Volume 3 — DISEASES OF THE RESPIRATORY SYSTEM. (continued 20)

If there are complications with other acute diseases, such as pericarditis or pneumonia, the prognosis may be far from favorable, more particularly if pleurisies supervene when the organism has been exhausted by a long continuance of the primary disease.

If absorption begins soon after the acute symptoms subside (and we expect it to do so where the general health and strength are good), and goes on vigorously, we can with confidence predict a favorable result, especially if there be no contraction of the walls. The earlier the reabsorption takes place the more favorable the prognosis. If, however, four or five weeks pass without any perceptible diminution in the extent of the effusion, there is cause for uneasiness. Especially is it dangerous if, in addition, we have those ugly symptoms, emaciation, weakness, and hectic fever, which point to the conversion of the fluid into pus. There is the prospect of protracted formation of pus with its dangerous sequelæ, including tuberculosis from infective absorption.

That these dangers can in a great measure be obviated by prompt thoracentesis ought now to be universally admitted. Anstie predicts that the experience of the next twenty years will enable us to ensure an absolute immunity from fatal results from either of these serious complications. Symptoms of oedema of the lungs or of cyanosis are bad prognostic signs; so is diminution in the amount of urine secreted, which indicates that the arteries are incompletely filled. Still worse are the symptoms of over-distension of the veins, dropsy, and the appearance of albumen, casts, and blood in the urine.

The prognosis in secondary pleurisies is much more serious. In cases where the effusion is purulent at their commencement, the prognosis is graver than when it becomes purulent after remaining some time in the cavity. This is because they are often pyæmic in their origin.

With modern treatment, however, the percentage of recovery is greater than it formerly was. When we have to contend with chronic purulent cases occurring in cachectic constitutions or in those debilitated by other illnesses, especially tubercular, the prognosis is necessarily unfavorable. The most fatal of all secondary pleurisies are those supervening in the course of pyæmia or puerperal infection. Here death is the rule, recovery the rare exception.

Pleurisies supervening on Bright's disease or nephritis, following scarlatina and idiopathic fevers, have a high rate of mortality. The modern employment of the thermometer is of the greatest assistance to us in forming our prognosis. Marked variations of temperature, whether they be below the normal or constantly high or advancingly high, have grave significance. Anstie's valuable results from the use of the sphygmograph, as giving us the favorable and the unfavorable pyrexial pulse-forms, cannot be over-estimated. We fully concur with him, "that in the dangerous secondary pleurisies the combined use, for prognostic purposes, of the thermometer and the sphygmograph is more valuable than all the other modes of observation put together." It is so because they give us accurate physical data by which we can estimate the exact condition of the patients.

Relapses, with a rapid increase in the amount of fluid after reabsorption has been active and convalescence apparent, are frequently attended with danger, because they often denote a tubercular or hemorrhagic development. A very unfavorable sign is the rapid increase in the effusion after spontaneous or artificial discharges, especially if the fluid has become fetid in its character and has the dark appearance of unhealthy, purulent matter.

TREATMENT.—The study of the natural history of acute fibrino-genic pleurisy teaches us that there is always in it a tendency toward recovery unless there is some constitutional weakness behind the disease or a large fibro-serous effusion resulting from it. We have all met with cases where patients have recovered in the course of a month or six weeks spontaneously, without any treatment. Of A. L. Mason's 200 cases, 132 recovered without having to resort to thoracentesis. It is often a harmless disease when left, as far as medical treatment is concerned, entirely to itself. Of course the body-temperature and the physical evidence of the effusion ought always to be carefully observed. The hygienic treatment ought never to be neglected. We should insist upon rest in bed in the most comfortable position to the patient. The temperature of the room should be from 65° F. to 68° F., the approximate in-door winter degree for healthy adults.⁵³ The body, especially the chest, should be kept quiet; all unnecessary movement should be avoided. The food ought to be nourishing in quality, easy of digestion, and in quantity sufficient to keep up healthy nutrition. Stimulants are unnecessary, but it is a mistake to withdraw water, which contributes so much to the comfort of the patient and cannot injure him in the first stage. We should take care that the patient has enough sleep. If necessary, mild hypnotics should be used. The effusion results from the inflammatory process, and not from simple transudation. If the pain is very severe, we must resort to the administration of opium by mouth or to hypodermics of from one-eighth to one-sixth of a grain of morphia; this, however, should be avoided when possible, as preparations of opium impair the appetite and depress the patient. The pain ordinarily passes off in 48 hours, and can often be relieved by application of hot-water bags, turpentine stupes, or anodyne liniments. Bloodletting, general or local, is rarely necessary. Leeches will give relief to the acute pain, but opium does that more effectively. Depletory remedies are hurtful and retard convalescence, and do not control the amount of the effusion, which in itself is depletory. If the patient is seen at the initiation of the disease, a large dose of quinia (from ten to fifteen grains), especially if the temperature goes to 101° F., often has a marked effect in controlling the temperature and also the tendency to effusion. Smaller doses may be repeated every few hours. Liq. ammonii acetatis, in fluidrachm j to fluidrachm ij doses every two hours, and Apollinaris or other alkaline drinks, relieve vascular tension and promote the action of the skin and kidneys. During the pyrexia, with the effusion increasing, we endeavor to lower arterial pressure within the pleural vessels by aconite, diaphoretics, mild salines, diuretics, with complete rest of the body. Hot applications (not heavy poultices, however) may sometimes be used at short intervals, with a view of dilating the superficial vessels and thus relieving those of the interior.

⁵³ Boston City Hosp. Reports, 3d Series, 1882.

Under this simple treatment many patients are sufficiently well in a few weeks' time to sit up. They ought not to be permitted to move about unless there is a very small amount of effusion. Roberts⁵⁴ of University College Hospital applies adhesive strips over the chest in all cases from the beginning. Mason prefers Martin's india-rubber bandage, three or four inches wide, extending from the lower border of the ribs to the axilla, as it adapts itself better to the chest-walls and supplies an easily-regulated elastic pressure. He considers it also useful in promoting absorption after tapping. Generally in three or four weeks, in favorable cases, the effusion has been absorbed and the patient is able to resume his ordinary duties. The writer cordially endorses Anstie and Bartholow's protests against the employment of mercury for any supposed aplastic properties. It really exhausts the recuperative forces of the organism, and probably injures instead of benefiting in pleurisy.

⁵⁴ Quain's Medical Dictionary.

If the exudation be in considerable quantity, three or four weeks may be required for its absorption. If this process is sluggish, can we by medicines promote it? Mercury has lost its old reputation as a remedy for this purpose. Iodine externally, and iodide of potassium in decided doses, still retain, to a limited extent, the confidence of practitioners. Preparations of iron, especially the muriatic tincture, have had better effects in the hands of the writer than any other remedy. Large blisters cause great discomfort, and their utility is very questionable. Alkalies possess the power of dissolving exudation, and of these the most efficient is ammonia, especially carbonate of ammonium in doses of from five to ten grains. Saline laxatives, by producing watery stools, have some power in reducing the amount of fluid. Some authors recommend highly the acetate and citrate of potassium dissolved in a decoction of scoparium. J. W. Hunt⁵⁵ places most reliance upon pilocarpus pinnatus, which has given him most marked and successful results, even where other remedies have failed. He pushes it to the extent of producing extreme diaphoresis. He commences with thirty minims of the fluid extract four times daily, rapidly increasing the quantity and the frequency of the doses to the extent of fluidrachm j every two hours. The one-eighth of a grain of its alkaloid, pilocarpine, given hypodermically, acts very promptly. He admits that the vital forces are so exhausted by this treatment as to require at once the administration of tonics, especially of iron with strong food. Grasset⁵⁶ reported 5 cases of effusion treated by jaborandi. They were cases of pleurisy without fever or sign of inflammation—cases which ordinarily require several blisters to produce an effect.

⁵⁵ Dublin Journal Med. Sci., Dec., 1882.

⁵⁶ Journal de Thérapeutique, Avril, 1876.

Ernest Wernaere⁵⁷ reported 7 cases of acute pleurisy where there was considerable febrile reaction. Jaborandi was effectual in every case, and the effusion rapidly disappeared after two doses of the infusion. The fever at the same time was diminished, and there was no return of it, as frequently occurs in non-inflammatory cases. It has less effect upon children than upon adults. In a case of Wernaere's only one dose was given.

⁵⁷ Thèse de Paris, 1876.

The value of counter-irritants has been frequently questioned of late years. Fly blisters give relief in limited dry pleurisy. Many practitioners have great confidence in large blisters used over the chest after the febrile stage has subsided. Woillez, in tabulating the results of the various means of promoting absorption, puts purgatives first in utility, and blisters last. Blisters, he claims, had no effect in 90 per cent. of cases. The iodide of iron, in pills, or the compound syrup of the iodide of iron and manganese, with improved digestive powers, are the best means of promoting absorption. At this period of the disease it is an advantage to lessen, within certain limits, the amount of fluid taken into the stomach, forcing the blood to abstract water by absorption from the chest. Jaborandi has the same effect by withdrawing water from the blood.

There are cases of excessive quantity of fluid, and others which resist all drugs given to promote absorption. Among these are some acute cases, but many of a subacute and chronic nature, where the effusion remains stationary, injuring respiration and often mechanically endangering life. This occurred in nearly one-third of Mason's cases.

