PARACENTESIS  THORACIS.
      %vl %mlp\B of Chmttj-Jiiw Casts

                  OK

PLEURITIC   EFFUSION,
          IN AVHICII THIS OPERATION WAS PERFORMED.
READ BEFORE THE BOSTON SOCIETY FOR MEDICAL OBSERVATION,
              NOVEMBER 22, 1853.
BY HENRY I. BOWDITCH, M. D.,
ONE OF THE PHYSICIANS OF THE MASSACHUSETTS GENERAL HOSPITAL, AND MEMBER
   OF THE SOCIETIES FOR MEDICAL OBSERVATION AT PARIS AND BOSTON.
          NEW YORK:
BAKER, GODWIN & CO., PRINTERS,
      CORNER NASSAU AND SPRUCE STREETS.
             1853. 
^
S 
PARACENTESIS   THORACIS.
An analysis of twenty-Jive cases of Pleuritic Effusion, in which this operation
   was performed.  By Henry I. Bowditch, M. D., one of the Physicians
   of the Massachusetts General Hospital, and Member of the  Societies for
   Medical Observation at Paris and Boston.
   In  1851 I presented  to the Society, and subsequently published, some
cases* in which Paracentesis Thoracis had been performed.  I propose, in
this paper, to continue the consideration of that subject.  For this purpose,
I shall present an analysis of my preceding paper, together Avith the records
of sixteen more cases, in which I have operated or have seen others  operate,
since that  publication.  I shall give a tabular statement  of  some of the
prominent features of the tAventy-five cases which have fallen under my no-
tice since April 17, 1850, with several inferences therefrom, and shall con-
clude with a brief account of a paper on the  subject, published  recently
(Oct.,  1853) in the Archives Generates de Medecine.

                   Analysis  of my Previous  Paper.
    In the paper above alluded to, I briefly stated the facts relative to the
history of the operation, and to the state of medical opinion on the subject.
The operation, having been suggested by earlier  Avriters, has never been used
freely until since Laennec's discovery has enabled us to make our diagnosis
more accurate than was possible without auscultation.  Since 1843, Trous-
seau, Barby, Reybard, Schuh, Raciborski, and others, have performed it on
the continent of Europe, while Messrs. Hughes and Cock, Hamilton Roe, &c,
have operated in England.  There has been, however, an unwillingness on
the part of the great body of the profession,  in Europe and this  country, to
look upon the operation with  favor.  My own experience had, however, led
me, for many years, to think that some method should be devised for  tho
easy and safe removal of fluid effused into the pleural cavity.  I had  seen
patients die from simple effusion, I  had seen others  gradually  fall in phthi-
sis, or slowly recover, after perhaps years of  misery, with a distorted trunk
and shattered health.  I asked the  surgeon's best aid—by the scalpel.   The
result was very unsatisfactory.  Finally, from Dr. Wyman, of  Cambridge, I
learned the use of the small exploring trochar and canula, as he had applied
it a few weeks before, in the case of one of his patients.  I saw, at a glance,
    * American Journal of Medical Sciences for April, 1852. Article on Paracentesis
Thoracis, previously presented to the Boston Society for Medical Observation. 
4
BOWDITCII ON  PARACENTESIS  THORACIS
 the great value of his method.   A full description of it may be found in my
 first paper.   It is sufficient, for my present  purpose, to say that a  strong
 exploring trochar and canula have, in all the cases I shall  present, been in-
 troduced, usually between the 9th and 11th ribs, and beloAv the angle of tho
 scapula.  To this canula, by means of  an air-tight apparatus, a strong suc-
 tion pump has been attached, and the fluid has been draAvn out, without the
 possibility of the introduction of air, while the aperture that has been left has
 been so minute that no blood has flowed, and  it has  immediately closed on
 the AvithdraAval of the instrument.
     In that paper, I gave the details of eight  cases.   The prominent  points
 of these cases may be seen in the tabular statement in this communication.
 The results to which I arrived, from my previous thought on  the  subject,
 and from the examination of the cases, may be best expressed by the follow-
 ing extract from the preface :  " My OAvn mind is decided upon the following
 propositions:  I shall  puncture the chest; first—whenever, either  in an
 acute or chronic case, I find a pleural cavity distended or filled with  fluid;
 second—whenever, in any acute case, remedies seem to have but little  effect
 towards causing an absorption of the fluid,  and after a fair trial has been
 made of them for  two, three, or four Aveeks ;  third—I shall puncture in cases
 of larger effusion, complicated with organic disease, in the hope of relieving
 urgent dyspnoea or to lengthen life."
    Upon these principles I have acted since they were laid doAvn.   The
 only change I should make in  them, at the present time, with the experi-
 ence of the results of twenty-nine punctures  made in the sixteen  new cases
 is this, A-iz.   I would not wait so long as " three or four weeks " in  acute
 attacks, provided  I found that the  effusion continued steadily to augment
 in spite of remedies.   Moreover, if called in an acute  case that has lasted
 a month, and in which there is an amount of  fluid effused, sufficient to ma-
 terially compress the lung, I shall advise a puncture, as the first step  to be
 taken, previously to the use of the remedies commonly employed in pleuritic
 effusions.   I trust  that the result to which I have  arrived from seeing  tho
 patients, may not be different from  that to which the reader will arrive from
 the perusal of the folloAving cases.
   They are given in the chronological  order of the operations,  but  they,
 with those in the preceding paper, may be classed in four main  divisions'
 according to the effect of the operation:—
   First  Class, or those cases in which the  operation has been the chief or
sole  cause of the cure of the pleuritic effusion.  Cases* 1,7  8 11  12  14
 15, 18, 20, 21 (total, 10), are of this class.
   Second Class, or those cases in which the puncture  has given more  or
less,  and at times very great, temporary relief, so that some of the patients
have asked for the operation a second, third, or fourth time, for the sole ob-
                        See tabular statement. 
IN PLEURITIC EFFUSION.                     5
ject  of getting relief.  Cases 2, 3, 4, 9, 10, 13, 16, 17, 19 (total, 9), are of
this class.
    Third Class, or those in which no relief Avas obtained, because  no fluid
could be removed.   Cases 5, 6, and 25 (total, 3), are of this class.
    Fourth  Class, or those still under treatment, which are  progressing fa-
vorably, with more or less rapidity.  Cases 22, 23, 24 (total, 3), are of this
class.
                                 Cases.
    Case 9th.—Mr. G., set. about  20, clerk.  I  saw him with a physician
of this city, Oct. 17th, 1851.  During  the winter of 1850-1, he had had
some pulmonary trouble; but the  patient assured me he had been Avell from
that time until the  actual attack for consultation upon which I had been
called, and which proved to be one of very latent pleurisy of two  or three
weeks' standing.  He had had no pain or dyspnoea, and only a slight cough,
for ten days or more.  He was able to be at work, but felt not quite well.
On examination, I found signs of effusion  into  the chest.  They had been
recognised by the attending physician.  I advised blisters and iodide of po-
tassium.   This treatment was continued until Nov. 6th, but Avith a gradual
increase of all the symptoms.  On that day, there was perfect flatness of the
lower third  of the right back, the  sound changing by change of posture; a
peculiar  stomachic  resonance above the  line of flatness; segophony; on
succussion, some gurgling, but no  metallic tinkling.   The respiratory mur-
mur was slight, even at the  apex of the lung; but no rale was heard even
on coughing.   His general symptoms were improved.  He was able to walk
about, although some dyspnoea was evident.  Pulse 100; skin comfortable,
slight sweat at night.  As the iodide had not been thoroughly tried, and as
there was an indisposition to the puncturing of the chest, on the part of the
attending physician, I advised 5 grs. 3 times daily, and blistering to be con-
tinued, and certainly not to alloAV a much longer time to elapse before doing
the operation.
    Nov. 22d.  He was suddenly seized with pain in his other side, with
great dyspnoea and anxiety.  He had, however, obtained relief from a poul-
tice and Dover's powder before I  saAV him.  The auscultatory phenomena
Avere as before, except that there Avas dulness to the second rib in front;
there was no evidence of serious trouble in the left back, the murmur being
heard pure everyAvhere, even to the base of the lung.
    I uro-ed a puncture; and  on the 24th one was made, between the 9th and
10th ribs  below the angle of  the  scapula.  Nine ounces of yellow serum
flowed  readily, and aftenvards  not a drop  could be draAvn,  notwith-
standing I  passed a probe through the canula  and found  it perfectly per-
vious.   Convinced that more fluid remained, I AvithdreAV the instrument, and
introduced it under the axilla, one or two  ribs above ; and eighteen ounces 
6              BOWDITCH ON PARACENTESIS THORACIS
 more, of a similar fluid, came freely.  The chest became somewhat resonant to
 the point of the puncture, and the segophony was heard only at the  lowest
 part.  The patient suffered not at all, except  that a cough came on  which
 was rather troublesome.  DoA-er's poAvder and absolute rest were ordered.
    Dec.  2d.   Had  been improving; no returns of dyspnoea;  patient felt
 brighter; he was able to lie on either side;  pulse 108 to 112.  On percus-
 sion, was really flat only in the lower two inches of the  back.  Respiration
 heard, vesicular though indistinct, along the vertebral column to near the
 base of the chest.  Blister twice weekly, (3x3.)
    Dec. 13th.  Better in strength and appearance.   His  digestion  was
 good.  Pulse about 100, and occasionally a slight  flush, P. M.,  and a little
 SAveating at night.  Respiration less labored than formerly.   On inspection,
 the right side was evidently the larger.  Murmur heard  through the  whole
 back, though indistinctly,  to  a  line at  the  edge  of  the axilla; bronchial
 towards the base; absent on the side, under  the axilla, and  on the breast.
 No  rale,  but a metallic echo Avas heard  on coughing.  Good pulmonic
 sound, on percussion, on the back to where the bronchial respiration was
 heard.  There  it was stomachic ;  dull beloAv the line of the nipple, front and
 side.  As the patient was annoyed by the sound of liquid, and as he thought
 he had  breathed less easily for a day or more, he desired to be operated on.
 I accordingly punctured, and drew off eighteen ounces of an amber-Yike fluid.
 After the operation, the bronchial respiration  and the stomachic resonance
 were much lessened.  Cough again supervened, as at the previous operation ;
 the pulse was slightly accelerated, but the  patient was not at all fatigued.
 Continue medicine.   Tinct. of iodine to the side.
    Jan. 14, 1853.  The patient had continued without much change.  He
felt Avell—walked down stairs; was  able to  lie on  either side.  The  pulse,
 however, was always accelerated—often 120.  Auscultatory phenomena, how-
 ever, revealed a similar state to last report.   I drew off  twenty-one ounces,
 more purulent.
    Feb. 9th.   A similar condition of the patient, except  that he was  rather
 improving; he had  no hectics; he had gained flesh.  I drew off  again
 twenty-one ounces of a fluid still more purulent, and running  but slowly.__
 Cod-liver oil.   Ride  out daily.
    March 9th.  Looked finely;  able to walk out freely.  Cough, very much
 less.  Only slight dyspnoea.  No gurgling heard since last operation.   Dul-
 ness, much as before.  Respiratory murmur heard further out on the side.
 I operated between the 5th and  6th ribs, and further forward, toward the
 nipple.  Two pints of freely running'fluid were removed.  Patient was much
 more able to assist himself than after either of the previous operations.  He
 had  less cough, but a  sense of stricture across the chest.  Cod4iver oil and
 phosphate of lime ordered. 
£tf PLEURITIC EFFUSION.                      7
    Two days after this operation the patient went into Boston to a convivial
meeting, and after spending the day, drove out some miles.  The weather
was excessively cold, and he was very severely chilled.  A febrile paroxysm
supervened ;  and the pulse rose to 120, and a general feeling of distress, es-
pecially of limbs, was experienced.  On the 17th there appeared what seemed
to be a general inflammatory condition of the absorbents; small red lines
were  seen running along the legs and arms;  quite tender to pressure.  No
trace of inflammation on trunk—and the point  of puncture was perfectly
healed.  Patient  had  an anxious, sublivid look.  The attending physician
had used alcoholic lotions and 12 grs.  of iodide of potassium.   Meanwhile,
the physical  signs, though similar to what was noticed  before, were rather
more favorable.
    He recovered from this acute attack in a feAV days, but he never Avas as
Avell again; and, in about five or six Aveeks, signs of tubercular developments
shoAved themselves in the diseased side—marked  by crackling, and, subse-
quently, pectoriloquy at  the apex.
    Owing to illness,  I did not  see him afterwards; but in May, as there
Avere  signs of pointing, the attending physician  opened with a lancet, and
pus continued afterwards to flow, till he died suddenly, in the night of Au-
gust 7, without warning, in consequence of copious  haemorrhage  from the
aperture.  He had been, however, gradually declining for months.   His phy-
sician writes, " Life had been despaired of from day to day; and, previously to
the haemorrhage,  he had coughed very hard.  The opening in the side did
not become fistulous, in the true sense  of that term, for it showed a disposi-
tion to heal from time to time, so  as to render necessary the introduction of
a tent.  Injections of a Avatery solution of gum myrrh had been used every
other day for some time before his death, whereby the patient was comforted,
the discharge was lessened and made less offensive."
    Reflections.—I had no doubt, when I was first called, that the case was
one of pleuritic effusion of  the most latent kind.   But I feared, from the
fact of even a trivial cough having existed before, that it was of a tubercular
origin. I felt the importance of an early removal of the fluid; yet the small
amount of it, and the  slightness of the symptoms, connected with the fact
that medical opinion was adverse to thoracentesis, prevented me from sug-
gesting the operation at my first visit, Oct. 17.  At my second, twenty days
afterwards, I submitted  the idea  to the  attending  physician;  but as the
same  reasons existed, the operation could not be performed, although the
fluid had increased.  Finally, the sudden attack of  dyspnoea, on Nov. 22, a
little  more than six weeks from his attack, led all parties to feel that more
active measures should be used.  As I view the case now, in the broad light
of ulterior experience, I think the delay was probably pernicious, possibly
fatal;  for, although in  our present knowledge of the subject, we cannot be 
8
BOWDITCH  ON  PARACENTESIS THORACIS
sure that an early operation will prevent the tendency to tubercular develop-
ment, the fact that whenever any amount of fluid is drawn off, tho rational
signs  almost invariably improve, and the examples we have of the excel-
lent results of an early operation in cases of pleurisy evidently tuberculous
in their origin—these facts prove, almost conclusively to ray own  mind,
that it is better  always to operate as early as  possible in any case in which
there is any considerable amount of fluid, especially in one of a tuberculous
tendency.
    In  regard to the  other interesting points in this history, I Avould state
that the patient ahvays experienced so much relief from the operation, that
he Avas  sure to be the first to  ask for its repetition.  It may be  remarked,
also, that he had no  alarming return of dyspnoea,  subsequently to the first
operation.
    The last  topic, specially suggested by this case, is the violent haemor-
rhage,  causing death.  It  will  bo  remembered that  this  took place  at
least three months  after the  opening by the lancet, and  six months from
the last puncture.  I have seen a similar case,  under the care of another, in
which  exactly similar phenomena occurred, except that the case was one of
pure empyema, punctured after months of illness, and again opened Avith
the lancet when pointing.   After the second opening, the patient improved
very much, but a fistulous passage remained.  From this occurred a haemor-
rhage,  Avhich was repeated to an alarming degree  a feAV days after.  The
patient was, becoming anaemic.  A surgeon was called, who enlarged the
opening;  could find no vessel, but a bleeding granulating surface.  The
aperture into the  thorax  being fully dilated,  the patient  had  no more
haemorrhage, and slowly recovered.   The question  may  be asked,  if the
puncture had any connection with this state of things.  My own opinion is,
that there is no proof of their connection.   On the contrary, the facts as
they stand are decidedly opposed to the idea of such a connection.  I speak
of it, hoAvever, in order that  all circumstances may be known that seem,
even remotely, to  be favorable or otherwise to  the operation, as urged in
this paper.

