Volume 3 — DISEASES OF THE RESPIRATORY SYSTEM. (continued 23)

The next year (1844) Trousseau read another memoir on the same subject. He used the trocar with Reybard's gold-beater's skin at the orifice. While he was popularizing the operation and laying down the indications which called for its performance, several English observers³⁰⁵ were turning their attention in the same direction. The paper by Hughes and Cock³⁰⁶ showed that they had been operating in Guy's Hospital for four or five years, and with great success, using a simple trocar and canula of the diameter of one-twelfth of an inch. They imputed their success to the small size of the instrument used, which allowed the fluid to flow slowly and never permitted air to enter the chest during respiration. They gave a tabular account of 20 operations. Hamilton Roe³⁰⁷ at that time was operating successfully with the trocar. Roe's paper was replete with information and with practical suggestions. He tabulated 39 cases where syncope (one great objection which had been urged against the operation) did not occur even once. He disproved another popular objection, that there was great danger of the admission of air into the pleural sac. Owing to the size of his trocar, a considerable quantity of air entered the pleura during his operations, and in some of them so freely as to produce all the physical signs of pneumothorax, but in none of them did it produce any permanently evil effects. In one instance only was even temporary inconvenience caused. When the fluid was ascertained by the exploring-needle to be purulent, he advised the immediate performance of the operation. In acute cases he recommended a delay of three weeks as the time for testing nature's powers of absorbing the fluid. He advised the closing of the orifice after operation. This author gave an account of his 24 cases. He concluded by stating that the operation is not more dangerous than any other which is performed upon the human body, and that the evil consequences supposed to attend it are imaginary rather than real, inasmuch as it was only fatal in 1 out of 24 cases, and does not produce even temporary inconvenience. Thompson in the same year justly condemns the practice of leaving the canula in the orifice—a proceeding he considers as capable of converting a serous into a purulent fluid. In 1848,³⁰⁸ at the request of H. I. Bowditch of Boston, J. M. Warren operated by the usual method recommended in the works on surgery. Partial relief was obtained, but the amount of suffering undergone by the patient during the operation, and the fact that an aperture was usually left open by this method, decided Bowditch that he would never recommend it unless under very urgent circumstances. Soon after this, Stone operated with the common trocar and canula, by the advice, in consultation, of Bowditch. In 1849, Bowditch saw another death resulting from effusion where he had advised the operation, but the consulting surgeon would not consent.

³⁰⁵ London Medical Gazette, 1847.

³⁰⁶ Guy's Hospital Reports, vol. ii., 1844.

³⁰⁷ London Lancet, 1844, copied into Amer. Journal Med. Sciences, Oct., 1845.

³⁰⁸ Bowditch, Amer. Journal Med. Sciences, April, 1852.

To illustrate the opposition Bowditch found in the United States, he quotes³⁰⁹ a remark of W. W. Gerhard, the distinguished auscultator of Philadelphia, "that he should be as willing to have a bullet shot through his chest as to have paracentesis performed on one of his patients."

³⁰⁹ Unpublished MS., 1882.

About 1850,³¹⁰ Bowditch saw the paper published by Hughes and Cock, and it determined him in future to try the trocar they had used or something like it.³¹¹ "Fortunately, a few weeks before (April 10, 1850) M. Wyman had a sudden and severe case with large effusion and intense orthopnoea. Death was threatening, yet Wyman felt called upon by public opinion, medical and lay, to summon a prominent practitioner from Boston. They both agreed that the patient was in extreme danger, and Wyman urged tapping with an exploring-trocar. It was decided to postpone surgical interference until next day, when another meeting would be held, the consulting physician returning to Boston to advise with the ablest men of the faculty and render their decision the following forenoon. That was done, and it was found that no prominent practitioner in Boston would consent to the idea of tapping. Nevertheless, the oppression was so severe, and death so imminent unless the patient could be relieved by some means, that the country physician agreed to Wyman's proposal that an exploring-trocar should be introduced. The fluid flowed out imperfectly, but some relief and no harm resulted" (Bowditch). Two days after this, Wyman operated again with the exploring-trocar and a suction-pump. Wyman³¹² demonstrated to John Homans on the 23d of February, 1850, that the chest could be safely punctured with his instrument and the serum evacuated in acute pleurisy.

³¹⁰ Ibid.

³¹¹ Ibid.

³¹² Private letter to author, 1883.