Thoracentesis.—In studying the history of this operation we have seen how frequently, since the time of Hippocrates, it has been in favor with practitioners, and then has fallen into discredit. During the past thirty years, thanks especially to Bowditch and Trousseau, its unquestionable value has been established, and is now universally recognized. Improved knowledge of pathology, safe and easily-applied instruments, together with the discovery, by Lister, of the means of securing the operation from septic dangers, have perfected this surgical treatment. Observation in hundreds of cases has proved that, properly used, it is almost without risk. As a means of diagnosis it is the most accurate we possess; as a treatment for affording positive relief it is a boon to suffering humanity; as a method of cure it has been most successful.

Such being the estimate of its value, let us study, 1st, the indications for its use; 2d, the manner of operating; 3d, and finally, the objections founded upon the accidents that have followed its application.

The indications are met with in two conditions—that of excessive accumulation of fluid, and where there is non-absorption of the effused liquid. In going over the symptoms we have seen the effects of large collections of fluid in the pleura—how the heart is pushed out of its normal position, and how the large blood-vessels are distorted. We have called attention to the retraction and compression of the lung until in many cases it is airless, and thus not able to perform its functions. We have shown that all the adjoining organs and cavities are sometimes forcibly thrown out of the position nature placed them in. The liver is pressed forward into the abdominal cavity, and the diaphragm is unable, from mechanical pressure, to ascend and contract. The mediastinum, with its contents, is materially interfered with. Observation has shown that such a state is a very dangerous one. Not only does it cause great dyspnoea, pain, and oppression, but the risk to life is imminent. In a number of instances it has caused death. Trousseau tells us of 3 deaths; Lacaze reports others. Bowditch, having seen several fatal cases produced by the quantity of fluid, worked with energy and perseverance until he was furnished by Wyman with his ingenious aspirator, of which he promptly availed himself, notwithstanding the objections he met with from others. "Ridicule," he says, "was pointed at me by some high in surgery: at first the whole medical profession was against me." He could not stand still and see men die whose lives could be saved. Chew had a patient die suddenly from this cause. Many authors mention cases of death from the large amount of fluid. Wilson Fox summed up from the records between 50 and 60 deaths from effusion in the pleural sac. Moreover, many patients have died where the disease was not recognized. The condition of the circulatory apparatus is such that we can readily understand that emboli would form in the heart, in the large blood-vessels, and in the parenchyma of the lung itself. These clots produce grave results. If they form in the pulmonary veins or in the left heart, they determine an embolic obstruction of the central artery, with all its consequences—apoplexy, hemiplegia, etc. If it forms in the right heart or in the pulmonary artery, it may produce rapid aphasia and death (Paget). Louis was certainly wrong when from his 150 cases of pleurisy he deduced the law that none died of this disease per se. It is thus a matter of the utmost importance that we should be able to recognize that there is a quantity of fluid capable of producing such serious results. The call for relief and diminution of the amount of fluid by thoracentesis is urgent. What amount is dangerous to life, and how can we arrive at an accurate estimate? To what extent can we judge by the subjective symptoms, especially by the dyspnoea? Andral and Trousseau both speak of it as a very fallacious and uncertain symptom, and by itself may be unimportant as an indication. In the beginning of the disease we find suffocating dyspnoea for a time when there is very little fluid. Diffusible stimulants and anodynes give relief. On the other hand, there are patients who with large amounts of fluid, even two quarts, walk about with but little difficulty in breathing, and attend to their pursuits unconscious of being in danger of sudden death. Bowditch⁵⁸ speaks of several fatal cases in simple pleurisy from excessive amounts, "from sudden failure of the power of the heart, with or without more or less dyspnoea." This is especially the case where the fluid forms insidiously, without marked general symptoms. When, however, we meet with dyspnoea, together with other and more reliable symptoms, it is very significant of danger, and ought to force us to resort to thoracentesis to afford mechanical relief. If we rely upon general symptoms, we may be deceived as to the amount of fluid, and serious results may follow. However, we must bear in mind that the most imperative reasons for thoracentesis are the signs of threatened failure of cardiac power. Bowditch lays down the rule that "if the dyspnoea is excessive, so as to amount to permanent orthopnoea, or if I learn that within a few hours previous to my visit there has been even one attack of momentary orthopnoea during which the patient felt as if the breath would be wholly lost, I tap immediately, provided I am sure that there is even a small quantity of fluid in the pleural cavity, and that it is apparently the chief or perhaps only cause of the orthopnoea. I fear," he says, "death may occur before my next visit." This eminent American authority on this subject lays down as the result of his vast experience the rule that "when a patient comes under notice in whom a large quantity of fluid has been long effused, I advise thoracentesis as the first remedy." The author ventures to assert that where the amount is excessive there is imminent danger to life from the mechanical results of the presence of the fluid, even during the febrile stages; consequently thoracentesis is urgently necessary. I am confirmed in this view by Dieulafoy, Fernet, Clifford Allbutt, Marshall, and Cross. Barnes⁵⁹ says in all cases where the effusion is large and where dyspnoea is urgent it is better to operate at once. "It is my practice to operate at once when the chest is two parts filled with water, without waiting for urgent dyspnoea." Dieulafoy, in discussing these questions, states,⁶⁰ after consulting all the authorities accessible to him, that death has never been caused by less than two liters (equivalent to 62½ fluidounces), except in one instance reported by Blackey, where after death there was found 1500 grammes (47 fluidounces). In adults with well-formed chests he considers 1800 or 2000 grammes as the amount demanding surgical interference. He candidly acknowledges that he cannot make this an absolute rule, because the capacity of the pleural sacs must necessarily vary in different individuals according to their height, breadth, development of thoracic muscles, sex, etc.; consequently, the inconveniences and functional disturbances produced by a given quantity of fluid in the chest must be different in different persons. But how can we arrive at an accurate estimate of the amount in the chest? Dieulafoy,⁶¹ in calculating the quantity, states that if it amounts to 1200 grammes when it reaches the sixth intercostal space, it ought to be valued at 2000 grammes when it is found at the third intercostal space. This is only approximative and unreliable. The height of liquid is not always proportional to quantity. It varies with size of chest, resistance of organs and walls, and condition of lungs. Potain insisted upon the difficulties that the pulmonary hyperæmia caused in the diagnosis, the abundance of fluid, the variable degree of yielding of the lung, and the adhesions which have drawn the walls to the lung. The true way of judging of the necessity for the operation is from the grave functional disturbances and by the definite positive physical signs which give us unmistakable indications which we dare not neglect. We can calculate the amount of the effusion by the level of the flatness on percussion, by mensuration with the cyrtometer, and of the impaired thoracic movements by the stethometer. Physical examination reveals the extent of the displacement of the heart and other viscera. The displacement of the abdominal viscera, the liver, the spleen, and the stomach shows that there must be excessive amount of effused fluid in pleura—enough to produce serious intra-thoracic pressure. This is a condition demanding surgical interference. The Skodaic resonance under the clavicle, the complete flatness being horizontal instead of giving us the Ellis curve, impaired resonance over the posterior triangle becoming absolute dulness, the presence of cavernous or amphoric respiration near the sternal-clavicular articulation, and, in rare instances, subclavian murmur from pressure upon the subclavian artery,—all these signs give unmistakable evidences that the pleural cavity is full of fluid. It is important, in considering the treatment, to form a correct estimate of the degree of intra-thoracic pressure, for Erichson has shown that the mere collapse of a lung affects but little the facility of the circulation through it; its compression or forcible collapse necessarily retards the circulation and throws extra work upon the already overburdened heart. The more precise our physical diagnosis, the more appropriate will be our treatment. Douglass Powell found the intra-thoracic pressure to vary from a – pressure to ½ and 1½ inches of mercury at the commencement, and from –1/8 to –½, and even –1, inch mercury at the termination of paracentesis, there being in all cases a more or less considerable amount of fluid still remaining in the pleura. He states, as the result of his own observations, that in recent cases the period of effusion at which the intra-thoracic pressure is converted from a – pressure or zero to a positive pressure upon the lung and heart is marked clinically (1) by the flatness mounting up above the third cartilage (patient in sitting position), and (2) by the Skodaic resonance becoming changed from the full note to a more tubular quality. The extent of Skodaic resonance is a very valuable indication of the amount of fluid, and consequently of the propriety of operating. If this tympanitic resonance be down to the third rib, and the cyrtometer shows no decided enlargement, we had better not interfere. On the other hand, if the Skodaic sign is not heard, and instead there is flatness, we will be sure to find decided increased measurements and tubular breathing behind. Under such circumstances we may feel confident of positive intra-thoracic pressure of from one inch to one inch and a half of mercury—an amount sufficient to compress the lung and interfere with the heart's action. There is some danger of syncope, even if the patient remains motionless in bed, but if he moves about he is in imminent danger. The subject is annoyed by a straining retching cough with frothy, viscid sputa with perhaps some discolored points. The heart and the lung of the healthy side give warning of the danger, which ought never to pass unheeded. A murmur may be heard over the displaced heart, and over the lung on the unaffected side we may hear a fine crepitant râle, showing pulmonary hyperæmia and resulting oedema. The syphon or aspirator will afford, by withdrawing perhaps a quart, the necessary relief. Nature will do the rest in a large proportion of cases.

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.