    Case 10th.—Mr. T., set. 30, a rigger, I saw Feb. 17, 1852.  It appeared
that, for a year  before, he  had had cough;  but that, during the summer,
it had been slight, so that he kept at work until Dec. 18th, 1851.   He then
had sharp pains  in the  right side of the thorax, for which venesection was
performed.  He  kept his bed, at that time, for a week; and then, feeling
better,  went out, daily, for a fortnight.  He then became more ill, and  he
had been confined  to  the house for five or six weeks previously to my visit.
Hectics for the same length of time.   His appetite, from the first, had been
poor, but his digestion good ;  tongue red, and with a slight coat; dyspnoea 
IN PLEURITIC EFFUSION.                      9
 always from  Dec. 18th; at times orthopncea; expectoration considerable,
 opaque.  Pulse 124, skin warm and moist.  His countenance was haggard
 and distressed; he was sitting up, from inability to  assume a recumbent
 posture.  On  percussion, flat  below the third rib, front and behind—not
 clear above.  Respiratory murmur obscure to third rib, indistinctly bron-
 chial  beloAv,  Avith a metallic tinkling on  coughing or shaking.   Behind,
 similar results, and aegophony.  At the left apex, some rudeness of murmur.
 Right side of chest moved, during respiration, less than the left; intercostal
 spaces contracted. Diagnosis—tubercles and pneumo-hydrothorax.  I advised
 a puncture for relief to  the  suffering ; but  as the patient was umvilling to
 submit, I ordered iodide of potassium, 3 grs. three times a day, and a  blister
 every fifth day.
    Feb.  27,  i. e.  ten  days afterwards, much  more  dyspnoea—no  relief.
 Patient then consented to the puncture.   I  made it in the usual space, be-
 tween the  eighth and ninth ribs, and drew out a little purulent fluid with
 much difficulty.   I then punctured two ribs  above, and t\vo inches further
 forward, and removed 5 xv.  with very little pain and much relief to the dis-
 tress of the patient.
    March 3.   For a day, the relief continued, but soon the dyspnoea  began
 to return ; cough constant;  strength less.   At my visit of that date, he had
 complete orthopncea, and Avas in great agony.  I told him I would do as he
 chose.  I had little hope of giving, by any puncture, more than a temporary
 relief  to  his sufferings.   From  his previous experience, he requested  me to
 operate.  I punctured at the loAvest point, and dreAV off  §iii. of  a purulent
 fluid; and on puncturing above, I procured nothing.  The  patient felt no
 uneasiness, except that after the operation, he, having lowered his arm, struck
 the canula, and caused much  pain by its motion between the ribs.  The next
 day, there Avas some redness and tenderness  at the point, Avhich subsided
 under a hop fomentation.  The patient died on the 8th. No autopsy was
 allowed.
    I present this case simply as a specimen of the relief obtained in a hope-
 less disease.   This relief was more evident to the patient than appears from
 my record.  The  fact, hoAvever, that  a  request  Avas made by himself for a
 second operation, is a proof of the little real suffering sustained, and the
 relief  procured.   The  inflammation after  the  fourth  puncture,  though
 slight, was more than I  ever noticed before; and Avas, doubtless, OAving to
 the striking of the canula Avhile in the Avound.  Its rapid subsidence, hoAV-
 ever, especially when connected with the ordinary absence of all symptoms
 of the  kind, is not unfavorable to the operation.