Although suction, as we have shown, was used as far back, probably, as Galen (second century), by Scultetus in 1662, and was in use in 1707, as shown in Anel's work, in 1742 in Laurence Heister's work, by Ludwig and Lehren in 1768, again in 1796 (Benj. Bell), yet it had been abandoned and lost sight of, with the exception of Laennec's suggestion of its application in the form of a cupping-glass over the orifice of puncture, until Guérin (1841) used it. The author followed Trousseau's clinics in 1849 and 1850, and saw him repeatedly operate with Reybard's canula guarded by gold-beater's skin, but never with Guérin's suction apparatus. The French seemed to have lost sight of it until 1865, when Guérin, at the French Academy, recalled attention to it, showing how he aspirated liquids, instead of allowing them to flow outward after the puncture. His apparatus consisted of a curved trocar, the end of which was made tapering and sharp enough to puncture the thorax through the skin and the muscles; of a pump, the piston of which was perfectly adjusted to produce a vacuum; and of an adjuster at the extremity of the pump, consisting of a stopcock which enabled the operator alternately, without removing the instrument, to aspirate the fluid and evacuate it into a basin. Wyman's pump, invented in 1850, was arranged very much in the same way, only it contained valves which were opened and closed by the movement of the barrel, to enable the operator to suck out the fluid and then force it out of the pump. After the operation the skin, being drawn over and closing the orifice, acted as a valve which prevented at the same time the entrance of air and the escape of fluid. Dieulafoy, in November, 1869, invented his aspirator, which is based upon the same principles as those used by Guérin (1841) and by Wyman and Bowditch (1850)—namely, pneumatic aspiration, which the vacuum of the air-pump supplies. Guérin's instrument was large and costly. Wyman's trocar was of a very small diameter, being only one-twenty-fourth of an inch, and the canula but little larger. This was attached, at first, directly to the aspirating syringe, afterward by means of a flexible tube. With this apparatus Wyman demonstrated that tissues could be safely punctured and cavities evacuated without the admission of atmospheric air, that the wound, causing but a drop or two of blood, was followed by no inflammation, and that no dressing was required. The smallest trocar used previously to Wyman's was that of Roe, which was one-twelfth of an inch in diameter. From 1850, Bowditch appreciated the great value of Wyman's invention, as shown in one of the first operations on a patient of his. He adopted and practised it. His position as professor of diseases of the chest, and his great reputation in that branch, gave him an extensive practice and brought him many cases of pleurisy. He met with great opposition from the surgeons and prominent practitioners of the country, but his results were so favorable that he forced an unwilling and an unbelieving profession to accept, as he expresses it, "the beautiful thought of Wyman of thoracentesis or aspiration with a fine needle." "I considered the operation so simple, and yet so effectual, and never harmful, that I deemed it my duty to print cases illustrative of its value." Bowditch had been for eight or ten years endeavoring to get some effective plan of opening the chest without risk. He readily caught at Wyman's plan, and he operated so frequently and successfully as to demonstrate its value to the medical public both of this country and of Europe. As he states,³¹³ it was, in fact, what he had been for years longing for—viz. a simple and painless, or almost painless, operation for removing fluids from the thorax—one that could be done without danger and leave no open wound. Bowditch relates³¹⁴ that when he visited Europe, nine years after his first publication of cases, he showed the instrument in England, Scotland, France, and Germany, and that he met with very indifferent recognition of its value. Only W. T. Gardner of Edinburgh and Budd of London seemed to appreciate the plan. They had instruments made after the American pattern. All others had no faith in the operation. In Paris his old master, Louis, smiled incredulously at his enthusiasm for it and doubted its necessity. At Vienna Skoda turned with apparent scorn and left the room as Bowditch was demonstrating its employment. The Parisian authors, Woillez, Peter, Moutard-Martin, Peyrot, and others, do not even mention Bowditch, but give Trousseau alone the credit of popularizing thoracentesis.

³¹³ Unpublished MSS., 1883.

³¹⁴ Ibid.

Trousseau's first publication was in 1843, and yet in 1859 there was no general adoption of the operation, nor was there until 1869, when Dieulafoy rediscovered Wyman's wonderful improvement of the application of negative force to draw out fluids from the chest.

In estimating the value of the substitution of aspiration for the trocar-and-canula method, we must bear in mind that with the latter there was danger of the introduction of air into the thoracic cavity, of the production of fistulous orifices, and the too rapid, and therefore dangerous, evacuation of the fluid. Moreover, there are cases where the trocar and canula is not effectual, although the quantity effused be considerable—where, indeed, the fluid cannot flow out, although the canula be pushed in actual contact with the fluid. The explanation of this is now understood. The fluid is kept in the pleural sac by a negative pressure of from 4 to 5 inches of water (Stone), 6 millimeters mercury (Donders), 5 millimeters mercury (M. Foster), exercised by the lung in its elastic contraction, and by the passive tension of the arched diaphragm. The fluid has no tendency to flow out, and this suctional pulmonary force must be antagonized by an external suctional force, that of aspiration, before the fluid can be withdrawn.

The invention can best be appreciated from the standpoint reached by modern investigations of the physics of the living mechanism of the chest. The principle of applying suctional force in pleurisy is in imitation of nature's gentle methods in connection with respiration. We have shown that most of the dangers connected with aspiration are caused by not taking into consideration the adjustment of lung-tension with thoracic resilience, and consequently of using too great negative force and withdrawing the fluid too rapidly and in too great quantity.

Thoracentesis by aspiration, with greater or less force as may be necessary, is now placed upon a scientific basis. We claim that this modern method is an American invention—that Morrill Wyman was the discoverer and H. I. Bowditch the utilizer of the discovery. As such they may be regarded as benefactors of the human race.