Wedal's⁶³ results confirm this view of the harmlessness of punctures during the febrile stage; and, more than this, they show that they hasten the cure. He operated on 17 patients from the second to the fifth day, and three times from the eighth to the tenth day. In cases of acute disease, where the patients were exempt from pulmonary or bronchial complications, the cure was not protracted beyond the twelfth day. Some were cured by the sixth day. His patients were, for the most part, vigorous men, young soldiers—very favorable subjects. Ordinarily, however, as shown by J. L. Mason's⁶⁴ report of 132 cases where the operation was not performed, the duration of the attacks was weeks, and in some cases months. He considers the operation more apt to be successful if performed early in the disease, and that the existence of fever is no contraindication. The author has always pursued a more conservative course, and abstained from operating in the febrile stage unless, as in three instances, the effusion was so rapid in its formation that there was danger of serious consequences from the amount of the fluid. In these three instances the result was successful and without unpleasant sequelæ. Moutard-Martin⁶⁵ states that aspiration made during the febrile stage is in no way prejudicial to the patient. Dieulafoy⁶⁶ advises us to wait until the fever falls.

⁶³ Étude clin. des épanchments pleurit., 1877.

⁶⁴ Boston City Hospital Reports, 3d Series, 1882.

⁶⁵ Loc. cit.

⁶⁶ De la Thoracéntèse dans la Pleur. Aigue, 1878.

To remove the effusion during the inflammatory stage does not appear to be rational treatment unless the quantity is so excessive as to endanger the life of the patient. The fluid remains limpid unless exposed to air or contact with foreign substance. When, after a time, there is some coagulation, it is only of a thin layer which covers and protects the roughened surface of the pleura. A certain amount of effusion is useful; it separates and bathes in a bland fluid the tender and inflamed surfaces, and keeps at rest the affected portion of the lung. The lung in health exercises a constant traction upon the pleural sac, the vessels of which have therefore to sustain a negative or aspiratory pressure: this being so, it is physiological that if these vessels become temporarily weakened and congested by the inflammatory process, increased exudation proceeds from them. The effect of this exudation is to neutralize lung-traction, and therefore to lessen the afflux of blood to the weakened vessels. "Fluid effusion being thus both natural and salutary, in acute pleurisy we must be watchful, but not meddlesome" (Powell). We must not hurry, but we must try if nature will not by spontaneous absorption cause it to subside. We can ordinarily do this up to the end of two or even three weeks before resorting to artificial means.

The defervescence in pleurisy, we have seen, has no fixed period, as in pneumonia. In favorable acute cases the absorption begins as soon as the temperature begins to fall. Moreover, the liquid may be absorbed, notwithstanding the continuance of fever, and the effusion may continue notwithstanding the defervescence. In the subacute form the febrile period passes by unnoticed, although the effusion is often in large quantity.

When not urgent, how long should we wait for absorption of fluid? This is a question much discussed, and not yet settled. What becomes of the effusion in the acute pleurisies?

In the first days of its formation the liquid portions of the effusion are reabsorbed by the normal vessels of the serous membranes at the points left intact and the recent vessels of the neo-membranes, but the organization of these last demands, to be complete, from two to three weeks; it is not until the end of that time that they will be most favorable to reabsorption. Dybkowsky points to the anatomical fact that the lymph-vessels are found only in those parts of the costal pleura which cover the intercostal muscles, while the portions which are reflected over the ribs are destitute of such vessels.

On the other hand, the eccentric pressure made by a considerable effusion on the pleuræ may retard their vascularization and lengthen out the work of absorption. Moreover, during the time necessary for that organization a certain quantity of coagulable fibrin is deposited on the surface of the serous membranes. The pseudo-membranous bridles are not slow in forming, and cause the adhesions which press the lung against the costal wall, the vertebral gutter, and the superior parts of the thoracic cage, toward which the effusion tends to force them.

In very favorable cases the effusion may disappear by the twentieth day of the disease. In many cases, however, it lasts with the false membranes for several weeks, and not infrequently for many months. Cases are recorded by Powell and others where the effusion remained of a sero-fibrinous character for eighteen months and two years. Flint mentions two cases where the effusion was permanent, having lasted for years. Wilson Fox⁶⁷ thinks that there is but slight danger of the fluid becoming purulent from mere lapse of time unless the patient should have another fresh inflammatory attack. It must be noted, however, that such is not the case in children. Voyet⁶⁸ says that simple pleurisy in infants is transformed into purulent pleurisy with facility and extreme rapidity—so much so that when with these a serous effusion is slowly absorbed there is great danger of suppuration taking place. M. Vertiac⁶⁹ states that chronic serous pleurisy may not exist among children. In 13,000 sick children in eleven years Barthez did not have a single case. Pathological anatomy has demonstrated to us that this fluid in separating these neo-membranes on the parietal and pulmonary pleuræ increases their development. The plastic rugosities collect the fibrils of fibrin on their surface, in the same manner as they are found on the twigs in whipping the blood, and as the atheromatous deposits on the interior of blood-vessels favor the formation of emboli. These false membranes may cause a number of complications by surrounding the lung with a thick, inelastic shell. The collapse of one part of the lung diminishes necessarily the field of hæmatosis, and consequently causes a compensatory congestion of that lung, and even of the lung of the other side. This occurring in an individual predisposed to tuberculosis or in a condition to develop and cultivate the bacillus tuberculosis may start the disease. Formad⁷⁰ maintains that pleurisy is a very frequent cause of pulmonary tuberculosis. These imperfectly organized embryonic membranes cause deformities of the thorax; they are good ground for the growth of pathological products, such as cancer or tubercle; their fragile capillary vessels are the principal cause of a most troublesome form of hemorrhagic pleurisy. (See HEMORRHAGIC PLEURISY.) If the lung be compressed but a short time, it does not undergo irreparable injury, but if for a considerable time, the thickened organized membrane, with the effusion, causes a more or less considerable atelectasis, binding down the lung and preventing its expansion. The author holds that the effusion, after the fever has subsided, is, in itself, a foreign and troublesome element; for even with a medium effusion we are not exempt from unpleasant results.

⁶⁷ Brit. Med. Journ., Dec., 1877.

⁶⁸ Thèse de Paris, 1870.

⁶⁹ Ibid., 1865.

⁷⁰ Paper read before the Baltimore Clinical Society, February, 1883.

Although, in moderate effusions, there is no compression of the lung, yet there is necessarily collapse of it pari passu with the amount of fluid. This interferes with its retractive power—the aspiration force, as it has been called—by which the venous blood is drawn into the right side of the heart. T. B. Curtis of Boston calls attention to this very important fact, and shows that the result must be disturbance of circulation, with imperfect blood-supply to the heart, interrupted cardiac action, feeble arterial tension, together with venous repletion and stagnation. In consequence of this condition there is a diminution of the quantity of urine, and, as generally occurs where there is venous congestion, a small quantity of albumen, cyanosis, etc. Fraentzel, Traube, and Lichtheim attribute the venous stagnation, etc. to obstruction in the pulmonary circulation resulting from pressure exercised by the effusion. Curtis and Garland hold that these bad symptoms are not caused by pressure, but by the diminished pulmonic retractility which exercises the negative pressure of emptying the large venous trunks.

Such being the ill-effects of the retracted lungs, is it well to allow even a moderate amount of fluid to remain in the pleural sac after Nature has failed to remove it? Besides, the presence of liquid alone displaces the organs, especially the heart and lungs; adhesions form and keep them in an abnormal condition. The retracted lung, bound down by bands, becomes enfeebled, loses its suppleness, and is rendered rigid, seriously impairing respiration. There exist three factors—false membranes, adhesions,⁷¹ and interstitial pneumonia—which tend to seriously disable the lung and even to produce complete atelectasis pulmonum. We must bear in mind that there is some danger of the fluid becoming purulent, especially if a fresh inflammatory attack should occur. The less time a pleurisitic effusion lasts, the sooner the patient will be placed beyond the probability of these serious injuries to the process of hæmatosis. It is but right to give Nature an opportunity, assisted by iron, salines, diuretics, iodine, and even blisters, in cases of moderate effusion. The rapidity of Nature's work in many cases in removing large quantities of fluid here and elsewhere is wonderful. But if she does not act, we ought not to let our patient become feeble and depressed in his nutrition, or perhaps maimed for life, by not withdrawing the fluid. Sometimes the absorbents only half do their work of removing the fluid, and leave a quantity in the chest. Under these circumstances tonics, good diet, and change of air will complete the absorption.

⁷¹ According to Wilson Fox, the density of the adhesions and false membranes is determined within the first fortnight of the effusion.

The question arises, How long shall we wait for absorption? Test first, by exploratory puncture, the nature of the fluid: if it is fibro-serous day after day, try by the cyrtometer the size of chest and by percussion the exact amount of flatness. If there is no evidence of any decline of the effusion in two weeks, slowly withdraw some of the fluid. This will start the absorbents into activity, for the natural absorbing power of the pleura is diminished when it has been unduly stretched for some time. The layer of lymphatics subjacent to the pleura and communicating by stomata with the pulmonary lymphatics, together with the other absorbent vessels, appear to be unable to remove the fluid. We maintain that the pressure on the orifices of the lymphatics is often too great for absorption to take place, and that by removing the pressure we can start the absorbents into activity. Aspiration under these circumstances shortens the duration by several weeks and hastens convalescence. J. W. Hunt⁷² advises that we should wait two or three weeks before operating. Loomis⁷³ says if the fluid remains stationary for one week, or is increasing when the cavity is half filled, we must operate. Barnes⁷⁴ would only wait a few days if the chest is half full, to see if absorption will begin to remove it. When the chest is two-thirds full, he advises immediate surgical interference. Oxley⁷⁵ advises a delay of three or four weeks before operating. Anstie's⁷⁶ rule is to postpone operating for one month. T. Clifford Allbutt's⁷⁷ general rule is, if an effusion rises above the angle of the scapula, and abides in that quantity or increases for two or three weeks in spite of adequate treatment, it must be drawn off, whether the patient be embarrassed by it or not. Bowditch⁷⁸ says: "If the effusion does not subside under the medical treatment, and the symptoms have not lessened after two or at the utmost four weeks, I have, after long experience, been led to the following general rules for my own guidance: 1st. I never allow any time to elapse before performing thoracentesis after a decided and prominent dyspnoea appears, or if a sudden and very threatening orthopnoea occur, or if I find the chest has become full or more than half full of fluid in a perfectly latent manner during a month of illness. 2d. After there is dulness to the angle of the scapula, with the other rational and physical signs of pleuritic effusions, I tap within four weeks, even if the patient seems quite comfortable, if the line of dulness does not get lower and seem to subside under the treatment. I think fatal mistakes are made by delaying too long before tapping." The author prefers ordinarily to wait for the subsidence of the fever in acute cases, unless the effusion is in dangerous quantity. The practitioner must continually use the thermometer as well as observe physical phenomena and general symptoms. Cyrtometric tracings give very valuable indications as to the activity or non-activity of the absorbent vessels. After the fever subsides the fluid may be regarded as a foreign body doing harm to the two principal organic functions upon which the nutrition of the animal frame is dependent—respiration and circulation. It is from this standpoint that Dieulafoy⁷⁹ advises, if absorption is slow or difficult after two or three days, that the fluid should be aspirated. The greatest success has been obtained in cases where the fluid has been present but a short time. The number of fatal cases is increased by delay of operation. Toussaint's cases show this:

4 deaths in 176 cases operated upon between 1st and 20th day.

6 " 80 " " " " 20th and 60th "

1 " 7 " " " " 60th and 120th "

In the quiet kind of pleurisy, formerly designated the subacute or latent, thoracentesis is especially applicable. Ordinarily, when the practitioner is consulted, there is considerable fluid, without any febrile movement. Here we are in duty bound to assist nature. Iron in the form of the tincture of the chloride and the syrup of the iodide are our best remedies. We cannot give the patients the tonic influence of outdoor air with exercise, because there is danger in their moving about; but they should have an abundant supply of nourishing food, with light wines. Absorption is very inactive and sluggish. Even with moderate effusion to the extent of one-third of the pleural cavity, we cannot let the fluid remain too long. Pidoux designated this form of pleurisy as the thoracentesis variety.

⁷² Loc. cit.

⁷³ Dis. Resp. Org., etc., 1875.

⁷⁴ Loc. cit.

⁷⁵ N.Y. Med. Ex., Sept., 1882.

⁷⁶ Syst. Med.

⁷⁷ Quain's Dict. Med.

⁷⁸ Unpublished MSS.

⁷⁹ La Thoracent. par Asp. dans les Pleur. Aigues, 1878.

Conclusions.—1st. The author wishes to be distinctly understood as not advocating aspiration simply because there is an effusion, as a mere matter of routine, for its indiscriminate employment is undoubtedly attended with risk. He does claim that its performance is imperatively called for when the pleural cavity is full or nearly so; when there is much displacement of the heart or other viscera; when the patient is suffering from serious dyspnoea and danger of syncope, and when there are complications of disease of any kind of the other side or of the heart; finally, when there is double pleurisy. Bowditch states that he has seen thoracentesis give great relief in effusions following Bright's disease and cardiac diseases.

2d. He thinks that in acute cases, after the subsidence of the fever, if the pleura is one-third full of fibro-serous fluid, Nature will probably do her work of removal promptly. If she shows no sign of doing so, we should come to her assistance in about ten days or two weeks, and draw off a portion of the fluid—enough to relieve pressure and to encourage the absorption of what is left in the sac.

3d. In the subacute or chronic fibro-serous effusions it is not well to wait over three weeks before operating. As he shall show in the study of the dangers and objections, he considers the operation a perfectly safe one if the simple rules now generally observed by operators are faithfully carried out.

In studying the advisability of operating where there are not urgent indications we must ever bear in mind that while it takes a large quantity of fluid to compress the lung, the retracted lung may, by neo-membranes, be kept to its diminished volume. As long as the lung is able to lift up the fluid and the diaphragm it is in no danger of atelectasis. It is in a state of physiological rest. In a subject of bad constitution interstitial changes may indicate an earlier operation, but, if an effusion exists on the side on which there is already lung disease of a phthisical nature, we should be loath to interfere; for "experience has shown that an effusion checks, and sometimes arrests, the tubercular process" (Powell).

Contraindications.—These are principally in connection with the general condition of the patient. If it is such that there is no hope of his rallying, if he is very old, or if he has intervening croupal pneumonia, the operation is not justifiable. If the quantity of fluid is not large and does not interfere with organic functions, we can wait for some time.

Mode of Operating.—The old trocar method of operation is now abandoned. It was not always an easy one, was painful, and there was more or less danger of cutting the intercostal artery, of introducing air, and of establishing, by the size of the puncture, a fistulous orifice. If, perchance, the lung was perforated by the trocar, pneumothorax was established. In some cases of sacculated and limited effusions, and in chronic cases where the membranes were thick, it was not effectual, and if the fluid was not reached, the operator hesitated to introduce the trocar elsewhere. When the fluid flowed through the trocar, it came frequently in jets with painful coughs. The above operation was quite a formidable one. Now thoracentesis is always performed with very fine perforated needles attached to aspirators of some modern pattern, and guarded by Fitch's dome-trocar or Castiaux's protected point. We employ Dieulafoy's Potain's bottle-aspirator, Castiaux's of Paris, or Raumussen's of Copenhagen. Flint recommends the use of Davison's syringe. We fear it would be found too rough an instrument for so delicate an operation. The points of attachment of the bulb with the tubing are not sufficiently air-tight. The valves are very imperfect, and easily get out of order. In our efforts to pump out the fluid we might throw air in, and with it particles of organic matter.

The operator has his choice among no less than thirty-odd instruments similar to Dieulafoy's. They all work upon the same principle—the close operation, the withdrawal of the fluid by aspiration. The needle or trocar must be capillary: the smallest that is effective is the best—say a half millimeter in diameter—in order to make the orifice as minute as possible.

If we prefer the syphon, we must use a larger canula than we employ for aspiration—one of four millimeters in diameter. It should have two outlets—one straight, for the trocar, and one at an angle, for the attachment of the tubing. It should also be guarded by an air-tight collar. Into the syphon tubing a T-tube may be inserted for the purpose of attaching a side tube to be connected with a mercurial manometer, by means of which the exact intra-thoracic pressure may be observed during the operation. The syphon tube should be long enough to provide a fall of one, two, or three feet, as may be necessary. A fall of twelve to eighteen inches is usually enough, as we wish to remove the fluid slowly. We can easily increase the force by lengthening the tube. If the canula should become obstructed, lowering the basin suddenly will probably remove the piece of lymph. The trocar can be pushed again through the canula if necessary. In case the aspirator should be needed, the end should have a metallic joint affixed to it. In all the instruments used, absolute cleanliness should be observed. The tubing previous to operation should be filled with a solution of carbolic acid (1:40).

In cases of rapid effusion, especially during the febrile stage and when the intra-thoracic pressure of fluid is great, some prefer using the feeblest form of aspiration. Southey's capillary trocar, with drainage-tubes attached, is used as a syphon for this purpose. The fluid is drained off through a narrow india-rubber tubing which is placed under water to prevent air being drawn into it. Ordinarily, the use of the fine aspirating-needle without much force, and slowly drawing off the fluid, answers the same purpose. The fear some have expressed, of the danger of injuring the lung by the force of the rarefied space, is more theoretical than real. Even with a canula of the size that Southey employs there is some danger of leaving a fistulous orifice, for it has to be kept in for hours. If the smallest tube is used, from which the fluid simply comes in drops, the operation consumes five or even ten hours. Southey speaks of cases where the flow was kept up for twenty-four hours. Unless aspiration is resorted to, flocculi may easily stop up the canula, and then we are compelled to reintroduce the trocar, and afterward to reattach the tubing. Oxley, who thinks that the best results are obtained by the use of these tubes, acknowledges that so much time was consumed that he inserts four canulas, drawing off 44 fluidounces of fluid in one hour and ten minutes, thus defeating the object of using this method, which was to draw off the fluid very slowly, so as to enable the lung to expand gradually and healthfully.

There are cases where, to withdraw the fluid, more suction force than is usually employed with the syphon has to be used in order to antagonize the negative force exercised by the traction of the lung and the passive tension of the diaphragm. The author recently had a case where, notwithstanding the presence within the right pleural sac of a quantity of fluid large enough to obliterate the Skodaic resonance under the clavicle, not a drop could be drawn out by a syphon attached to a canula of 2 mm. in diameter. Having no additional tubing to increase the force of the syphon at hand, he used Dieulafoy's rack aspirator, ½ mm. in diameter, and drew off a quart of fluid—enough to relieve the symptoms of oppression. Stone reports a case of the kind where, although there were two quarts of fluid in the pleural sac, no fluid could be drawn out with a syphon exerting a force of 1½ pounds to the square inch, or one-tenth of an atmosphere. In the same case there was actually, in inspiration, a negative pressure exercised by the lung of two inches of water. Stone mentions another case where a boy fifteen years of age died from the quantity of fluid, which would not flow out when tapped. If he had had an instrument by which he could have used aspiration he would have saved the life.