    Case llth.—Mr. R., aet.  59 ; "An old soldier," wounded at Waterloo;
in U.  S.  23  years, where  he had had  numerous occupations, and had
                            2 
10              BOWDITCH ON  PARACENTESIS  THORACIS
indulged in free living.  He was " well," till his disease began, for which
he entered my service at the hospital.   About five Aveeks before his entrance,
he had had*pain over the left crista ilii, and in a few days had haematuria,
with dysuria..  Appetite  lessened;  very costive;  some slight dyspnoea;
cough very seldom.  Very little treatment previously to entrance.  At his
entrance, he could  lie  easiest on the right side ; but he had been, however,
able to lie on either.  He sat up, and could talk, but with evident dyspnoea.
Respiration, 17 ; pulse, 96  ; skin, normal;  tongue, moist, with a thin white
coat.  On inspection, intercostal spaces filled in the Ioavoi- half of  the left
chest.   Percussion, flat all around  the same side, below a line on a level
with the second rib.  Murmur scarcely perceptible throughout.   Puerile at
right, with slight, fine  crepitus at the  base.  ^Egophony over  dull  space.
Heart beating to the right of the sternum. I ordered inf.  sennae comp. f. 3 hi.
with cathartic enema;  broth for dinner; house diet at other meals.
    Dec. 29, I punctured  between the eighth and  ninth  ribs, behind,
and dn.'Av off § xxiii. of a yelloAV serum, Avith relief to a sense of fulness there,
and Avith more ability to  lie on the  right side.  Pulse, a short time after
operation, Avas 98.  Ordered iodide of  potassium, gr. iii., three times daily,
in syrup of sarsaparilla.  Blister (3X3) to left side.   He had an opiate given
at night.
    Dec. 30.   Much lighter since  operation; less cough, and not painful;
urine much increased.   Blister very troublesome.
    He soon after left the Avard, and consequently fell under the  care of my
colleague, Dr. BigeloAV.  His subsequent history is  as  folloAvs.   Sol. mag-
nes. sulph. Avas given several times before the 11th of February.  Afterwards
he drank freely of cream of tartar.  Under these remedies, his boAvels were
freely opened, so that,  at one time, the cream of tartar Avas suspended.
    Jan. 2 (four days after the operation), his chest Avas flat in the lower two-
thirds  of  the back; bronchial  respiration  and aegophony  there.  Obscure
respiration in the left breast.
    Feb. 1.  Friction sound at the loAver part of the left breast.  On 15th it
was much stronger.  But Feb. 1st, he had some cephalic symptoms ;  cephal-
algia, scintillations, <fec. Nausea and vomiting on 8th. Pulse quickened. On
18th, some wandering of mind. 21st, tAvitching of muscles, and insensibility.
On 22d, he died comatose.
    Feb. 24, autopsy by Dr. J. B. S. Jackson.  The  records of the chest are
as follows, " Left  pleura mostly quite free ;  strong old  adhesions  over apex
only, and along the lower lobe near the spine. A few ounces of turbid, serous
fluid only in the cavity ; nothing like pus.   A  delicate film of false mem-
brane was seen over most of the pleural surface, just enough to obscure its
polish for the most part; in some parts £ or £ an inch thick, translucent, or-
ganizing.  Left lung small, but more or less air everywhere in it.  Consider- 
IN PLEURITIC EFFUSION.
11
able congestion ; weight  I xiii., length 10 inches.  Right lung, everywhere
old pleural adhesions ; lung itself healthy, but congested.  Stomach, exten-
sive cadaveric softening of mucous  membrane of left extremity.  Kidneys
healthy, except for a  simple serous cyst, the size of a  nutmeg.  Prostate
generally  enlarged.  Lobe  stands  out directly into the bladder, size of
a marble,  and round.  Head acute meningitis at base, not very extensive.
Pia mater there,  red, flabby, and  rough, but  no  decided  granulations.
Convolutions flattened, and surface dryish.  Lateral ventricles  contained
 5 v. of serum, with softening of the surrounding substance."

    Remarks.—The  totally  latent character of  this attack ; the prominent
symptoms (haematuria, &c),  in fact, leading the physician to suspect nephritis
rather than pleurisy ; the easy diagnosis by means of the physical signs ; all
these are facts of importance.
    As  to the advantage derived from the operation, no one, I think, will
doubt about  it, who remembers the improvement in the rational and phys-
ical signs; and, above all, the  appearances at the autopsy.  A very little
fluid was  found in the  pleura; the membrane Avas inflamed only in  the
slightest degree ;  the  patient evidently had  died of his  acute meningitis,
while  recovering from his pleurisy, which recoveiy commenced  with  the
time of the puncture of the chest.

    Case 12th.—Mrs. S., aet.  21, I saAV Avith a  physician of Boston, Feb. 27,
1852.   The antecedents of her actual condition Avere somewhat vaguely ob-
tained, owing to the sufferings of the patient.  It appeared, however, that
she had had a cough during the autumn, and that, about six Aveeks before I
was called in consultation,  she had what was called pneumonia (? pleuro-
pneumonia, or, more probably, pleurisy), Avith severe pain in the right side.
From the  more serious symptoms caused by this, she had recovered in about
two weeks,  and she was able  to walk about, though she was weak.
She soon became ill again, and Avith evident signs of pleuritic effusion.  She
had had hectic paroxysms.  Menorrhagia she had been  subject to till two
months before, and since  that, amenorrhcea.  At our visit, she appeared in
great suffering with dyspnoea, pain and discomfort in the side.  Her previous
night had been very bad. Her countenance  was pallid  and haggard ;  her
pulse was  108.
    The physical signs Avere, flatness over the Avhole of the right chest;
strong tubular respiration to the third rib;  Avith  great vocal resonance.
iEgophony at the back and  side, below the middle of the scapula.  Puerile
respiration in the other lung.  No rale anywhere.  The right side of  the
chest  Avas  very prominent, and at one spot, it Avas very tender; and as it had
given evidence of  fluctuation, an escharotic  had been applied  some days 
12
BOWDITCH  ON PARACENTESIS THORACIS
previously, but the eschar had not separated.  The intercostal spaces were
more contracted than usual.
    I punctured at the usual spot (viz. below the angle of the  scapula and
betAveen ninth and tenth ribs), i. e. about five or six inches from the spot that
was pointing, and  I xli. of very thick pus Avere slowly drawn  out, with-
out any difficulty, save at one time a slight stricture across the  chest.  The
prominence described above, subsided at least one-half, and some resonance
Avas heard, on percussion, down to the line of the puncture.  The cavernous
voice in front, and the  aegophony  behind,  Avere nearly gone ;  Avhile the
bronchial respiration in front was very much lessened.  The whole aspect of
the patient was wonderfully improved.   She smiled, and felt much relieved.
Pulse  96 ; hand  cool, damp; asked for food.  Ordered iodid. potass. 3i.,
syrup sarsaparilla 1 iv.,  3i. three times  daily.   Eat meat, and  drink  ale
cautiously.
    29.   Night very comfortable; much less oppression and soreness of chest;
but the part cauterised had risen again, Avas puffy and crackled from air in it.
Similar crackling felt in the cellular membrane above, on the parietes, as high
as the second rib.  On percussion, good resonance to the point punctured—
dull beloAv. Cavernous respiration and aegophony wholly gone ; and in their
place was a Avant of respiratory murmur  in the back, and metallic tinkling
in front.
    March  3.   Much  better; appetite  sharp;  bowels costive ;  no night
SAVeats ; pulse 90  ; chest, less prominent; eschar removed.   Physical signs
as before, except more vesicular respiration to the  angle of the scapula, and
across a space of  three inches broad from the  vertebral column.   Rochelle.
    March 9.  On 4th, the abscess broke where the eschar had been  made,
and  discharged, after a violent cough, an immense quantity of pus, so that
the mattress was thoroughly soaked.   Relief was obtained, and the dis-
charge continued until 8th ; some cough ;  slight expectoration.  Physical
signs—crackling,  whole  of  the front of  the chest (evidently from the lung
expanding).  Metallic resonance gone.   Percussion very much  better be-
hind, and the respiratory murmur was heard even out to the axilla.   Con-
tinue treatment.
   March 13.   Steady improvement;  digestion perfect;  slept  well;  no
fever ; sat up an  hour yesterday ; I  learned that a new discharge  from the
same point had occurred, copious, and that from  that time it had been more
or less constant.   At the  visit it ran freely ; cough very light;  able to lie on
either side ; pulse 110.   Respiratory murmur a little more, but much as at
previous  Aisit.   Slight aegophony, at the very base of  the chest; side still
motionless ; some emphysema still, but less in front.
   Subsequently I did not see her; she Avent into  Maine in August, was
feeble at the time.  After a few weeks residence there, she returned to East 
LN PLEURITIC EFFUSION.
13
Boston  in  September, when the fistulous opening closed entirely.   From
that time she has gained perfect health.   Now (Nov. 18,  1853) she feels
better than for years before her illness.  She has no cough, except occasionally
on taking cold.   She is a stout, able-bodied woman.   Her side is but little
altered in form.   Through her clothing, the change is not perceptible ;  but
the dressmakers  perceive that  the left side is the larger.   The respiratory
murmur is vesicular everywhere, but less  throughout the right, especially
in the lower part of the loAver lobe, Avhere it is scarcely perceptible.

    Remarks.—The  puncture in this case gave the  most gratifying relief;
and, although the pleura opened in a few days, the patient looks back upon
the operation  as  having given her  the first  step toAvards  recovery.   She
never suffered afterwards as she had suffered before.   Could not relief have
been obtained earlier ? Undoubtedly, such might have been the fact;  and the
reason why the operation was not performed was the general unwillingness,
at that time, on the part of the profession, to believe in the advantage to be
derived from it.   The same reason allows, at the present time, hundreds to
be suffering from the  same cause, in various parts of our country.   May  I
hope that this paper will tend to the alleviation of their sufferings %

