301 Unpublished MS., 1883.
302 American Journal Med. Sciences, April, 1852.
303 Medicinische Jahrbücher der K. K. Oesterreich Staates, 1841.
304 "Notes on the Treatment of Chronic Pleurisy," in Medico-Chir. Review, London, 1841.
Thus we see that up to 1841 these unsettled controversies over the dangers and advantages of the operation were still going on. Fred. Bird's results in 1843 proved the possibility of its successful employment, doubted up to that time in England. Trousseau's attention was strongly drawn to the necessity of the operation of thoracentesis as early as 1832, when he attended a case at the Hôtel Dieu that died from excessive pleuritic serous effusion. Louis, from the observation of 150 cases of simple pleurisies that had recovered, had enunciated the law that pleurisy is never the immediate cause of death. This fact, together with Récamier's want of success, had so prejudiced the minds of French practitioners against the operation that it was loudly condemned in acute cases of effusion and in all cases of hydrothorax. Having no fears of fatal termination in pleurisy, they saw naturally no necessity for surgical interference. Trousseau states that it was not until after he had witnessed three patients die from acute pleurisy that he ventured to operate (Sept. 11, 1843). He did not summon a consultation, for fear of being thwarted. It was so successful that he was emboldened to operate without hesitation. After his third operation he read his memoir to the Academy of Medicine in 1843. Trousseau in these memoirs maintained the proposition which extensive observation has now after forty years fully sustained, that dyspnoea and orthopnoea may occur when the effusion is in moderate quantity, and that they may be absent when the effusion is considerable, especially if it has formed slowly. Furthermore, that the signs that constantly indicate the gravity and imminent danger of effusions, and which consequently demand the operation, are the displacement of the heart (whence results syncope), displacement of the mediastinum, depression of the spleen and of the liver, acceleration and feebleness of the pulse, and an anxious countenance.
The next year (1844) Trousseau read another memoir on the same subject. He used the trocar with Reybard's gold-beater's skin at the orifice. While he was popularizing the operation and laying down the indications which called for its performance, several English observers305 were turning their attention in the same direction. The paper by Hughes and Cock306 showed that they had been operating in Guy's Hospital for four or five years, and with great success, using a simple trocar and canula of the diameter of one-twelfth of an inch. They imputed their success to the small size of the instrument used, which allowed the fluid to flow slowly and never permitted air to enter the chest during respiration. They gave a tabular account of 20 operations. Hamilton Roe307 at that time was operating successfully with the trocar. Roe's paper was replete with information and with practical suggestions. He tabulated 39 cases where syncope (one great objection which had been urged against the operation) did not occur even once. He disproved another popular objection, that there was great danger of the admission of air into the pleural sac. Owing to the size of his trocar, a considerable quantity of air entered the pleura during his operations, and in some of them so freely as to produce all the physical signs of pneumothorax, but in none of them did it produce any permanently evil effects. In one instance only was even temporary inconvenience caused. When the fluid was ascertained by the exploring-needle to be purulent, he advised the immediate performance of the operation. In acute cases he recommended a delay of three weeks as the time for testing nature's powers of absorbing the fluid. He advised the closing of the orifice after operation. This author gave an account of his 24 cases. He concluded by stating that the operation is not more dangerous than any other which is performed upon the human body, and that the evil consequences supposed to attend it are imaginary rather than real, inasmuch as it was only fatal in 1 out of 24 cases, and does not produce even temporary inconvenience. Thompson in the same year justly condemns the practice of leaving the canula in the orifice—a proceeding he considers as capable of converting a serous into a purulent fluid. In 1848,308 at the request of H. I. Bowditch of Boston, J. M. Warren operated by the usual method recommended in the works on surgery. Partial relief was obtained, but the amount of suffering undergone by the patient during the operation, and the fact that an aperture was usually left open by this method, decided Bowditch that he would never recommend it unless under very urgent circumstances. Soon after this, Stone operated with the common trocar and canula, by the advice, in consultation, of Bowditch. In 1849, Bowditch saw another death resulting from effusion where he had advised the operation, but the consulting surgeon would not consent.
305 London Medical Gazette, 1847.
306 Guy's Hospital Reports, vol. ii., 1844.
307 London Lancet, 1844, copied into Amer. Journal Med. Sciences, Oct., 1845.
308 Bowditch, Amer. Journal Med. Sciences, April, 1852.