The value of this syphon method has within a few years grown much in favor. It is simple and inexpensive. It allows the fluid to be drawn out with a uniform and feeble aspiratory force. The flow is very slow, which gives the lung time to expand gently, and the displaced organs to return gradually to their normal position. With the manometer attached we can judge accurately as to the intra-thoracic pressure. The size of the canula has to be larger than when we employ the aspirator—4 mm.—whereas with the latter we use ½ mm. or 1 mm. in diameter. If by any accident the lung should be perforated, the larger orifice would not be as harmless and insignificant as the smaller one. It must be borne in mind, especially in cases of long standing, that the neo-membranes are very vascular, and that with a 4 mm. perforator we may rupture the blood-vessels and complicate matters by the escape of blood into the pleural cavity. It is claimed that when the canula and syphon tubes have been introduced the patient can be left in charge of the nurse. This, the author thinks, should never be done, for nurses are rarely competent to judge whether a sufficient amount has been withdrawn, nor are they fit to assume the responsibility of acting in cases where promptness of treatment may be of the utmost importance. The operator or a competent substitute must remain until the operation is over. The withdrawal of fluid must, moreover, be slow, for slowness contributes in a great degree to lessen the dangers. Fraentzel recommends testing the force of the aspirator in the palm of the hand. Garland⁸⁰ employs needles which are 1–2 mm. in diameter and remove only 50 to 100 grammes per minute. The thoracic pressure must be relieved by the withdrawal of only enough fluid to effect that purpose. It has been objected that the negative force of the aspirator is uncertain. It is a well-founded objection, yet we can employ with it a feeble force by exhausting only a portion of the air from the cylinder or bottle, and thus remove the fluid cautiously and very deliberately. It is admitted that if there is no intra-thoracic pressure the fluid will not flow out unless we introduce air or negative force. We claim that the syphon and the aspirator with capillary needles, employed with the precautions dictated by modern experience, are both safe and effective. Ordinarily, we prefer the bottle aspirator of Potain, or Dieulafoy's instrument with the manometer attachment.

⁸⁰ "Dis. of Pleura," in Ziemmsen's Appendix.

Modern aspirators, if in perfectly good order, completely prevent the possibility of septic contamination by admission of air. Unclean needles and canulæ can—and we fear formerly often did—convert sero-fibrinous into purulent pleurisies. A case came under Powell's observation in which carelessness in this respect apparently led to decomposition of the fluid, suppurative pleurisy, and ultimately to the death of the patient. Before operating we ought always to test the instrument, and see that it works well by passing carbolized water through it. The points should be put in the flame of a spirit-lamp, and then dipped in carbolized water and glycerin—not in oil, which may be rancid. The hands and clothes of the operator should not be overlooked in this regard. The atmosphere of the room should previously be completely cleansed by ventilation, and afterward purified by atomization of disinfectants. We must not, in a word, incur the slightest risk of converting a simple inflammatory effusion of fibro-serous fluid, a mild disease, into a suppurative inflammation, a very troublesome, dangerous one.

A needle of not larger diameter than 1 millimeter (No. 2) should be connected with the end of the tubing. Next turn the stopcocks which shut off the barrel from the tubing on both sides, producing a vacuum in the receiver. The patient should then be placed in the recumbent position in bed, with his head and chest raised. We prefer this position, as the easiest for the patient at the time of operation and less apt to produce syncope or faintness. He can, without being moved, lie down in the horizontal position, which he should maintain for at least two hours. Bowditch has, without any accident, had his patients to sit during operation sidewise in a chair, with one arm resting upon a pillow placed upon the top of the back. The operation is accompanied with so little pain that it is not necessary to use either general or local anæsthesia. Some surgeons advise before operating the administration of a small dose of morphia hypodermically, or a stimulating drink of whiskey. We are not in the habit of using either. We have generally allowed patients to take a good meal of easily-digested food (milk if they consent) about two hours previous to the operation. Whiskey and ammonia we have ready in case of need. If we find it necessary to use a 4-mm. canula for syphon, it may be best to spare the pain of its introduction by local anæsthesia by ether, or by rhigoline in Richardson's spray, or by applying a piece of ice surrounded by salt, as suggested by Powell.

The point of puncture should vary according to the quantity of fluid. If the fluid is excessive, we can operate as high up as the fifth intercostal space on the right side and the seventh on the left. We can choose a lower intercostal, but as it is not proposed to draw off all the fluid, the higher operation is preferable. If the chest is two-thirds full, we can take the seventh or sixth intercostal space on the right side and eighth on the left. If only one-third of the cavity is occupied by fluid, we can go as low as the eighth intercostal on right and left sides, on a level with the angle of the scapula in the axillary line. If the quantity of liquid is so great as to force the abdominal viscera, especially the liver and the spleen, below their normal position, we may be safe in puncturing below the seventh intercostal space. But if such is not the case, the diaphragm may easily be touched on a level with even the seventh intercostal space. Aran plunged a trocar into the liver when operating through the seventh intercostal space. Ch. Bernard impinged upon the peritoneum at the same point. Woillez and Paul Barbille recommend the fifth intercostal space. Cruveilhier advises the third or fourth as being the point of the spontaneous openings. The author usually inserts the needle in the sixth intercostal space in the mid-axillary line: it is out of reach of the diaphragm and is accessible when the patient lies in the position in which he prefers placing him. The space is sufficiently wide and the parietes thin. Before operating the point must be examined carefully by percussion, auscultation, and palpation, so as to be accurate in the diagnosis that there is fluid at that point, and that nothing can be injured—lung, heart, or diaphragm.

Before inserting the needle the skin should be wiped over with an antiseptic solution. The skin being drawn up, the nail of the left index finger serving as a director, the point, having been first made aseptic, is introduced along the upper margin of the lower rib, taking care not to injure the periosteum—not by a boring motion, but by a sharp push, giving it a downward direction instead of a perfectly straight one, so as to avoid striking the lung. When the fluid is reached the stopcock is turned, so as to convert the needle into an aspirator. The index tells us whether we have struck the fluid, and its nature is shown. In chronic cases, where the bands are thick and partitions are firm, we may not find the fluid the first time. In such cases the needle is withdrawn and another point selected. The author had a case where he made no less than eight punctures before getting the fluid. At the last insertion of the needle he found it, and drew off a large quantity. The patient feels relieved in a very short time. As the fluid flows out the aspirating force should be only sufficient to draw it out slowly and gently. It is well to stop for a few minutes after aspirating about 4 fluidounces to watch the effects. The fluid running in a very small stream, we give the lung time to accommodate itself to its altered condition. The lung by this process is led, rather than forced, to resume its normal position. It is a difficult matter to fix the quantity that ought to be drawn off at one time. This must vary according to the circumstances of each case. Our rule has been to draw off more when the pleurisy is acute than when it is chronic. The long continuance of the fluid in the cavity has so impaired the lung's capability of expansion by the adhesive bands or compresses that the sudden withdrawal of a large quantity is attended with risk. If the patient bears the operation well, we may remove much more than if the contrary is the case. The amount withdrawn at the first operation should vary from 8 fluidounces to 16 fluidounces in a child, and 12 fluidounces to 24 fluidounces for an adult. We must bear in mind, as to the quantity to be removed, that ordinarily there is more or less danger of producing fresh engorgement of the capillaries and hyperæmia of the lung in removing a large quantity; and, moreover, it is unnecessary. We wish to remove the intra-thoracic pressure upon the lung and to promote the absorption of the fluid. The manometer will tell us accurately whether it is necessary to take out one, two, or three pints. If nature does not in due time remove what is left, the operation can be again resorted to. Slowness in the withdrawal of the fluid, as well as the small quantity drawn, lessens the probability of any unpleasant effects. Bowditch says: "I always draw with great deliberation. I pull so lightly upon the handle of the piston that it seems as if the fluid itself were pressing out from the chest and pushed the piston upward, my hand simply following that impulse. The instant that the patient becomes restless, especially if he have any constriction or sharp pain in the chest, I withdraw the tube, even if a large quantity of fluid remains. If I do this, I find the patient is soon relieved, and in most cases nature appears stimulated even by the withdrawal of a very small part of the effusion. The absorbents begin to act well, and the fluid that is left is speedily removed."

One point is of the utmost importance: the needle should be instantly withdrawn at the onset of dyspnoea, constriction, much cough, or any tendency to syncope. These symptoms are warnings we should never neglect. This is the time to administer stimulants, and ordinarily the patient soon recovers from these effects. We must not, especially in cases of long duration, expect to find much expansion of the lung until next day. The greatest success has followed cases treated by early operation and partial removals, repeated, if necessary, every day or two until absorption is commenced.

The needle should be taken out suddenly, the operator having previously turned the stopcock, and the skin allowed at once to fall over the orifice, which is so small that no air can enter. It is indeed obliterated at once. It may be well, however, to put some collodion over it, with a small compress. The patient ought not to be permitted to move for twenty-four hours after the operation. He should lie quietly in bed and partake of simple nourishment. The removal of fluid causes the return of friction sounds and of pleuritic pain. Nature slowly does her work of absorbing the fibrinous bands. The breath-sounds in some cases are not heard for weeks, or even months, after the operation. Complete recovery being slow, and the shock to the organism very serious, the patient should thoroughly re-establish his health and strength before reassuming his active duties. A protracted rest in an invigorating climate or a sea-voyage should be advised. If the lung is slow to expand, the patient should frequently practise long, deep inspirations.