     Case 13.—Mr. B----•, aged 40, Irish laborer, I saw  with Dr. E----,
 Dec. 30,1852. Generally well; two years ago, some dysenteric symptoms for
 eight Aveeks. Well afterwards till July ; then slight dry cough ; on 14th, fell,
 and struck his left side upon some stones. He had pain in the side ever after-
 wards,  and although  he was able to be out of  doors, he did but little  hard
 Avork.  Shortly after his fall, he was exposed in the night to  a drenching
 rain, and was thoroughly Avet. He had a bad chill, and  the  pain was much
 increased.  He  was  then treated by a physician, and got better again ; but
 about six Aveeks  afterwards, while pushing a raft, he fell into the water, and
 was obliged to walk some miles with his wet clothes upon him.  After that
 period he had done no work, but till within nine weeks he had occasionally
 gone out of doors.   During these nine weeks, he had been confined to the
 house with a gradual aggravation of all his symptoms.    During the  three
 Aveeks  preceding my visit, he had heard " a  splashing " in the chest.  His
 cough had been at times very hard.  His expectoration had been slight, never
 bloody, generally Avhite and frothy.  He Avas unable to sleep  on the right
 side, although he could lie a short time upon it.  Tongue smooth ;  appetite
 poor ; bowels well. He panted very much, and wasjn great distress. He was
 seated,  moaning, on the bedside, with  his head bent forward ; respirations
 from 48 to 52 per minute ; pulse, 96 ;  skin of natural warmth ; urine  suffi-
 cient, and by report  of patient was natural. Little motion of the left side  of
 the thorax ; on succnssion and coughing there Avas a sound of fluid and  of 
14             BOWDITCH ON  PARACENTESIS  THORACIS
air in the chest.   The left chest was dull over a large space, dulness vary-
ing AAith the change of posture of the patient.  Metallic echo heard in the
breast on coughing ; heart pushed strongly to the right of the sternum ; lower
part of the left chest rather prominent, quite tender, soft, but  no evident
pointing.
   A puncture Avas made betAveen tho eighth and  ninth ribs;  great  relief
followed.  In fourteen minutes I had drawn out  I lxiv of a purulent fluid.
Cough came on then as the sole unpleasant symptom  during the operation.
The heart fell back a little.    Tincture of  Iodine externally, and Iodide  of
Potassium internally, Avere ordered as in the other cases.
   Jan. 3.  His  nights had been much easier; less cough.   No moaning,
and Avhole aspect much improved ;  appetite poor; pulse 96 ; had  kept  in
bed all the time ; urine as before operation ; some tenderness, low down  on
the left back, but more particularly near the  point of the  puncture.   The
respiratorv murmur seemed  a  little more  evident at  the apex of the lung.
OtherAvise, the signs remained  as before the operation.
   Jan. 10.   The  tenderness and peculiar prominence of the back had
subsided ; the respiratory murmur Avas heard indistinctly along the vertebrae,
and some resonance to about an inch above the point of puncture ; other-
Avise,  physical signs as before ;  patient had become more feeble,  and had
had more dyspnoea for a few days, and lay, moaning, at my visit.   Desired a
second puncture as a relief, though he had no hope of a cure.
   Jan. 11.  I operated a  second time, and in 46 minutes removed gclxxv
 of thick pus; previously to  the  operation, the left  side  was 2§ inches
 larger than  the  right;  afterwards it was only  l£.   Strong metallic tink-
 ling Avas heard evervAvhere  front and back.  The operation was borne very
AA-ell,  and afforded vast relief;  the patient sat up on the side of the bed, Avith
 much less dyspnoea, and  chatted with his friends.   He Avas advised to enter
 the hospital, but  he died within  forty-eight hours, having accidentally taken
 an overdose of opium.  No autopsy Avas alloAved.
    Remarks.—Let it be remembered that this  patient had been  ill more
 than  five months  with a pleuritic effusion.   When I saAv him, he had orthop-
 ncea, great emaciation, and  all the marks of approaching death,  unless relief
 Avere obtained.   I conceived it  right and  best to operate, but I did so with'
 little hope of doing permanent  good.  There was a chance of permanent
 relief, and almost positive certainty of temporary relief from agonizino- dis-
 tress, and by an  operation,  as I believed, perfectly innocuous.   The results
 as far as they went, were satisfactory.  He obtained so much relief from  the
 first puncture, that he eagerly sought for a second, Avhen I dreAv  off the larg-
 est quantity of fluid,  and that likewise being pure pus, I had e\'er extracted,
 viz., about 5£ quarts, which, added to the  two quarts previously taken, made
 about 1\ quarts in twelve days.
MttB 
IN PLEURITIC EFFUSION.
15
    Case 14.—March 19, 1853.  Saw with Dr.-----of Roxbury, Mr.-----,
age 24, clerk.  I learned that he had lost a brother and sister by phthisis ;
he had a cough seven years before, and slight  haemoptysis ; he  went to
Cuba,  and returned well, and had been in active Avork since, with only an
occasional cough ; two years ago he had a slight pain in the right side, and
could not, for a time, easily straighten himself; a fortnight before I saAV him
he weighed 162 pounds,  and felt in perfect  health.  On 8th, he went to
his warehouse as usual, and, P. M., he had chills, a slight cough, and a very
few sputa ; he returned home, and did not leave the house afterwards.  In
two days a  stricture  came  on in the chest, which gradually augmented
from day to day ; no  marked fever ;  his  sleep had gradually become more
and more disturbed, and finally he was unable to  lie  on the left side ; he sat
up most of the day ;  his appetite  was lessened.  Dr.-----had discovered,
early in the disease, an insidious  attack of pleurisy ; and the effusion had rap-
idly progressed until  the time of my visit, while the patient had been daily
getting worse in his general symptoms. I found him sitting up, rather pale,
and thin ;  no great  dyspnoea,  but some labored breathing while  talking;
pulse 120, small and irritable.   The right side of the chest was larger than
the left, and felt solid on percussion.  Flat percussion, except at the very apex,
behind;  absence of  respiration in the  same space;  slight  crackling on
cough, at the left; aegophony all over back, below the spine of the scapula.
Diagnosis: very large effusion, probably tubercular.
    On 20th I punctured  in the usual place, and removed three pints of a
yelloAV serum;  severe  stricture across chest, and coolness of surface, Avith
weakness of pulse and debility supervened. Wine and water. Iodide Potassium
 grs.iij in infusion digitalis, three times daily.  Series of blisters to the side.
     22d.  Much relief; had slept better, more appetite, urine augmented ;
 looked better ;  stricture in chest  gone, Pulse 96 ;  could  lie down easily on
 either side.  Percussion clearer, even doAvn to the point of puncture behind
 and  to the  third rib in front.  Respiratory murmur heard indistinctly to
 the same parts.   Less  crackling at the apex.  ^Egophony gone, except in
 loAver two or three inches.   No inflammation about the point punctured.
     From the time of the operation, the rational signs improved ; so much so,
 that Avithout the physical  signs to guide us, we should have considered him
 as getting well quite fast.  The  treatment Avas continued.   The  physical
 signs however indicated that the lung did not readily expand in its entire
 mass.   On April  30th, I reported the physical signs as follows :—Decided
 contraction of the right chest;  scapula projecting.   Resonance better to the
 base of the lung.  Respiration heard all over chest, but obscure and occasion-
 ally with a click or rubbing sound.  Bronchophony, which had been marked
 from the first at the right  apex, Avas less.   No rale there,  even on coughing.
     Nov. 12.  To-day I saw this patient, he had been travelling and  riding 
16
BOWDITCH  ON PARACENTESIS THORACIS
 on horseback, and using cod-liver oil during most of the summer.   He had
 partially resumed business  during the  previous  six  Aveeks.  He  looked
 healthy ; felt as well as he tner did in his life, except that he had dyspnoea
 on running up stairs, which subsided easily after  rest.   His digestion Avas
 better than for months before illness.  If' had no  cough, nor any appear-
 ance  of hectics.   He  had  gained  flesh.  Once,  he  had  an attack  of
 asthmatic Avheezing, a distinct paroxysm of asthma lasting  about Iavo days,
 during  Avhich,  by the  account  of his  physician, he  had  sonorous rales
 throughout the left or healthy lung.  I ausculted him, and found some
 dulness  on percussion of the loAver half of the right  back and under tho
 axilla to nipple ;  less sound generally on that lung.  Respiratory  murmur
 almost null in  the lower third,  and obscure but healthy  in  upper parts.
 Voice scarcely heard at all in the  loAver third—not especially  morbid
 anywhere.  Left lung Avell.   Patient regards the operation as the first step
 towards his present relief.  He had been steadily groAving Avorse until the
 puncture,  and  he has  been as steadily,  though slowly,  growing  better
 since.   I presume  that during life there will always remain  some physical
 signs; for I presume that  the lower part of the lung  is in the condition
 described by Dr. (iairdner* of Edinburgh, as occurring after pleurisy, bron-
 chitis, Arc.  The vesicles cannot and probably never will fully expand.

    Case 15.—June 10th, 1853.   Mrs. B-----,  I  saw at E. Boston,  with
 Dr.-----; aet. 45.  She  Avas the mother of  a large family, Avhich she had
 usually superintended until  her illness  ; but she had been considered tuber-
 culous, and for months had used cod-liver  oil, under which, previously to
 her actual attack, she had been tolerably well.   For three months before  I
 saAv her, she had felt not quite so well.  Six weeks previously, she had had
 an acute pain in the right side; but it did not prevent her from going about
 the house.  Three Aveeks before the operation, she went to church all day.
 While dressing for  this purpose, she was surprised to find that her gown was
 too tight, and she had some dyspnrea.  She, however, continued at work for a
 few days, Avhen, OAving to an increase of the symptoms, she Avas compelled to
 desist; she lost her appetite ; the cough became dry and  hard ; the dyspnoea
 was extreme, so that at length she could not get up into her chamber and
 fits of suffocation occurred, threatening death.
   I found her Avith an  anxious, veiy livid countenance, in bed, half erect
 pulse  115.  Respiration  much labored.  On percussion, the right side was
 flat everywhere, except  at the apex behind.  Respiration scarcely heard
 even under the  clavicle; bronchial for a small  space along the vertebrae
from top to bottom, absent  elsewhere.  Puerile  through the Avhole of the
left.
» British and Foreign Med. Chirurg. Rev., April 1853, Art. XI. 
IN PLEURITIC EFFUSION.
17
     I punctured between the 8th and 9th ribs behind, and drew eighty-three
 and three-fourths ounces of yellow serum.   The patient  experienced the
 greatest possible relief, and suffered scarcely at all, except at the last of the
 operation she had some stricture across the chest and the cough was a little
 troublesome.  The  sounds on  percussion instantly became more clear, to
 the  point of puncture.  The  bronchial  respiration  was replaced by the
 vesicular.  Crackling was heard throughout the right breast, evidently from
 the expanding lung.  The pulse fell to 108, and she Avas able to lie on the
 left  side, in a position Avhich  nearly  suffocated her only  twenty minutes
 before the operation.  She Avas allowed broth and wine.  During the  next
 twenty-four hours, she coughed much and raised nearly a quart of frothy,
 Avhite fluid.
     I saAv her, P. M.,  June 11, and found  her  quiet, Avith much  more  easy
 breathing; she  Avas much less livid ;  she relished her broth and wine.
     From this time, she  steadily progressed, the lung expanded  rapidly, as
 marked by rales that Avere heard everywhere in it.  The  little fluid  that
 remained in the pleural caAaty was soon absorbed; the urine Avas much
 increased.  The oedema of the  legs,  that existed before the operation, was
 Avholly gone by  20th (10 days after operation)  ;  the lividity  of the skin had
 subsided.   The appetite and digestive  functions improved,  and were excel-
 lent at the above date; no dyspnoea ; pulse 84, quiet;  little cough ; only felt
 Aveak.  On percussion (20th),  10th  day from puncture, there Avas only a
 difference of pitch between the two sides—no real dulness.   Vesicular
 murmur was heard in every part,  only a little  less at  the right than at the
 left, Avith a dry crackle at the top on coughing.
    Sept.  23.  I  found she had been going on  Avell,  though she Avas  still
 feeble ; scarcely any cough ; digestion excellent; slight feeling  as of pain or
 obstruction in the right side on full breath; was able  to superintend her
 domestic  affairs ; she visited me at my  office.   On percussion, less sound at
 the  left than the right  top, and  the voice was more resonant there; and I
 thought  I heard, at times on coughing, a  slight crackle there.    Murmur
 obscure at the right apex.  Equal and clear in both lower lobes.   In other
 words, the signs Avere those of the chronic previous disease, the acute pleurisy
 having left little or no traces of its existence.  Ordered to resume cod-liver oil.
    This  case I  deem of  especial importance :—1st. It indicates  that  a
 suspicion  of tubercular  disease  of the lung  must not prevent us from
 operating.  This, with No. 7, proves the truth of this  assertion.   2nd.  I
 believe the operation saved human life.  The patient Avas livid, and looked
 almost suffocating.   TAventy minutes  before the puncture she had, in fact,
nearly expired.   TAventy  minutes after, she  Avas  like  one  restored  to
existence,  and yet no operation of severity had been performed on her.   3d.
The intensity of  the cough Avas in exact proportion to the rapid unfolding
                  3 
18             BOWDITCH ON PARACENTESIS THORACIS