It is extraordinary that Trousseau never alluded to Bowditch's operations, and that Dieulafoy should never have heard of them. Fraentzel acknowledges that Bowditch was the first to introduce aspiration into practice. The Germans have been very slow in appreciating its value. Fraentzel states that he did not use it until 1871, and that it was not until 1879 that it had in Germany any ardent supporters. Bowditch³¹⁵ has now operated 387 times upon 246 patients without any unpleasant result.³¹⁶ The distinctive points in Dieulafoy's ingenious modification of the aspirator are that the needles are very fine, even one-half of a millimeter in diameter; that the barrel of the exhausting pump is of glass; that there is a pre-existing vacuum; that we are not compelled to jar the side of the patient by the process of pumping, and moreover by turning the cock we produce at once a vacuum in the needle itself, and know with certainty the moment the fluid is reached, and can see it flow through the glass index in the tubing, even if it be in drops. We can judge of the nature of the fluid, whether it be serum, pus, or blood. The minuteness of the needle is a great cause of safety, because it allows the fluid to flow so gradually that the lung has time to expand slowly. We can in an instant arrest the flow of the fluid by turning the stopcock, and if necessary by drawing out the needle. By giving the needle a downward direction after it enters the cavity, we prevent the point from pricking the lung. So small an orifice is made that even if the needle does touch the lung, there is no danger, for the orifice closes over at once. As Dieulafoy claims, "the fineness of the needle guarantees the harmlessness of the puncture." Castraux's concealed point (invented in 1873), and Fitch's (of Nova Scotia) protected canula (invented in 1873), are valuable additions to the aspirator-needle. These dome-trocars, as they are called, prevent the possibility of injuring the lung, for the sharp-pointed needle, after it has penetrated the pleural cavity, is at once, by a slight movement, converted into a blunt-pointed needle with an orifice near the end. With these very fine needles the force is sufficient to draw up the thickest fluids. We are compelled to admit that Dieulafoy's instrument is a great advance on any other that has been invented. Its simplicity, its easy application, its safety, have rendered paracentesis a harmless operation and one of great value in serous effusions. While Guérin and Wyman may both claim priority of invention, all must admit that Dieulafoy has improved upon their ideas and given us a beautiful and effective instrument. There have been proposed, since Dieulafoy showed his instrument in 1869, no less than forty other aspirators, modifications in form or dimensions of his apparatus. Of these, to us the most valuable is Potain's bottle aspirator, with which aspiration can be so easily and effectually employed. It is simple and cheap. An india-rubber cork accurately fitting a strong bottle is perforated for two tubes each having a stopcock. One of the tubes fits on the end at the exit in the basin, and the other is adapted to an aspirating syringe.

³¹⁵ London Lancet, vol. ii., 1879.

³¹⁶ Letter to author, 1883.

One of the most important of the improvements to the aspirator-canula is the addition—first suggested in 1858 by Charles Thompson,³¹⁷ and afterward adopted by Potain, Powell, and Fraentzel—of a lateral tube for the outflow connected with the main canula through which the trocar passes. By this improvement, in case the canula is clogged up, the trocar can be pushed down to remove the obstruction without danger.

³¹⁷ Med. Times and Gazette, 1858.

The principle of aspiration is now well established, and the indications for its use are becoming more defined and more accurate. New applications as a means of diagnosis, as well as of treatment, daily render it more valuable.

To guard against the dangers shown by modern experience to be sometimes attendant upon the operation of aspirating the pleura (see Dangers of Thoracentesis), it is now generally admitted that the removal of the contents of the chest should be slow and gradual; and that, ordinarily, it is safest at one operation to remove only a portion of the effused liquid. Our object should be to remove pressure and allow nature by absorption to take away the remainder, for positive pressure is an urgent indication for thoracentesis. It is therefore of primary importance to properly estimate the quantity present, and thus to test the intra-thoracic pressure. Great care and caution must be used, because if we extract too much the operation may be followed by serious results.³¹⁸ Large-sized canulæ should never be used, for fear of too rapid withdrawal of fluid. It has been demonstrated that even with a capillary perforated needle we can exercise more negative pressure than is safe, especially toward the close of the operation, when there supervenes a negative pressure exerted by the fluid remaining in the pleural cavity. It is from these well-known facts that we recognize the great value of Potain's ingenious addition to the aspirator of a manometer of extreme simplicity, a kind of barometer or cuvette, which is placed along the tube which withdraws the fluid. If we are not satisfied with this new safety improvement of the aspirator, we may adopt Douglass Powell's suggestion (On Consumption, etc.) of fitting into the bottle a pressure-gauge, so as to know at any moment what degree of aspiration is being used.

³¹⁸ Trans. de l'Assoc. pour l'Adv. des Sciences, 6th Session, 1877.

The syphon method has been of late years very extensively used, especially by Southey, W. H. Stone, and Garland, A. T. H. Waters, Wilks, Oxley, and habitually by Douglass Powell. It is a feeble aspirating force, which has very decided advantages. It is effective, and acts slowly and uninterruptedly with a gentle and uniform negative pressure. Its action allows the lung gradually to expand and the displaced organs slowly to resume their normal position. It thus in many cases furnishes us with a safe means of thoracentesis. (See Surgical Treatment, in Pleurisy.)

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