Dangers of and Objections to the Operation.—Thoracentesis as a means of relieving suffering humanity has from time to time been praised and proscribed, even in this century. Boyer operated several times, and never saved a single case. Dupuytren had only 2 successful cases in 50. He said he preferred that his patients should die by the hand of God rather than by the hand of man. Sir Astley Cooper had only 1 successful case, Gendrin not 1 out of 20 cases. Davis saved two-thirds of his cases. The eminent W. W. Gerhard of Philadelphia looked upon the operation as nearly always attended by fatal results. What a contrast to modern views and clinical results! Since Bowditch and Trousseau popularized the operation, and Dieulafoy improved the aspirating instruments, there is now no difference of opinion as to the imperative necessity of operating in cases where there is, from the quantity of fluid, imminent danger to life. Up to Nov., 1882, Bowditch⁸¹ had operated 386 times in 245 cases, without a single fatal result, and with only 1 case in which alarming symptoms supervened. Dieulafoy's⁸² cases in 1878 amounted to 150, without the shadow of an accident. My colleague, S. C. Chew, has never met with any unpleasant result from his operations. The author has had 84 cases, with 138 operations, without any unpleasant result beyond temporary cough and slight dyspnoea. Fraentzel⁸³ had 85 different cases, with 164 operations. A. L. Mason⁸⁴ performed 122 operations in 70 cases, with no unfavorable result which could be attributed to the operation in any instance, but usually with great and permanent relief. In 42 of his cases 1 operation was all that was necessary. So common is the operation that cases are not reported unless there is something to attract attention to them. As illustrative of the great interest taken in the operation see the number of writers on the subject and the numberless articles in medical journals, and the modifications of instruments of all kinds connected with aspiration and drainage. Such being the case, we ought not to be surprised that some operators may have used the aspirator-needle when they ought not to have done so—that some should have neglected the simple rules now insisted upon as the result of experience.

⁸¹ Unpublished MSS.

⁸² Tho. Pleu. Aig., 1878.

⁸³ Ziemssen's Cyc., vol. iv.

⁸⁴ Loc. cit.

Although thoracentesis by aspiration is always a harmless operation in itself, there are dangers and accidents which may follow. They may be slight, serious, and sometimes even fatal. The number of deaths which have been the result of the operation, however, is small compared to that of persons dying from the effusion whose lives might have been saved by the withdrawal of fluid. Thoracentesis was frequently made use of without accident, and was considered a perfectly safe operation until Terrillon⁸⁵ called attention to an accident which occurred sometimes after operating, a complication which Pinault⁸⁶ had mentioned in 1853—the albuminoid expectoration. Terrillon reported 2 cases of sudden and rapid death with that symptom. Several similar cases, resulting in death, had been previously reported. Dieulafoy has collected from different sources reports of 6 deaths with albuminous expectoration, caused by acute oedema of the lungs brought on apparently by the operation of thoracentesis in twenty-four to thirty-six hours. In one of these cases (Gérard's) death occurred in ten minutes; in another (Gombault's) in fifteen minutes; in another (Bouveret's) in two hours; in Behier's in four hours. Terrillon's cases, where there was this frothy, albuminoid, and sometimes bloody expectoration, numbered 16, of which 6 were fatal. The patient is attacked with cough and oppression, with the characteristic expectoration. Auscultation shows the fine subcrepitant râles of oedema of the lungs, mingled with tubular quality and ægophony. Gradually, in favorable cases, the cough subsides, respiration is re-established, and in one hour the danger has passed. In fatal cases the cough becomes irregular and jerky, the agony increases, and the patient throws up the yellowish and albuminous expectoration in quantity varying from 50 grammes to (in one case reported by Moutard-Martin) 1 liter. The intensity of the dyspnoea and its duration vary very much—from twelve to twenty-four hours.

⁸⁵ Thèse de Paris, 1872.

⁸⁶ Ibid., 1853.

There has been considerable discussion among different authors as to what produce this serious condition. The view sustained by Hérard⁸⁷ is the one generally admitted to be correct—viz. that it is from rapid congestion and acute oedema of the lung, and not from the passage of serous effusions of the pleura through the bronchi. Foucart⁸⁸ relates a similar case of albuminous expectoration occurring in heart disease. This condition could not be produced by perforation of the lung, for the pre-existing vacuum renders the aspirator-needles the safest to introduce, because if there is fluid present it at once flows out and warns the operator not to push the implement farther in. In no autopsy has the orifice made by the needle been found, nor has it ever been known to produce pneumothorax. The quantity of albuminous sputa is out of all proportion to the orifice made. In several cases of reported perforation these symptoms did not occur. After the lung has been a long time compressed by an effusion, and when, in consequence of the expulsion of the liquid, it retakes its normal proportions, there occurs a rush of serum which is expelled by the bronchi. Hérard has seen patients in whom he could not find more than traces of liquid after the puncture, and who at the end of a half hour or an hour expectorated 500 to 1000 grammes of fluid which did not come from the pleura. That oedema of the lungs, or serous exudation from the capillaries into the walls and on the free surface of the alveoli, is a result of hyperæmia and pulmonary congestion is admitted by Robin, Bernard, Niemeyer, Jaccoud, and others. We have first congestion of the lung, then oedema resulting from it, ending in free albuminous expectoration, which comes not only sometimes from the diseased side, but from the healthy side, owing to pressure against the mediastinum and the other lung. This is an accident the possibility of which should be always before us in operating. No precaution ought to be neglected which will ward it off. It is instructive to analyze Terrillon's cases as to the cause of the oedema. As he considers that the aspirator, by draining out the lung, is likely to produce this unfortunate result, it is satisfactory to find that of the 16 cases where this unpleasant symptom was found, 12 were where the old trocar (Reybard's) was used without aspiration, and 4 where aspirators were used. Of the 6 fatal cases collected by Terrillon, 3 were with the trocar and 3 with the aspirator. Five out of the 6 fatal cases are found to have been not simple pleurisies, but pleurisies with complications, such as heart disease, bronchitis, tuberculosis, numerous adhesions, double pleurisy. The same may be said of the benign cases. In addition to these complications, large quantities of fluid had been drawn out at one time. Dieulafoy challenges his confrères to produce an instance of death from this cause when the fluid removed did not exceed 1200 grammes. His rule now is never to withdraw more than 1000 grammes of liquid at one time, and in large effusions to empty the sac by several operations. The older and more complicated the effusion, the more rigorous should be the rule, because there is great danger in thoracentesis when the fluid has existed long enough to have compressed the lung to a serious extent by bands. All careful operators now follow this rule. It is dangerous, and withal unnecessary, to draw off large quantities at a time. The gradual removal of fluid diminishes the risk of syncope where a sudden withdrawal may be serious in its effects. The effect is to suddenly deprive the lung of pressure which has for weeks perhaps made it anæmic. The blood rushes into the empty vessels, the air into the alveoli, and violent congestion and consequent oedema result. If, on the contrary, we draw out moderate quantities at different times with the capillary needle, which is so small that its introduction is harmless, the lung resumes progressively the functions it has lost, and the circulation gradually enters. Thus there is no risk of congestion.

⁸⁷ Acad. Méd., 30 Juillet, 1872.

⁸⁸ Thèse de Paris, 1875.

In examining the fatal cases reported by different authors, Foucart, Dieulafoy, Mercier, Lerebenthel, and Gagnet, we find other modes of death in addition to those by oedema of the lung, such as asphyxia and pulmonary emboli, and, as connected with the heart, syncope and cardiac thrombosis. In most of the cases these accidents resulted indirectly from the operation in twenty-four hours or a longer time. In a case reported by Guyot it occurred three days afterward. Congestion by itself may cause sudden and rapid death by determining asphyxia.

There are other lung causes which produce sudden death following thoracentesis, such as atelectasis, consecutive to effusion; secondary pneumonia, caseous or not; pulmonary tubercles. Besnier reports a case of gangrene of the lung following paracentesis. Of the 8 cases collected by Dieulafoy which may be put into this category, we find death from pericarditis, cardiac clot, and from thrombosis of the pulmonary artery. Death from the heart may be due to old lesions, to syncope, or to the presence of clots in the heart or small circulation. Stokes has given fatty degeneration of the heart as a cause of death in simple pleurisy without operation. Syncope, with death after operation, is caused by the sudden return of the heart to its normal position. The heart being pushed out of position, the larger blood-vessels are distorted, and the course of the circulation is severely interfered with. A very slight cause will arrest the circulation. By aspiration the mechanical cause is removed, but a small embolus, may, by the increased force of blood, be carried into the pulmonary circulation. Death by emboli in the capillaries of the lungs is very similar to death from clots in the right side of the heart and at the origin of the pulmonary artery. These clots may be formed in the pulmonary vessels, or may be transported in the small circulation to points more or less distant. Potain in 1861, and Vallin in 1869, reported sudden deaths from effusion in the pleural sac, causing embolism of the cerebral artery. How far aspiration is responsible for accidents of this kind it is difficult to decide. Were they caused by thoracentesis or notwithstanding the operation? They are unquestionably the cause of death without the operation in excessive effusions. The conditions which produce these results ought to be well considered previous to operation. We notice that in most of these cases large quantities of fluid were withdrawn—2000 grammes (Legroux), 3 liters (Vallin), 3500 grammes (Guyot), 1500 grammes (Chaillon and Goquel). The withdrawal in cases of long standing of such large quantities had, beyond a doubt, considerable influence in producing the fatal result. Bowditch⁸⁹ addressed letters to 60 physicians, living in 31 of the States and 2 in Canada—representative men—asking if they had ever seen or heard of fatal results following thoracentesis by aspiration. Of this number, 53 replied in the negative, and 7 in the affirmative. "Upon an analysis, however," he states,⁸⁹ "of the circumstances under which death occurred in these last, I found nothing to shake my confidence in the operation, provided it be performed with proper precautions during and subsequent to the tapping. In no one of these cases had the operation been the sole cause of the fatal result." "In 4 there was extra motion on the part of the patient after operation, and in the other 3 the disease had been allowed to continue without aid from a surgeon long after the operation was needed. In 1 the operation was a forlorn hope. One patient died on the table from anæsthetics." Bowditch adds: "These cases should not lessen our confidence in the operation, but simply teach us caution on three points—namely: do not delay too long; be very careful to direct the patient not to move, if possible, for twenty-four hours after operation; be cautious of using anæsthetics." Bowditch, from 29 fatal cases collected from Otto Leichtenstein,⁹⁰ from his own knowledge, and from European literature, tabulates the causes of death in American and European practice: 7 of these cases were caused by extra-exertion after operation; 3 from cyanosis and coma; 4 from spray injections; only 1 from syncope; and 2 from albuminoid sputa. He quotes the final remark of Leichtenstein: "Death or any serious symptoms are so rare that they ought not to have the least influence upon our estimate of this most benign and blessed operation." Bowditch states that there were only 7 deaths in this country (as far as he could ascertain), and 29, or four times as many, in Europe, although the operation has been done much more frequently here and for a much longer time. Does not this show that in this country, in following Bowditch's precepts of great care and deliberation, the operation has been more successful? He never ceased in his lectures and writings to caution us to suspend the withdrawal of fluid the moment the patient begins to suffer in breathing, even in the slightest degree. Of course there may have been other cases occurring in American practice of fatal results, of which no reports were made to Bowditch.