of the lung *  In 10 days, and probably before that, the lung was in contact,
in every part, with the thoracic parietes.  Surely, the operation did good
service.'  Is there any possibility of a like result having  occurred from the
use of the common  remedies ?   I think not.

    Case 16.—Mr.  II----, entered Mass. Gen. Hospital, May  28,  1853.
Irishman, in U.  S.  2  years.  Sick  three months  only:  he first noticed  a
cough, which came on after an exposure to wet and cold—no haemoptysis.
He was very ill  at  his entrance into  the hospital,  and continued to grow
worse, with signs of disease in both  cavities of the  thorax.  Flatness on
percussion was observed in the  lower part of both backs ; the respiration was
rude and bronchial  at the left;  mucous and sonorous rales everywhere.   He
was supposed to haA'e pleurisy of both  sides, and disease of the lungs, proba-
bly tuberculous.  On 11th of July, the report by Dr. Storer Avas as follows :
" Has been gradually failing during  the last week;  greater dyspnoea ;  at
 ach  A-isit  bathed  in cold sweat;  countenance, haggard, although he
constantly reports himself as comfortable ; pulse usually was 120."  On this
day I operated, at the request of Dr. Storer, between the  9th and 10th ribs,
and drew off twenty-three ounces of highly-colored serum.  On the subse-
quent day  the record was—" Comfortable day and night; respiration less
labored; pulse 110; countenance more tranquil."   He continued improving
until 17th, Avhen the dyspnoea was augmented.  He afterwards grew worse ;
and Aug. 5th, I punctured anew, and drew off thirteen  ounces  of colored
serum.   Little relief ensued, and he soon after left the hospital to die.
    Reflections.—The peculiar  nature  of the  fluid  is  the most  interesting
feature of this case.  No. 3 presented  the same fluid, and with similar result.
I Avould  draw the attention to the late date and the severity of  the symp-
toms before the operation was  allowed, but he obtained so much relief from
the first operation that he  gladly submitted to the  second.

    Case 17.—July 18, 1853.   I  operated  on a young  child, 6 or 7 years
old, who had been  operated  upon several times  by Dr. Wyman, of  Cam-
bridge, and who fell under my charge in the  absence  of  Dr. W. in Europe.
I removed twelve ounces  of pus with ease,  and with some relief to  the
patient.  He has, however, died since.

    Case 18.—July  18, 1853.   Saw J. B—, with Dr. W-----,  of Jamaica
Plains.   M, 19. Clerk, from a city in one of the  extreme Southern States.

   * This fact fully sustains the view of Valleix, and as certainly is opposed to that
held by Barth, upon the cause of  the cough after thoracentesis. See, in Appendix,
the analysis  of an  article on thoracentesis recently (Oct. 1853) published in the Ar-
chives Generalet de M&decine. 
IN PLEURITIC EFFUSION.
19
It appeared that he had been ill from December, when he had "fever" and
some cough, and obscure  symptoms.  From these he  slowly recovered  in
tAvo months, and resumed his Avork.   He, however, was never Avholly well,
and in the spring he came north to recruit.  At New York, he was seized
with what was called " fever," and was ill a few days.  Finally, four weeks
before I saAv him, he arrived at Roxbury.   He Avas then not well, but he was
able to walk about.  On the evening of July 4th, he was exposed upon the
Common, while viewing the fire-AVorks.   From  that  moment,  he became
rapidly worse, Avith debility, emaciation, total loss of appetite, febrile parox-
ysms every P.M., a very slight, scarcely noticeable cough; no expectoration;
no evident dyspnoea, even on going up stairs.  He could lie as Avell on one
side as the other, and move rapidly from one to the other, without the least
apparent difficulty of respiration.
    At my visit, I found him a frail-looking youth, evidently much emacia-
ted ; he Avas reclining on a sofa, and without  any marked  symptom.  His
breathing, during  conversation,  was  only a very little labored.  His  pulse^
usually about 80, Avas  rapid, apparently from emotion of  mind.   Only two
days before, auscultation had been performed,  and flatness  of the whole of
 the  right side of the chest, even  to  the apex, was found.  There was
 bronchial respiration in the breast, and absence of murmur elsewhere.  No
tegophony.  Fulness and Avant of motion of the intercostal spaces.
    July 19th.  I punctured in the usual spot.   More than eighty ounces of
yellow serum were drawn off, without the least  trouble to patient.  From this
moment may  be dated the commencement of the perfect cure of the disease
from Avhich he had suffered so many months.
    On 20th I found him in every  respect better—stronger, appetite better;
 less fever; sleep easier; respiration not heard outside of the axilla, but heard
 indistinctly along the vertebrae to  the base of  the back.  Friction sound to
 4th rib in front.   Iodide of potassium internally, and iodine tincture  exter-
 nally, Avere used as in the previous cases.
     26th.  Murmur pure to nipple; obscure in the lower half, and generally
 in the back.   All general symptoms better.  Countenance much  improved.
     30th.  He had ridden out  freely, and had gained strength daily; had
 eaten full diet, and his  digestion had  been  excellent;  had gained flesh.
 Rubbing sound heard on the back, down to the point of puncture. Percus-
 sion equal in both backs,  to the same point.
     August 15.  Fat and rosy, able to walk, ride, and eat as he pleases
 He felt well, better than since his  first attack in December.  Murmur heard
 to the base of the right lung, without  rale or  friction sound.   Percussion
 nearly like other side.  Continue  remedies.
     Aug. 26.   SaAv him at my room.  Weighed more than is  usual, when 
20             BOWDITCH ON PARACENTESIS THORACIS
 in health.   All rational and physical signs  improved.  Only the  slightest
 difference perceptible, on auscultation, between the tAyo lungs.
    Reflections.—Surely nothing can be more significant of cause and effect
 than the immediate commencement of recovery from long illness, after the
 operation.   The record gives but a faint idea of the  sudden, elastic bound
 with which every function of the body leaped into  healthy action,  the  mo-
 ment the incubus,  which had  been  for months depressing them, was re-
 moved.  On the  folloAving day the appetite Avas keen, the strength  aug-
 mented ; the urine, scanty before, flowed freely; the nights became easier;
 and the mental condition, as evinced  by his  countenance, showed that  a
 great load had been removed.
    The case is deeply interesting in other respects.  The length  of time  it
 had continued latent Avas thoroughly peculiar.  I do not believe, however,
 that he had had as much fluid as I removed, ever since his  first attack in
 December, that is, for six months.  Probably it had accumulated gradually
 at NeAv Orleans, Staten  Island, and Boston.  I have  never seen a case in
 which so much fluid existed with so little dyspnoea.   A moment  before the
 operation I made the patient turn rapidly from side to side on his couch,
 which he did without the least apparent dyspnoea.  Not a  single untoward
 symptom arose after the puncture, but everything tended  towards  restored
 health.  On the  11th  day he  rode  out, had gained flesh, &c.   On  27th,
 he was, as he  thought, in  perfect health, and the respiratory murmur  was
 heard to the base of the lung, while percussion gave almost equal results in
 both backs,—and this, too, after months of illness.

