CHAPTER LII

DIAGNOSIS AND PROGNOSIS OF PLEURAL EFFUSION IN PULMONARY INVALIDS

GREAT variations are observed in the course of pleurisies developing among pulmonary invalids. The fever which is often present in the beginning may not continue longer than a week or ten days, but in some cases the temperature may remain elevated for prolonged periods, and be associated with other symptoms of constitutional disturbance, more or less profound, according to the bacterial nature of the effusion. As a rule, the manifestations of cardiac and respiratory embarrassment correspond approximately to the size of the exudate. It is surprising, however, to note occasionally considerable dyspnea with temperature elevation and a rapid pulse in comparatively small effusions. Comment has been made upon the fact that astonishingly large pleural exudates may exist without the slightest symptoms of their presence. The effusion may remain of small or moderate size for a short period and disappear, or it may persist indefinitely without perceptible increase in volume.

While the effusion in many cases is absorbed with varying degrees of rapidity it sometimes is found to increase progressively in size, the volume of contained liquid being so great as to demand removal. In such cases, particularly among pulmonary invalids, there is considerable likelihood of reaccumulation, even if the effusion be serous in character. I have never seen sudden death from pulmonary embolism in connection with pleural effusions, although instances of this have been reported, especially when the heart has been greatly dislocated. In one instance, however, a sudden fatal termination took place twelve hours after the withdrawal of a large effusion.

From what has been stated with reference to the physical signs, it is conceivable that errors of diagnosis should occur, only in exceptional cases, provided there be conducted an intelligent chest examination. Non-recognition of pleuritic complications is occasioned in the majority of instances, not because of any absence of readily available data for this purpose, but through failure to apply the established principles of diagnosis to the evidence presented. In this connection it may be stated that the frequent unfortunate results of treatment are sometimes due not so much to the lack of adequate therapeutic measures, as to the misconception of their rational scope in individual instances. It may be stated parenthetically that, unlike many diseases of the lungs, the primary obstacles to success in the management of pleural complications in pulmonary tuberculosis may not be ascribed invariably to delayed diagnosis. It is a humiliating reproach to state that not infrequently the interests of the patient would be better subserved if the condition remained unrecognized. The justice of this reflection upon the medical and surgical management, in some cases, will be later explained. While early diagnosis must be encouraged through detailed examinations of the chest, the essential considerations relate to a correct interpretation of the prognostic significance of the effusion in individual cases, and an intelligent appreciation of the rationale of remedial measures. Let

it be emphasized that the existence of pulmonary tuberculosis very materially modifies the consideration of those surgical methods which may be styled operations of expediency. At the same time the consumptive, no matter how hopeless his condition, is entitled, by virtue of every instinct of humanity to the fullest measure of surgical aid in conditions involving so-called operations of necessity. My conclusions are derived from the errors as well as the successes incident to personal experience. More of real benefit sometimes accrues from an opportunity to witness the deplorable results of mistaken judgment than from the elated observation of a successful issue following a fortunate choice of procedure.

In support of views to be presented, a few illustrative cases will be presently introduced.

The diagnosis of pleural effusion is too frequently dependent upon an employment of the aspirating needle. A provisional diagnosis having been established by the physical signs, verification is commonly attempted through recourse to exploratory puncture. This procedure, though often affording positive results, does not invariably yield information of a reliable nature, owing to errors of technic in inexperienced hands. I have known numerous instances of moderate effusion, particularly of circumscribed empyema, to remain unconfirmed by aspiration.

The tendency to withdraw the pleural exudate is especially strong among young practitioners. So far as the diagnosis per se is concerned, the use of the aspirating needle by trained clinicians affords a most trustworthy and reliable aid to accuracy of conclusions. In the majority of cases, however, a rigid and painstaking examination of the entire chest is sufficient to enable a skilful clinician to arrive at an accurate diagnosis. Attention has been called, however, to the peculiar difficulties sometimes involved in the physical examination of pulmonary invalids with complicating pleural effusions. For years it has been customary for writers to emphasize the variation in the level of percussion dulness in pleural effusions upon change in the position of the patient. While I am not prepared to deny with positiveness that some slight modification of the level of the effusion may be detected in exceptional cases when the patient assumes a different position, my own experience is to the effect that such mobility of percussion outlines, as a rule, is exceedingly slight, and rarely constitutes a factor of especial diagnostic value. It appears unwise to lay stress upon a technical point which is often incapable of detection even by expert examiners, for confusion and discouragement must unavoidably result in the minds of students who attempt to recognize the existence of so slight and inconstant a variation of percussion boundaries. As a matter of fact, the only practical value attaching to change in the level of the effusion simultaneously with differing postures, is found in cases of pneumopyothorax, in which there is not only liquid, but air, in the pleural cavity. In these cases the change is most pronounced and should be capable of recognition by the veriest amateur in physical examinations. There are other interesting features in connection with the level of the liquid in the latter affection, which will be discussed in their appropriate place.

