Paracentesis thoracis as a therapeutic agent : introduction to a discussion in the Section of Pharmacology and Therapeutics at the Fifty-second Annual Meeting of the British Medical Association / by W. Henry White.

  • White, William Henry.
Date:
[1884]
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Licence: Public Domain Mark

Credit: Paracentesis thoracis as a therapeutic agent : introduction to a discussion in the Section of Pharmacology and Therapeutics at the Fifty-second Annual Meeting of the British Medical Association / by W. Henry White. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    two-thirds with the posterior third of the chest-wall. In order to find the eighth intercostal space, he directs that the chest he marked where the angle of the scapula is ordinarily situated when the arm is by the side and again when the arm has been raised above the head. It a line be drawn between these two points, the desired site corresponds to a place one inch below the middle of this line. Due regard being had to the position of the various organs, and to the conditions peculiar to the individual case, which may require special consideration, I prefer to operate in the sixth interspace upon the right side, and in the seventh on the left side, in the axillary region? There is less danger of failure to enter the chest from the thickened pleura;, or of interference with the cannula by fibrinous deposit here, than in the site at the angle of the scapula. In this position there is less likelihood of detaching the inflamed and thickened pleura, and of pushing it before the instrument without penetration, and consequent failure to obtain fluid from a full pleural cavity, as not seldom happens; and, besides, there is no difficulty in evacuating the exudation, seeing that this position is sufficiently low for the purposes of withdrawal of the fluid, without being so low as to become interfered with by the elevation of the diaphragm when the pressure is reduced. Moreover, the risk of striking the lung is not so great in the axilla as in the subscapular region. Empyema, or pus in the pleural cavity, is a much more serious condition than serum, and requires different treatment, seeing that it is necessary to remove all the purulent fluid ; whereas in serous effu- sion the complete evacuation of the cavity is to be deprecated. Although sero-fibrinous exudations do, no doubt, undergo spontaneous decomposition, accompanied by all the usual septic symptoms, yet, on the other hand, we may regard it as certain that the operation of paracentesis thoracis not unfrequently changes a serous effusion into an empyema. In many such cases it may be argued that it would have become thus converted in any case. It is comparatively rare for a serous effusion to be transformed into pus by its non-removal. The explanation of the gravity of purulent effusion is that, if it be allowed to remain in the chest, disastrous consequences happen. Either the patient will die of exhaustion, or of syncope ; or, if he should escape the more immediate consequences, he will still have to run the risk of as great, if not greater dangers in the future. These are due, in a large measure, to the adhesions formed, binding down the lung and preventing expansion, when it is no longer compressed. Again, pul- monary and thoracic fistula; may form, and the chest, greatly dis- torted, still contains a pus-secreting cavity which cannot be com- pletely obliterated as the ribs have probably fallen in, the lung has expanded and the diaphragm has risen towards the chest as much as is possible, but not sufficiently to allow adhesions to form all over the surface of the pleura;. Therefore, the patient with a discharging fistula is liable, after some time, to succumb to albuminoid degenera- tion of the organs essential to life. Although it is admitted that pus in the pleura has been in rare cases absorbed, yet the dangers in- cidental to the condition, even where this has taken place,” are so great that we must not count upon such an occurrence. For the caseous residue left behind, after absorption, is liable to give rise to tuberculosis at any time. As soon as we know that pus is contained in the pleura, arrange- ments should bo made foi its evacuation i for the longer pus remains in the chest, the less the likelihood of a satisfactory issue. Pus may make its way either through the soddoned lung or through tlieparietes of the chest, but although cases recover after the occurrence of such the patient is exposed to grave risks, which should, if possible bo averted by early treatment, and especially as these spontaneous open- ings do not rescue the patient from subsequent operative interference.