    Case 19.—July 30,  1853.  Mrs. L., I saw at Weymouth, in consultation.
 Mt. 20.  Two years before, she had been married, and had  been nursing till
 a few months  previous  to my visit.  Her  strength had been  much pros-
 trated.   A cough, with pain in the  right side of the chest,  came on in Feb-
 ruary, but she thought little of it.   The pain having subsided under a blis-
 ter, she kept at  her household employments, though not  entirely well.-
 Gradually, however, the nursing  and the local trouble overcame her, and  she
 had been obliged to give up nursing, and to  be confined to  her  house  for
 three  months, with evident disease of  the same side.   The  debility had  be-
come  greater, and she had taken to her bed.  The symptoms were pains,
never very severe, in the right side;  no, or but very slight, expectoration,
never haemoptysis   Coughed  less for tAvo Aveeks before my visit  than  two
weeks  previous;  but the cough was severe if she  lay on her left side.
Her appetite had been almost wholly gone for months. Urine normal in quan-
tity and color.  Occasionally, she had had a  chill, but no marked hectics.
   I found her lying m bed, emaciated  to  the last degree, and evidently
approaching her end, unless some relief could be obtained.   The right side 
IN PLEURITIC EFFUSION.                      21
of the chest was dull to the 2d rib; flat from there doAvmvards in front, and
throughout the Avhole of the back; no motion of that side; general promi-
nence of it.   Obscure bronchial respiration was heard generally throughout
the lung, with an indistinct broncho-aegophony;  no rale, even on coughing.
The other lung had puerile respiration throughout.
    I advised an operation, as a means of temporary relief, at least.  Accord-
ingly, I punctured in the usual spot, and  drew off ten ounces of yelloAV serum,
which coagulated  on standing.   Suddenly, she complained of faintness and
great stricture across  the chest; she was paler, and  evidently much dis-
tressed.  On the removal of the canula, and  putting her  upon the bed, all
unpleasant symptoms left her.  No apparent change in the physical signs.
    I advised a tonic course, and a repetition  of  the  operation, if sufficient
relief were obtained from that just finished.  She passed a comfortable night,
and afterwards she Avas able to lie with  ease on her left side, which she had
been unable to do for months before.  The next day, by report of her phy-
sician, the dyspnoea was less.  The fluid taken from the chest was nearly all
coagulated.
    In a few days  the swelling of the legs, which had previously subsided
after the operation, returned; and, with it, the cough became more urgent,
attended with an increase of many of her other symptoms.  The patient re-
quested that I should be asked to operate again.  Accordingly, on Aug. 3
(five days from her former operation), I examined her anew.   The tubular
respiration was extreme, and perfectly cavernous throughout the affected side.
In truth, it was so marked that I should have hesitated upon  the  propriety
of puncturing, for fear of  piercing a solidified or excavated lung.   The fact
of having found fluid previously, induced me to puncture again.  I did so, the
patient being in a horizontal position.  I  could not remove but four ounces of
fluid.  Some  air rushed into the cavity as I was probing  the  canula.  No
apparent  effect, either then  or subsequently, Avas produced thereby.   The
patient bore the operation well, fell into a quiet sleep afterwards, and her
cough, from  that  time, ceased  to be troublesome.   No unpleasant effects
followed the puncture; but the patient gradually greAv feebler, and died Aug.
13, i. e. on the tenth day from the last operation.
    Autopsy hurriedly made at 4, P. M., the same day.   A quart  of fluid
Avas found in the right pleura, about a pint in the left.  The  left  lung was
free and healthy, except one small dot of tubercular disease.  The right lung
stood out from the vertebrae, solid and firm to the last degree.   It was uni-
versally tuberculous.  The upper lobe consisted of one large, solid, tubercu-
lar mass.  The pleura was opaque with lymph, and  at its upper  part Avas
adherent.
    Remarks.—The strong cavernous or bronchial respiration, in connection
with a fluid, and condensed  lung, is an  interesting fact, and corresponding 
22
BOWDITCH  ON PARACENTESIS THORACIS
verv exactly with observations recently made in Paris.   In regard to the
advantage of the operation in the case, I have merely to say, that if I  were
to have a similar case, I should advise the  same course.   The  relief which
the patient obtained after the first puncture, in being able to he easily on
the left side, and the total cessation of the severity of the cough, after the
second; the fact that the patient begged to have a second operation, because
of the relief afforded by the first,—all these convince  me of the importance
of the operation as a means of relief.

    Case 20.—August 30, 1853.—Miss-------, of Maine, I  saw in Boston.
A\i. 23.    She had  never  been very  strong, but neArer seriously ill till
present illness; always liable to  cough on  taking cold, i.e. Avhen having
corvza.  In August, 1852,  she  had hoarseness,  lasting for  months  and
growing worse until  December, at Avhich time her strength was very much
reduced and she had  night  sAveats.  She  had slight  cough ever after.
Never pain in the chest; no tickling or trouble in  the throat.   Her expec-
toration had been, at times copious, frothy, and generally white ; once she
had hiemoptysis, perhaps an ounce,  after  walking.  During February, she
was quite  ill, and Avent rarely out of the house.  After the 1st of March, she
began  to ride, and improved  rapidly.   She also used the cold-Avater sheet
daily.  About the 1st  of June, after "taking the  sheet" more thoroughly
than usual, she Avas seized with a chill and a fever, and  a bad cough with
great soreness of  the chest  and shoulder, and orthopncea.  As these symp-
toms subsided, the cough which she had had before subsided, and she again
"ained very rapidly.  From  this  attack she had  continued somewhat  to
improve under cod-liver oil, but the left side had always  been  a little  more
" sensitive " than the other.
    I found her rather  thin, but unusually bright and acti\'e.   She had no
apparent dyspnoea, save on  exertion, especially after walking up stairs; then
it was  manifest, though she  complained of it but little.   She  had no hard
accesses  of cough, but a  frequent sense of  irritation about the chest,
provoking a cough.  No expectoration; always some irregular action of the
heart, with fluttering at the pit of the stomach, until  within the three weeks
previous to my seeing her.   Tongue, clean; digestion, good.  The urine, in
June Avas,  for tAvo  or three weeks, dark colored and small in  quantity ; of
late, perfectly normal.
    On percussion, less sound through the  whole of left  back than the
right; quite flat  towards the base.   Line of dulness varied with change of
posture.   No rale, except perhaps, on coughing, at the top of the left lung
and just below the angle of the scapula.  The respiration was heard in the
left breast, but below and under the axilla  and in the  back it Avas indistinct. 
IN PLEURITIC EFFUSION.
23
iEgophony in the lower half of the back.  Left side more rounded than the
right.  The heart beat to the right of the sternum.
    P.M.  I punctured, and drew off eighteen ounces of a yellow serum,
which was all  that  could  be extracted, notwithstanding the patient was
placed in various positions.   She was nauseated, and vomited her  dinner.
There was little cough, and her pulse was small and regular, at 80.   The
heart fell somewhat toAvards its nonnal position.  The  patient stated that
she felt as if she needed support, and as if she had " lost half of her side."
Treatment as in previous cases, with nourishing diet.
    August 31.  (i.e. 24 hours after the operation),—could go up and down
stairs with much  less dyspnoea.  The heart was  no  longer dislocated.
There was crackling throughout the lung, even to the base.   The night had
been rather restless; she could not lie on the left side, owing to a pain in it
when so doing; no fever or other trouble;  her pulse was 92; she Avaa
sitting up and looking finely; her cough was more, but no expectoration.
    From this time  till September 10th (11 days  after  the  operation), she
continued improving.   On that day, I noted as  follows:—Much  stronger;
cough only of the most trivial character; some dyspnoea still (but less than
before) on walking  fast, &c, had walked, however, a mile or more without
fatigue.   Percussion gave nearly equally good results in both  backs ; but
under the axilla and around to the front, near the cardiac region, it was dull.
The  respiratory murmur was heard  throughout the left back, but where
there was dulness  on percussion the murmur was indistinct, with a crack-
ling on full breath.
    September 21.  No cough or scarcely any  for the past week.   Her
strength was less  and her appetite was not quite so good;  some dyspnoea
on exertion, but she would be disposed to exert herself much more than her
friends deemed prudent.  She soon after returned home.  I advised her to
use the cod-liver oil, and to ride out daily.
    October 30.  I learned by letter  as follows :—" I have  been very well
since I left Boston, I have had no cough  or cold, I am, however,  slightly
hoarse  most of the day."    She states, that  some dyspnoea  remains on
walking fast.   She had gained a great deal of flesh and strength, so that
she could endure much fatigue.  I learned from  a friend, that  our  patient
seemed  to those about her, nearly if not quite well.  From the physician
in attendance, it appears that the dyspnoea of late has been augmenting.
    Remarks.—I regard this  case as one probably tuberculous.  The attack
 of pleurisy for which I operated came on in  June, the patient having had
 cough  for months  before.   Phthisis,  I  think,  will  probably   be  the
 result, but  the pleuritic effusion was relieved,  as in  cases  7  and 15,  as
 evinced by the lung expanding immediately.  If the effusion should return,
I see no objection  to a repetition of the  puncture. The  chief points  of 
24
BOWDITCH  ON PARACENTESIS THORACI9
interest however, are the immediate expansion of the lungs and the sudden
improvement in the health, even if it be destined eventually to fail.