⁸⁹ Unpublished MSS., 1882.

⁹⁰ Deutsches Arch. für klin. Med., vol. xxv., 1880.

The author has carefully gone over Leichtenstein's collected cases, and he finds a number of deaths mentioned by other European authors which are not included in his list. (The reader is referred to the theses of Terrillon,⁹¹ Foucart,⁹² Foster,⁹³ Dieulafoy,⁹⁴ Mercier,⁹⁵ Pinault,⁹⁶ Wilson Fox,⁹⁷ and others.) Terrillon alone reports 6 deaths with symptoms of oedema of the lungs following thoracentesis. Leichtenstein does not mention any deaths from embolism, such as are quoted by Goquel, Chaillon, and Woillez. In his collection he gives only 1 death by syncope, whereas Dieulafoy comments upon 4 as found recorded by Trousseau and other French authorities. Toussaint's⁹⁸ statistical tables of 300 cases, collected from other sources, give 14 deaths. Wilson Fox collected between 30 and 40 deaths connected with thoracentesis. Besnier stated in 1876 that the mortality from pleurisy in the French hospitals had greatly increased since the practice of thoracentesis had been largely followed. It is difficult to account for this in the face of the statements made by so many of its innocuousness when properly guarded: it may be explained by the fact that suppurative pleurisies are often confounded with those of a fibro-serous nature and treated by simple aspiration. Many fatal cases of empyema are complicated with phthisis; formerly these were added to the mortality for phthisis; where paracentesis was performed upon them they were added to the pleurisy column. Bearing in mind that chronic pleurisies, serous and purulent, are frequently consecutive to diabetes, Bright's disease, chronic alcoholism, cirrhosis of the liver, and other organic diseases, patients die of the primary lesions, though they have been relieved of the secondary ones. These statistics may record the deaths as resulting from pleurisy, for which there was operative interference, instead of from the organic diseases.

⁹¹ Loc. cit.

⁹² Loc. cit.

⁹³ Clin. Obs.

⁹⁴ Loc. cit.

⁹⁵ Thèse de Paris, 1876.

⁹⁶ Ibid., 1855.

⁹⁷ Brit. Med. Journ., Dec., 1877.

⁹⁸ Thèse de Paris, 1878.

Formerly, when trocars and canulas of considerable diameters were used, only extreme necessity from peril to life made surgeons consent to operate. We claim that by capillary needles, gentle force, and protected points all the old objections are obviated. As Anstie says, there is no opposition to the modern operation by men who have fairly tried Bowditch's practice. Only theorists who are afraid of its imaginary results and men too timid to act hesitate to make use of it. We have discussed elsewhere (Purulent Pleurisy) the danger of admitting air into the pleural cavity, but we insist that in the close method, with capillary needles, there is no danger whatever of air entering. The puncture is so very small that it closes at once by the elasticity of the structure of the chest, just as the knuckle of the intestine in hernia closes after the needle has drawn gases and fluid out of it.

Another objection urged against puncture of the pleura in such cases is the possibility of perforating the lung by fine needles, thus letting air into the cavity and causing cough.⁹⁹ Marotte read a memoir on the subject to the Academy in 1872. He reported 4 cases, in all of which there were only temporary effects, no serious ones. Dieulafoy¹⁰⁰ says: "I have been witness to the puncturing of the lung several times, and I have never seen any accident supervene under any circumstances. I have thoroughly convinced myself that punctures performed with a No. 1 needle, diameter half a millimeter, are harmless, and experiments on animals have given me the same results." He even suggests aspirating a few grammes of blood from a congested lung in the first stage of pneumonia, and thus practising local bloodletting. The author has 3 times pricked the lung in aspirating—twice with a No. 2 needle, diameter 1 millimeter, where a few drops of blood were drawn into the instrument, and they did not even produce a cough or the slightest inconvenience. The third time was with a No. 4 needle (2 millimeters). From this puncture some air escaped into the pleura, and for a few days there was evidence of pneumothorax. It then disappeared entirely, the air being absorbed. The case was a circumscribed empyema, which entirely recovered.

⁹⁹ Allbutt, Quain's Dict. Med., 1883.

¹⁰⁰ Treatise on Pneumatic Aspiration, Eng. trans., p. 256.

It will be noted that throughout the discussion of this important subject liberal use has been made of a valuable communication specially prepared by Henry I. Bowditch for this purpose, and embodying the mature results of his study and experience of thoracentesis. It seems not only to establish conclusively the claim that to him, in conjunction with Wyman, is due the great credit of introducing the principle of aspiration, but also to how great an extent it was through his persevering and skilful advocacy and performance of the operation that it became so firmly established in America upon a true scientific basis.

Purulent Pleurisy.

DEFINITION.—Purulent pleurisy is that disease in which the pleura secretes pus instead of fibro-serous fluid, as in simple pleurisy.

SYNONYMS.—Pyothorax; Empyema; Suppurative pleurisy.

HISTORY.—The term empyema was applied originally to any internal collection of pus—[Greek: en] and [Greek: pyon]. It is now restricted to pus in the pleural sac. The ancients, from the time of Hippocrates, diagnosed and treated empyema by thoracentesis and pleurotomy. They were familiar with the fact that it would sometimes discharge through the bronchi and make an orifice through the walls of the chest, and discharge outwardly. Their views of its pathology and its connection with other forms of pleurisy were necessarily crude and indefinite. Of late years, owing to the aids given by exploratory punctures, purulent pleurisies have been thoroughly investigated. Townsend¹⁰¹ divided the disease into four varieties, all of which are from degenerations of acute serous pleurisies, from increase of intensity of the inflammatory phenomena, or from modification of the secretion of the serous membrane. More modern researches have shown that frequently such is the case, and that purulent pleurisies often succeed serous pleurisies. The liquid when first thrown out is serous and limpid in character, and afterward becomes cloudy, opaline, then more and more opaque and purulent, owing to the pus being freely secreted and mixing with the fibro-serous effusion. In a certain number of cases, however, the effused liquid has from the first the appearance and anatomical composition of purulent fluid—d'emblée purulente. This has been shown by autopsies in cases of women who died in childbed from suppurating pleurisies, and in persons attacked with pyogenic fever, not simply from deposits of pus, but where an inflammatory period, of longer or shorter duration, preceded the deposit.¹⁰² Dieulafoy¹⁰³ showed that in all effused liquids in the pleural sac there were present red globules and leucocytes.¹⁰⁴ Laboulbène¹⁰⁵ has established the fact that the exuded fluid in all pleurisies, even those apparently serous, contained, from the time of their formation, purulent globules. All cases, then, are historically purulent; but clinically serous and purulent pleurisies are distinct in their progress, termination, and treatment. Purulence is not always the sign of chronicity of pleural inflammation. It may, and does, show itself in many instances from the very commencement of the attack. Wilson Fox¹⁰⁶ shows there is but little natural tendency in serous effusions to undergo purulent transformations. He thinks in the vast majority of cases suppurative pleurisies are so at early periods of disease. He states the proportion of primary suppurative pleurisies as from 14 to 20 per cent. It is when the number of leucocytes, from the intensity of the inflammation or modification of the process, discolors the fluid and gives to it its distinctive properties, that we use the name of purulent pleurisy. Verliac¹⁰⁷ states that all chronic cases in infants become purulent.

¹⁰¹ Article "Empyema," Cyc. Prac. Med., vol. ii.

¹⁰² Pleurisie purulente, (Moutard-Martin), Paris, 1872.

¹⁰³ "De l'Examen histologique des Liquides, etc.," Soc. Méd. des Hôp., 1878.

¹⁰⁴ See section on Hemorrhagic Pleurisies.

¹⁰⁵ Traité d'Anatomie path., Paris, 1872.

¹⁰⁶ Brit. Med. Journ., Dec., 1877.

¹⁰⁷ Thèse de Paris, 1865.