The subjective symptoms in pleural effusions, though decidedly unreliable as diagnostic features, are nevertheless possessed in some instances of more or less clinical importance. The gradual development, the moderate fever, slight cough, and scanty, mucoid expecto

ration are distinctly suggestive of pleural effusion in contradistinction to the sudden onset, the chill, abrupt elevation of temperature, distressing cough, and tenacious or blood-streaked expectoration characteristic of pneumonia. The dyspnea is almost always accentuated to a greater degree in pneumonia than in pleural effusion. I have been in the habit of attaching considerable diagnostic significance to the presence of herpes labialis in pneumonia. Although by no means pathognomonic of this condition, it is, at least, quite unusual in acute pleurisies. The existence of leukocytosis in doubtful cases is, of course, suggestive of pneumonia.

The prognosis of pleural effusions in consumptives depends primarily upon the extent and degree of activity of the tuberculous process, and conforms to a great extent to the principles of prognosis enumerated with reference to the pulmonary infection. In addition to this the outlook for the patient depends largely upon the cause and nature of the pleurisy and the character of the therapeutic management. Many effusions may remain unresolved for years, and yet not seriously affect the welfare of the invalid. Other pleurisies, by virtue of their absorption, not infrequently produce a disastrous influence upon the general condition. Among pulmonary invalids I have noted that the development of moderate pleural effusions has sometimes been followed by most gratifying results, which had previously been impossible of attainment. The foregoing preliminary considerations will be more fully elaborated in connection with treatment.

Serous effusions are the only ones likely to become absorbed or not to reaccumulate after aspiration. Exudates which gradually assume a greater cloudiness with increasing number of leukocytes often assume eventually the characteristics of a purulent effusion, and become subject to the principles of prognosis and treatment applicable to empyema.

While serous effusions are much more benign than those which are purulent, the latter variety in many phthisical patients apparently exercises no more detrimental effect than the distinctly serous exudates. This statement applies exclusively to sterile effusions unattended by septic absorption. The prognosis varies materially, according to the specific microorganism present in the exudate, the degree of constitutional disturbance, and the nature of subsequent treatment.

The observations of Courmont concerning the seroprognosis of tuberculous pleurisies are extremely interesting. He has shown that the degree of agglutinating power of the blood in typhoid fever is comparatively small in the presence of the more virulent infections, and large in proportion to the resistance of the individual. Griffon, a few years later, demonstrated that the agglutinating power of the blood in pneumonia is greatest at the time of recovery, and almost absent in hopeless cases. Courmont and Arloing have reported that the maximum agglutination of the blood is greater, as a rule, in benign cases of pulmonary tuberculosis, and that it is slight in the desperate forms. Courmont has devoted a vast amount of study to the agglutinating power of the blood-serum and of the serous effusions in tuberculous and non-tuberculous pleurisies. He found that the non-tuberculous exudates do not agglutinate the bacillus of Koch, and that the greater part of the tuberculous fluids agglutinate tubercle bacilli in the proportion of one to five up to one to twenty. His more recent conclusions are to the effect that the prognosis of tuberculous exudates is favorable in proportion to a

high agglutinating power of the effusion, and becomes more grave with a diminution or absence of the reaction. The maximum agglutination took place as the patients proceeded toward recovery, while a diminution was found to occur as the condition became more desperate. His conclusions are as follows:

"1. The mortality is about 25 per cent. in cases the pleural effusion of which has agglutinating power, and 75 per cent., on the contrary, in those in which the fluid has no agglutinating power.

"2. Among patients with an agglutinating effusion the number of recoveries is large in proportion as the agglutination is high.

"3. One can observe the agglutinating power of the effusion increase in proportion as the case progresses to recovery, and, on the contrary, diminish in those patients in whom the termination is near."