    Case 21.—Aug.  18, 1853, Mr.-----, aet. 42,  generally in active busi-
ness ; and for a time before being taken ill he had been very much occupied,
and had been perhaps less strong than  usual; for many years he had had
some  trouble in the right knee ; three weeks before he called on me, a cough
had commenced which had continued ; expectoration slight, in the morning,
white;  two or three times he had been aAvakened by pain in his right side ;
on arising he had at  times some dyspnoea, but generally he had attended to
his business with comparative ease, although satisfied that he was not wholly
well; he Avas able to lie  on either side ; he could go  up stairs Avithout much
dyspnoea; digestion perfect; appetite excellent; some loss of flesh ; he had
consulted one or two physicians, who had advised trifling external applica-
tions which gave no relief;  no one had ausculted him.
    When he called on me, his countenance was not unhealthy, although his
face was rather thin ;  he Avalked readily to my room, and seemed to have no
dyspnoea; his pulse Avas 80, and regular ; his skin Avas normal; his tongue
was clean.  The rational  signs denoted  nothing of importance; no  hered-
itary  predisposition to pulmonary disease.  On percussion, there Avas flatness
in the lower two inches of the right back,  dulness varying  with change of
posture.  Murmur  heard to the bottom, but less than at the other side; no
aegophony.   Iodide  Potassium gr.ii., three  times  daily, and Tinct.  Iodine
externally.   He was told to use a chiefly vegetable diet, and  avoid all un-
due exposure and over-exertion.
    Aug. 20.  Less cough, and less oppression ; no pain in the  right side for
three  days, though occasionally he had  some in the left breast.   No fever;
and he looked wholly well.   On percussion, less dulness at the right back ;
rubbing sound in left  breast, and a  fine crepitation along cartilages  of left
ribs.  Iodine had produced a full effect.  Apply it to both breasts.
    Sept. 2.  General aspect and symptoms  same,  but the physical sign*
prove an increased effusion ; more  dulness, with aegophony, in the  right;
crepitus less at the left.
    Sept. 7.  Finding still an increase of the effusion,  so as  to affect the
lower half of  the  right chest, and that the patient was evidently losing
ground, having less strength  and much dyspnoea on exertion, I suggested an
operation.
   This  was attempted  on the 7th, but, owing to  an imper'ctipn of/ the
instrument, no fluid could be draAvn  out. The patient suffered  only momen-
tarily from the puncture.  On 8th, I drew off fifty-four  ounces of yellow
serum, rapidly coagulating.   The patient was a little faint after it.   Crack-
ling appeared  in the compressed lung.  In a few minutes after the opera- 
IN PLEURITIC EFFUSION.
25
tion he felt as he " did before his illness;" that is, all sense of oppression was
gone.  One half an hour after the operation,  the  urine, having been  dark
and  small  from the first of his  illness, suddenly increased to  double the
usual quantity, and became thin and  pale.   Pulse 92,  a little hard.   Or-
dered to keep quiet, and take bread and tea for food.
    Sept. 10.   Abed from Aveakness, but nights much easier ;  no dyspnoea ;
little or no cough.   By auscultation  it appeared that the lungs had ex-
panded to  a  level Avith  the point of puncture.  Dulness on percussion, and
;egophony  beloAv, but less marked.    Resumed  Tincture of  Iodine exter-
nally.   From this time the steady improvement continued.
    Sept. 12.  (Fourth day after the puncture).  There Avas crackling to the
base of the lungs, and the aegophony Avas nearly gone.   Pulse 80.   Tongue
and digestion excellent.  Strength  improving.  Ale at dinner.
    Sept. 14.   (6th  day from operation).  No cough,  fever, or dyspnoea.
Only trouble  was Aveakness.   Urine natural  the last feAv  days.   On full
breath, a fine, crepitous  rale to the point of puncture.   Voice only a  little
modified.  May have pigeon for dinner, and half  a pint of ale.
    Sept, 28th.   (20th day after the operation).  Had been gaining finely.
Able to ride and \valk out, and to eat and drink with relish.   Countenance
ruddy.   Percussion still slightly dull at  the loAvest part of the back, but the
respiration was heard everywhere without rale or  aegophony.   The murmur
was not, however, free except on  forced  breath, indicating that the lungs did
not even then expand Avith perfect freedom.
    Oct. 6.  Percussion  equal  in both  backs, and respiration  everywhere
pure.  By  advice, he this day  went into the country, and on  12th (that is
just thirty  days after the operation), at  his return, he looked and felt better
than he had been for many months. No cough or unpleasant symptoms, only
slight  dyspnoea on  active motion.  Physical  signs—difference  of  pitch
only, no real dulness.  Voice well.  A slight rale only, on full breath at the
bottom of the lungs.
    AlloAved to go to his  business, and has continued perfectly Avell up to the
present date (Nov. 14).

    Remarks.—The someAvhat  latent character of  the disease  in  this case
and the sudden relief, are as remarkable as in some of the cases previously
detailed.   The dyspnoea on the day before the operation had  become very
great, the nights were very restless, and the patient's Avhole aspect was that
of a man suffer s.g  from severe  disease,  which,  in  spite of remedies, was
progressing steadily.  An operation Avas performed, and instantly a change
took place.  He felt as he did before illness; his dyspnoea left him ; he slept
tranquilly at night; his appetite improved, and all the functions  of the body
went on healthily.  On the fourth day,  the compressed lung had expanded,
arid on 20th day from the operation, the respiration Avas heard everywhere,
                         4 
20
BOWL-ITCH ON PARACENTESIS THORACIS
 and the patient was able  to  ride, walk, and eat, like a man  in  health.
 Would he have  progressed  so  rapidly if the operation had not  been
 performed?  Did it not only relieve, but likewise act as the great means of
 cure ?   The patient dates from it, the  commencement of his cure : I believe
 him to be right in that opinion.

    Case 22.—September 28, 1853.—Mr.-------, lawyer,  I saw in Boston.
 He called  at  my office.  His history was as follows :—Never very strong,
 but never any severe diseases till the present.   This began last March, with
 some trivial pain in the  left side, and cough, with  little expectoration.  He
 was believed to have slight pleurisy.   The cough  decreased  much in May
 and June.  Afterwards,  all  the symptoms had gradually augmented, but he
 had travelled much and had been able to walk freely, though easily put out
 of breath within the foAv weeks  previous to calling at  my office.   He had
 experienced some difficulty of lying on his left side, and his cough had
 been more urgent, and within a week, it had been attended by retching and
 vomiting.  His appetite  had lessened, and he had been oppressed by food,
 with a slight tendency to diarrhoea for three or four months.   Urine small,
 normal in color.   Debility, emaciation;  chills occasionally, and  in  the
 summer he had some  sweats, none of  late.  At the visit, he appeared thin,
 and evidently suffering from long  disease,  considerable panting  while
 speaking.  Pulse 112.   The cough, on that morning, had  lasted for about
 three minutes, and had been quite harrassing.   The respiratory murmur, was
 less, front and back, at  the left than  at  the  right side, somewhat obscure
 likeAvise at the top of the right.  No rale  anywhere.  Flatness, changing
 with change of posture, and aegophony over the lower half of the  back.
 Heart  to the right of the sternum.  He had had  veiy little  medical treat-
 ment.
    I decided immediately,  that the first thing to be done was to remove
 the collected fluid; accordingly, October 2d, I punctured in the usual spot,
 and drew off seventy six ounces of yellow,  coagulable  serum.   The  heart
 fell back at least l£ inches  towards its normal position.  The murmur was
 heard  more  distinctly  front  and back.   The percussion was  less  dull.
 Ordered to keep quiet, to take light food, Iodide of Potassium grs.ii. three
 times daily, and to use Tincture of Iodine externally.
   From the time of the operation there was a steady  improvement, though
 slow.   On  5th, he reported  no dyspnoea, and that the cough was very much
 relieved.  Pulse 84, softer and fuller.   Urine a little  increased, and lighter
 colored.  On  7th  (5th  day  after the  puncture), looked much better;
 wanted to  eat  more and to go  out.  He had  sweats  at night.   Murmur
 heard to the base, and fine  taffeta crumpling on full breath.  Resonance of
voice, which had been very marked before the  operation along the vertebras 
IN PLEURITIC EFFUSION.
27
was  much  less.   No  aegophony.  Heart in normal position.  Walk out
carefully; eat simple meats, half glass of ale at dinner.
    October 22  (20 days  after operation).  Had sweated  less.   Able to
walk tAvo or three miles daily; felt he was gradually improving.  Right
side of the chest three-quarters of an inch larger than the affected one.
Still quite dull tone on back.   On full breath, lung seemed to expand with
crumpling.
    October 29 (27th day).  Percussion almost  equal in backs.  Respira-
tion heard indistinctly, but unequivocally, everywhere.  General symptoms
also much better;  cough very  slight;   no sweating  and  countenance ,
improving daily.
    November  5  (34th  day).   His  report was,—Had  gained strength;
cough, very little; no hectics;  appetite and digestion perfect; on percus-
sion, nowhere really dull, but least clear outside and under axilla; respira-
tion very obscure there; resonance of the voice less, behind.
    This  gentleman is still  under treatment,  and daily improving.  He
attends now (Nov. 14) moderately to  business.  Whether  the lung  will
ever come fully up, so that the murmur will be heard in both equally well,
is a question I cannot answer,—time must decide.   But as to the utility of the
operation, no one can doubt.  Look at the facts:—A pleurisy had existed,
with a gradually augmenting  effusion  and increasing  disturbance of the
general  system, from March till  October 2.  Then an operation was done.
Immediately, a change took  place.  The dislocated  heart resumed its
natural  position,  and the circulation went on well.   The lung,  that  for
months  has  been compressed,  expanded; the dyspnoea subsided.   The
digestive functions were restored.  The hectics left; and  all these  events
took place within a month !  Surely, no one  can doubt,—first, that the
operation was the primary cause of the  cure ; second, that  without it he
would probably have gradually  grown worse, and  would  have  been an
invalid for months.  Possibly,  after months, a fistulous opening might have
formed.

     Case 24.—October  14, 1853.   E. C----.   ^Et.  40.   Irish laborer.
Always strong, but in former days had very freely indulged all his appetites.
 His disease commenced  about  the  first of January,  1853, after a long
 exposure, during  more  than  twenty-four  hours, while  endeavoring to
restore to  its proper  place  a locomotive  that had run off  the track.  In
 addition to an exposure to a violent snow storm, he had had very hard labor.
 He felt at the time, that he had taken " a bad cold."   Very soon afterwards,
 a cough began, slight and dry at first, with " stitches" in  the right side.
 Once  he had raised a  tea-spoonful of blood, as he believed, from his throat.
 He did  not work for three months.  Finally, he undertook again  to do so,
 although the cough continued, and he knew that he was weak  and  by no 
 2S            'BOWL-ITCH ON PARACENTESIS THORACIS