ETIOLOGY.—The causes of purulent pleurisies are divided into local or traumatic, which are well ascertained and defined; and the general, the action of which is uncertain. Among the first are wounds of the chest, fractures or caries of the ribs, phlegmonous abscesses of the walls of the chest, effusions of blood, pathological liquids, pulmonary gangrene, rupture of tubercular cavities, and other injuries from adjacent organs, especially of those where pus is discharged into the cavity, for the presence of pus engenders pus. Thoracentesis has been accused of converting serous into purulent pleurisies by the admission of air into the pleural cavity. If the atmosphere admitted is contaminated by germs, we must acknowledge that such a result is possible. By the older methods, previous to the adoption of Reybard's protected canula, such a result may have been produced. We can thus, in a measure at least, account for the great mortality in cases operated upon. But since the adoption of the protected orifices of the small aspirating trocar of Wyman and the capillary perforating needles of Dieulafoy, we question whether, with such an insignificant puncture and the complete exclusion of air, thoracentesis can be justly accused of producing such serious mischief. Trousseau¹⁰⁸ earnestly denied such a deleterious effect of the operation in his day. We have now not only the results obtained by Demarquay, Leconte, and Manotte of injecting air into the pleural cavities of inferior animals, but we have the bold experiments of Matice, who, convinced that air could not have any bad influence, actually had the audacity to perform the operation a number of times, allowing the air to enter freely through the canula. From numerous observations there resulted the fact, unsuspected by many, that air, penetrating freely to replace the liquid extracted, never gave rise to purulence in pleurisy; that, owing to its rapid absorption, it did not in the least interfere with the expansion of the lungs; in short, that it produced no accident whatever. While admitting the force of Matice's conclusions, we think it preferable to avoid the possibility of doing harm.

¹⁰⁸ Loc. cit.

GENERAL CAUSES.—We have shown that secondary pleurisies frequently occur in the course of convalescence from eruptive diseases, measles, small-pox, and especially scarlet fever, and that they are purulent in their nature. The puerperal condition predisposes to suppurative inflammations of the serous membranes, and pleurisies in lying-in women are almost always purulent. In rheumatism, gout, and delirium tremens, and albuminuria as a rule, the pleuritic effusion is serous. It is purulent in persons suffering from severe injuries and among men exhausted by over-work or by alcoholic excesses, or protracted obscure diseases, such as typhoid fever and pyæmia. Analyses of the cases in which purulent transformation has occurred show that tubercles of the lung have only a minor influence in its production—only 34 per cent. of the whole number. Attimont's¹⁰⁹ observations were founded upon 130 cases, 80 of which recovered; of the remaining 50 that died, he found tubercle in only 9 cases. Sometimes malhygienic conditions and insufficient alimentation may account for them. Men are more subject to this disease than women in the proportion of 8 to 1,¹¹⁰ and young children oftener suffer from purulent pleurisy than adults. It is not easy to explain the transformation of serum into pus in pleuritic effusions that have existed for some time where there have been no grave symptoms. Imprudent exposure, affecting the general health, may thus produce disastrous results. This occurs so frequently that purulent pleurisies are generally called chronic pleurisies. There are cases where neither local nor general conditions explain the transformation of serous into purulent effusions in the chest.

¹⁰⁹ Thèse de Paris, 1869.

¹¹⁰ E. Moutard-Martin.

PATHOLOGICAL ANATOMY.—This is shown by an examination of the effused liquid, the different solid detritus that it contains, the false membranes, the pleura, the lung, and the thoracic wall itself. The liquid effused is purulent in character. It contains a greater or less number of leucocytes, some red globules, and voluminous granular cells, besides crystals of the fatty acids and plates of cholesterin. The pus is mixed with the serosity in varying quantities. The liquid may be slightly opaline or greenish-yellow, and sometimes gray. It may be thin or thick, with heavy flocculi, so as to pass with difficulty through a canula. The liquid is, ordinarily, inodorous, but it may be strong, and even fetid, where it has been in contact with air. In very few cases of old standing can the pus be regarded as active, the corpuscles being, as a rule, dead or having undergone fatty degeneration. Active suppuration is also more readily set up in a pleura which has already yielded pus.

Purulent effusions, independent of contact with air, may become in a short time the seat of putrid transformations. False membranes undergo alterations which produce fetid gases. The air, with its germs, its humidity, and heat, the three grand factors in putrefaction, is thrown in contact with substances of a putrescible composition. Marshall¹¹¹ holds that sero-fibrinous effusions appear to have a greater tendency to quick decomposition when air is admitted into the pleural sac than the sero-purulent or purulent products. Pus, he considers, is more stable and less inclined to rapid putrefaction than sero-albuminous fluid. In quantity it varies from a very small number of grammes to five or even six liters. By examining the fluid first drawn out we can predict, by the number of leucocytes present, whether the pleurisy will continue to be serous or will become purulent. If subjected to the influence of ammonia, it will become thready, just as happens when pus is suspended in water, if the fluid contains many of these pus-elements. The purulent fluid may fill the whole or occupy but a small part of the cavity, or again the interlobular spaces only may contain the fluid, the cavity itself being empty. False membranes are almost constantly present and adherent to the parietal or pulmonary pleura; we find them also floating in the liquid. These false membranes may be more or less voluminous. The flocculi, which may be as large as an egg, undergo transformation when air is admitted, and become horribly fetid. They may give rise to septicæmic symptoms. When we see these enormous masses in the cavity, and are unable to get rid of them by suction, we do not wonder that their presence should poison the patient and the case become incurable. Pleurotomy is the only effective mode of getting rid of these dangerous masses, with sometimes gangrenous portions of pleural or lung-tissue. These false membranes frequently form pouches and divisions for isolated quantities of fluid. The false membranes are partly adherent and partly free, especially in cases where there are pulmonary or thoracic fistula. These false membranes differ in acute purulent pleurisies from those found in pleurisies of long standing. They are but feebly adherent to the pleura, and have a slight rose coloration. In old pleurisies the false membranes are of greater density, sometimes from 6 to 8 mm. in thickness. They are more adherent, and cannot be separated, and have a grayish color. The physical state and position of the lung and disposition of the adjoining structures are very similar to what they are in serous effusions. In but few cases do the false membranes envelop the whole of the lung. They pass over one part, and on to the costal pleura. The pulmonary tissue is condensed, sometimes absolutely impermeable to air, so that it will actually sink when dropped in water, being in a state of atelectasis. In cases of shorter duration it is found crepitant throughout its structure. Brouardet¹¹² called attention to the inflammation in the under-pleural cellular tissue, as well as in the interlobular connective tissue, forming interstitial pneumonia, which determines condensation of this tissue and its retraction after the manner of cicatrices, and afterward its inextensibility. These explain the retraction of the thoracic walls and the narrowing of the chest.

¹¹¹ Loc. cit.

¹¹² "Interstitielle Pneumonie," Soc. Méd. des Hôp. Bullétin, 1872.

The most serious complication of this disease is the pleuro-bronchial fistula¹¹³ by which the fluid escapes through the lung. The firm adhesions between the lungs and walls, forming enclosed pockets, contribute in no small degree to the incurability of purulent pleurisy. These pockets cannot be emptied thoroughly, nor can the washings be made to penetrate them. The purulent secretion exercises a destructive action over the tissues surrounding it, as well as upon the viscera and walls of the chest: the soft parts become inflamed and abscesses form; the intercostal muscles suffer atrophy and undergo fatty degeneration, external openings occurring from ulceration. The latter are found less frequently than pleuro-bronchial fistula. This external perforation is habitually in front, in the upper intercostal spaces, which, near the sternum, are very wide and not protected by external intercostal muscles. The fifth intercostal is the most frequent locality. There may be one or several openings. They may be caused by the pus ulcerating through the parietal walls, or abscesses may be produced in the walls and burst externally. Exceptionally, the emptying of the liquid is by ulceration of the diaphragm into the abdomen, causing fatal peritonitis. Some years since the author saw, in consultation, a patient where the autopsy proved this condition. Rare cases have been reported where the fluid escaped into the pericardium, into the mediastinum, and into the opposite pleural cavity (Fernet¹¹⁴). Bouveret¹¹⁵ relates a number of cases in which the discharge of pus took place through such unusual channels as the oesophagus, the stomach, the intestines, and the pelvis of kidneys; also where the pus perforated the posterior cul-de-sac of the pleura and appeared in the posterior walls of the abdomen. In the last cases, he states, it may point in the groin, the lumbar region, the buttocks, or even in the thigh.

¹¹³ See section on Pneumothorax.

¹¹⁴ Loc. cit.

¹¹⁵ Journal de Méd., Dec. 16, 1882; N.Y. Med. Rec., March, 1883.

SYMPTOMS.—In a large number of cases of purulent pleurisy the general symptoms do not differ materially from those of fibro-serous pleurisies. Sometimes, however, they do. This is according to whether they are acute purulent or chronic purulent pleurisies.

In acute purulent pleurisy the disease commences in the same way as the ordinary acute fibro-serous pleurisy. Indeed, the first effusion is ordinarily serous in appearance, and afterward it becomes purulent. We have the initial chilliness more or less marked, accompanied by the characteristic pain in the side and dry cough, the fever keeping up, even as high as 103° to 104° F.; and soon the signs of an effusion supervene. In a few days, ordinarily, in acute fibro-serous pleurisies, the febrile exacerbation disappears. Graves¹¹⁶ states that the extent of a pleurisy is not augmented after twenty-four hours. In acute purulent pleurisy the fever persists in spite of treatment; the effusion increases, sometimes less rapidly than in the serous variety, but in a continuous manner. If thoracentesis is performed about the eighth or tenth day, we notice that the fluid is opaline and contains a large quantity of pus. After this the fluid is reproduced, and as it forms the fever continues; the skin is hot and dry, the appetite impaired, and sweats appear during the night. In examining carefully the thoracic walls we find oedema of the diseased side. Later on there will probably be oedema of the lower extremities.