CHAPTER LIII

TREATMENT OF SEROUS EFFUSION

To avoid confusion it is well to consider separately the management of serous and purulent effusions among phthisical patients. The treatment of serous exudates must necessarily vary in accordance with the strength and vigor of the invalid, the chronicity of the effusion, the degree of pain, the constitutional disturbance, and the extent of respiratory and cardiac embarrassment. There is no arbitrary system of management which is rationally applicable to all individuals. Each case should be regarded as a law unto itself, the therapeutic indications being determined upon the merits of the patient, as well as the effusion. Irrespective of considerations pertaining to the exudate, the course of procedure must be modified in accordance with the extent and activity of tuberculous change and the apparent effect of the effusion upon the general condition. The primary consideration relates to a determination as to whether or not the pleural involvement is doing actual harm by virtue of the pain, discomfort, fever, dyspnea, and cardiac embarrassment, or producing, for the time being, relief of cough, severe pleuritic pain, or tendency to hemorrhage. It is at once obvious that upon a correct interpretation of its influence will depend an intelligent. conception of its management. In some cases it will be found best not to disturb the effusion, while in others the indications for energetic interference become highly imperative. The precise manner of procedure appropriate for patients who are little reduced physically is scarcely appropriate for those with a similar effusion but much prostrated from prolonged disease, and offering but very slight prospects for recovery from the pulmonary condition. Among many individuals the size and effect of the effusion are not sufficient to demand operative interference in order to save life. Whenever the local condition is such as to demand operations of necessity, even an apparently hopeless general condition should in nowise preclude the effort to render surgical aid. It is needless to state that the condition of the patient necessarily modifies in some instances not only the choice of surgical procedure, but also the nature

of the medical treatment. Active depletion, venesection, and catharsis, though of undoubted value in selected cases, nevertheless may result in incalculable injury through their indiscriminate use.

Sometimes relief of pain is urgently indicated. In mild cases this may be accomplished by counterirritation, blisters, and warm applications. Hot flaxseed poultices are occasionally productive of great comfort. If but little relief is afforded by such means, I have been in the habit of resorting to dry cupping of the chest over the seat of pain, and the results, as a rule, have been highly satisfactory. Fixation of the ribs by tight strapping with adhesive plaster often gives immediate relief. It is desirable, however, that the overlapping plaster should be drawn very tightly, each strap being not less than two inches wide. When the pain does not yield to such measures, recourse may be taken to the administration of one or two doses of morphin hypodermatically until the early suffering is in part controlled. I have observed several obstinate cases in which large hypodermatic doses of morphin repeated at short intervals have been insufficient to afford relief. In a few instances I have not hesitated to resort to free general venesection, which procedure has been followed by the immediate disappearance of pain.

In general a brisk calomel purge should be administered early, followed by the daily use of saline cathartics, large watery evacuations tending to promote reabsorption of the exudate. The salicylates have been found to induce moderate perspiration and to aid indirectly in the absorptive process. In the non-acute cases, and particularly in the absence of fever, potassium iodid is, perhaps, of some use in promoting the disappearance of the effusion. Simultaneously with efforts to hasten absorption the patients should be instructed to ingest but small quantities of liquid. It is interesting to note that among pulmonary invalids marked general improvement may occasionally take place as a result of the development of small effusions. Several years before Murphy proclaimed his treatment of tuberculosis by the introduction of nitrogen gas into the pleural cavity, it had been observed that the compression of lung by pleural effusions sometimes produced a salutary effect upon the immediate course of pulmonary tuberculosis. There were occasionally manifested a diminution of fever, improvement in cough, marked lessening of the expectoration, absence of previous pleuritic pains, and a material gain in weight. The prompt removal of the effusion by aspiration was followed in several instances by an aggravation of annoying symptoms, which were previously held in abeyance. Such procedure was frequently the precursor of an exacerbation of temperature, increase of cough and expectoration, loss of weight, and an apparent renewed activity of the tuberculous process. This would suggest the positive benefit sometimes to be derived from the intrapleural compression of lung for varying periods. It should be remembered, however, that a favorable influence does not always obtain, even in pleural effusions; that these benefits are usually but temporary, and that no artificial compression, either by gas or external contrivances, save in exceptional instances, and to fulfil special indications, is to be commended. In other words, it is not the treatment of the tuberculous lung per se, nor the tuberculous effusion alone, that should represent the effort of the medical adviser, but rather the management of the tuberculous individual. Laudable as have been the