of thoracentesis. Subsequently, Schuh and Skoda, both professors at Vienna, published303 a monograph on the treatment of pleurisies, especially by surgical means, which, as Trousseau acknowledged, has become a classical work in Germany, and occupies a distinguished place in the history of paracentesis of the chest. They admitted that when the effusion is not excessive in quantity, and there are no complications, recovery generally takes place. When the effusion is excessive even, it may in time disappear, but it may prove a matter of months or years. They advised that the operation should be performed when there was no marked improvement for three weeks. These authors refuted the arguments urged against the operation, and gave details as to the mode of operating. The Germans were the first to consider the puncture as a means of radical cure in pleuritic effusions: Becker, Schuh, and Skoda gave it a decided impulse. Hope's304 paper endeavored to prove that pleuritic effusions did not require surgical interference, but would yield to general treatment.