 means well.   He  was  frequently  disposed   to  vomit.  This  stomachic
 difficulty was much more troublesome than the pulmonary ones.
     He continued vomiting more  or less daily until July 19, when he had
 an access of it more serious than  any of its predecessors.   He was obliged
 to cease Avorking from that time;  and although able to go about the house
 and was often  out of doors, he had been a permanent invalid till the period
 of his A-isit to me.   In  order to  do this, he  had walked upAvards of two
 miles and a half, and without much difficulty.   I learned that the vomiting
 ceased three months before ;  his cough  had been less severe, but it was at
• times very harassing;  his appetite was very poor ; he could not bear meat
 or liquors, because of the increase of the cough;  his alvine discharges had
 been  regular till a feAV days before his visit, since  then he had been costive.
 He had had hectic paroxysms, but less for a period previously to  my seeing
 him.   Eight  or  nine  weeks before  that, he accidentally  observed,  on
 moving in  his chair, that there was  a "swashing" in his  chest.  This
 phenomenon had continued on every rapid change of posture.  He had no
 pain or other  serious symptom in connection  Avith it.   His  aspect, at his
 first  visit,  was that  of a man  not  very  ill,  but evidently  suffering  with
 dyspnoea, as evinced by his short, panting breath, his lividity, <fec.  Pulse 92,
 regular.  Could not lie on right side because of cough, Avhich last was least
 when he Avas quiet.   Swashing heard at a distance from the patient; inter-
 costal fluctuation perceptible to  the hand placed on  the side.   Tongue,
 with a thin moist coat; appetite, very poor;  costive;  urine heavy, dark,
 smelling strong, and of the usual quantity.
    Inspection.—Left chest bulged  generally;  no local prominence; by
 measurement f inch larger than  the right.   Respiration Avholly absent at
 the left; puerile  at  the right.  On percussion,  resonant in front; but it
 became totally flat Avhen patient leaned forward to the  horizontal  position.
 Behind, flat in the lower half.  Voice scarcely  heard at the left;  no tegoph-
 ony.  Natural at the right.  A slight metallic  echo  (On speaking) in the
 left breast from under clavicle.
    Advised to enter hospital, and to have a puncture made.  The patient had,
 as already stated, observed the  existence of fluid, and had asked the attending
 physician to " open his chest;" which the gentleman  declined to  do, on the
 ground (and a true one too, so far as it relates to the  opinion of  the profes-
 sion), that the medical profession did not allow such  a course to be proper
 or prudent treatment.  October 21.—I punctured his chest at the  hospital,
 Avhere he was subsequently treated by my colleague Dr. Storer,  until  Nov.
 1st, when I took charge of the wards.   I drew off with the  greatest  ease,
 sixty-four  ounces of pure pus.  Considerable cough occurred during the
 operation,  and one  or two  bloody sputa were  raised ; but otherwise he felt
 quite comfortable; he was  bright in his  mind, and  was much  relieved of
 " weight."  Pulse 96. The lung, however, did  not seem disposed to expand, 
IN PLEURITIC EFFUSION.
29
but air appeared to take the place of the fluid, and  the metallic tinkling
Avas  heard  throughout  the  left chest.   Slight haemorrhage  from the
puncture;  stopped by a little lint and adhesive plaster.  A bandage was
applied to the chest to relieve the sense of vacancy.
    This  case  is  still (Nov.  10) under  treatment:   He  has sloAvly, but
steadily,  improved in his general symptoms.  He eats the house diet Avith
relish.  He has no fever paroxysm, and has more strength than  for months
past.  The lung seems very slowly expanding.   The " swashing " remains,
but there is no return of the fluid.  The left side isless than a quarter of an
inch larger than  the right;  that is, it is half an inch smaller since the
operation.  The heart is still dislocated, though less so  than before the
puncture.   A good vesicular respiration is heard to the spine of the scapula.
Below that, to the angle, it is less distinct; also, still less in front.  Outside,
it is not  heard.   No  crackling anywhere.  A metallic  echo is perceptible,
with each vocal  resonance, under the clavicle and  beloAv,  around to the
angle of the scapula.  Above, to the spine of the scapula, it  is distant.  At
the very apex it is not heard.  I believe that the  lung lies in contact with
the parietes at the apex, at  a short distance from it, down the back, and that
it has expanded a little generally.
     The  prognosis in this  case  is doubtful.   Evidently, the rational signs
 have improved.  The patient feels and looks better.  He can lie on the
 right side, which he could not  do.  He eats meat  now, which distressed
 him and increased his cough  previously.  The lung likewise has expanded
 slightly.   From Aveek to Ayeek it seems very slowly getting  larger.  I have
 determined that if the fluid  returns again, I  shall puncture and inject into
 the  cavity Tinct. of Iodine,  as  recommended by Drs. Boinet* and Aran, f
 I see no objection to  using such treatment, even where air alone exists; but I
 prefer to Avait for the present, while the patient continues to improve.

     Case  24.—This  Avas a case attended by Dr.  J. M. Warren, which he
 kindly  alloAved me  to  see.   I  saAv him October 20,  1853.  Mt. 21.   A
 farmer.   It appeared he had been ill Avith pleurisy since  March.  He had,
 however, been  able to Avalk out of doors, from two weeks after his first attack.
 In  June, he suddenly began  to  raise a large  quantity of pus.   This raising
 of  pus and mucus daily, had continued  up  to  the  hour of my seeing him.
 It was  then amounting to about a quart in the twenty-four hours.  His
 pulse Avas quick, 118  to  120; he  was  emaciated, but still did  not look
 exactly'tuberculous.  His  appetite was good; his bowels were regular.   No
 hectics.   Gurgling was heard on succussion.  The right side was larger than
  the left, but no part of it was pointing.  There was total flatness on percus-
  sion, from the top to the  base  of the lung,  front and back.  Crackling at
  the top, but no tubular sound or extreme vocal resonance in front.

     * Archives Gdne>ales de Me"decine.       f L'Union Medicale, August, 1853. 
30
REVIEWS AND  BIBLIOGRAPHY.
   Dr Warren punctured between  the 8th and 9th  ribs behind, and one
pint and a half of pus was removed with ease.  The patient  felt relieved.
Crackling was heard lower down, and the respiratory murmur was heard
along the spine, slightly but unequivocally.
   November 5.   He  visited Dr.  W., in Boston, who found  him much
better, and  the lung was expanded  much more.   I did not see him.   He
remains still under treatment.   He came to Boston, thinking to be operated
on again; but Dr. W. found such improvement in  the rational and physical
signs, that he forbore.
   Ten days afterwards, November 15 (26 days from the first operation), I
saAv him again.  He reported that  for several days  after the puncture, he
had coughed scarcely at all, and had improved much in his general feeling;
but Avithin  a week the  cough had  been  as bad and the expectoration as
copious.   On  percussion, there was  some  resonance  to an inch  above the
angle of the scapula, and the  respiration was heard there, but still much less
throughout the side than on the other lung.   Twelve ounces of pus were
removed with much comfort,  and the patient returned to the country.
    Is  not this a proper case for a permanent opening and for iodine injec-
tions ?  Air evidently gets  into the pleura through the lungs, so that the
objection of admitting the external air by a permanent opening is not valid.
2d.—The pus now  accumulates, and has to  be coughed up.   Would it not
be better to let it run out ?  Probably, the cough  would be much lessened
thereby.

    Case 25.—Sept. 28, 1853. I saw  at S., in consultation.  He had  been
ill from March, and particularly so from July, with acute pains in the left
side at this latter period.  His symptoms were  those of pleurisy, following
 tubercular disease.   He had cavernous respiration at the upper  part of the
 left lung in front.   The heart was not dislocated,  and it had a strong  thrill
 with each pulsation.  The lower half of the  back was quite dull, with ab-
 sence of respiration, a broncho-aegophonic vocal resonance.   Notwithstand-
 ing the cavernous respiration and the non-dislocation of the heart, I was
 disposed to regard part of the symptoms—dyspnoea and oedema, &c.—as, in a
 measure, caused by an effusion, to a small amount.   I proposed, therefore, a
 puncture, although satisfied that  serious tubercular  disease existed at the
 apex of the lungs.
    Oct. 1.—Having tested still further the existence of fluid, by a change of
 posture, I punctured a little outside of the line from the angle of the scapula.
 No fluid could be obtained—and I desisted.  The patient suffered no incon-
 venience.   I would mention, that before operating I stated that such might
 be the result, and that if any fluid came it might not give relief, but that,
 considering all the signs, I should advise that the operation should be done.
 No subsequent evil resulted from it.   It  may be asked, why no fluid was 
IN PLEURITIC EFFUSION.
31
obtained.  The answer is difficult.   Such an event has  happened before—
vide cases 5  and 6, also once in case 9.  I think it very probable the lung
was punctured.  The case is interesting as showing the innocuousness of the
operation, whatever may have been the nature of the case.

    Case 26.—Sept, 12, 1853.   Mr.-----, I saw  in  consultation.  Mt.  60.
He was a gentleman well known in political life, and of a very active tem-
perament.  He had been ill from February.  He had had  cough for some
weeks, but never pain in the side—nor dyspnoea.   He had had haemoptysis
slight, in the early part of the disease.  From the first,  he had felt that he
should  die, and, therefore, was  unwilling  to use  remedies.   When I saw
him, his mind had become very dull, and he lay most of the  time Avithout
speaking or  eating.  Pulse, 80  to 100.  For several days he had taken little
food.   There was dulness at the right back, and  less murmur throughout
same  side.  The dulness changed with the position of the patient.   At  the
bottom of the right back there  was a prominence, feeling solid, but  elastic,
and separating the ribs.  It resembled the lobule of a  scirrhous mass, but
there was no discoloration of the superficies.  I advised  the puncture, feeling
that it was the sole chance of possibly relieving him.  Great objection was
made to it for several days.  Finally, I was requested to see him again.   I
then, for the first time, knew of the existence of the  tumor.  He  was  so
much sunken, and the prospect that combined with  the pleurisy there was
malignant disease, the knowledge that the patient himself was opposed
to  all attempts to cure him, determined  me not to operate:  I therefore
declined.
    Following* is a tabular statement of the prominent features  of  all  the
cases I have had under my own charge since April, 1850, with a few treated
by others, and which I saw in consultation.
    From this tabular statement we see that—
    First, No one of the patients operated on  experienced a single danger-
ous symptom, or any materially unpleasant symptom, except for a short
period.
    Second, Out of twenty-five persons, only three failed of obtaining relief.
Of these three, two had had l^ng, probably tubercular, disease ; and fromtf
the other no fluid  could be drawn, owing, perhaps, to an imperfection of the
instrument which I used in my earlier operations.
    Third, In more than half of the cases, the puncture was the first reme-
dial agent, that decidedly arrested the progress of the  disease.  This it did
in two modes.  1st, by allowing the lung to expand immediately, and pro-
ducing thereby a rapid cure.   2d, by so stimulating  the functions of the
body, made  torpid  by long disease, that they immediately, sprang into
healthful, vigorous action, while the lung expanded more slowly.  Cases 7,
* See pp. 42—46. 
32
PARACENTESIS THORACIS
14,  15, 18, 20, 21 are illustrations of the first, and 1, 8,11, 12, 22 of the
econd class.
   That this stimulus which I have mentioned as occumng in the second
class, actually takes place in many cases, I am sure.  I have so repeatedly
noticed it  that I now confidently hope for its occurrence, when I do not find
that a case, after a puncture, is likely to be of the first  class.   I do not
mean to state that the stimulus shows  itself immediately, or that  it acts
Avith rapiditv in eveiy case, but simply that from the moment  of drawing
off the fluid", I have been able to trace a series of favorable influences tend-
ing towards  health.
    Fourth,  In about seven-eighths of the cases, the operation has  given great
relief to prominent  and  distressing symptoms, insomuch that the patients
have asked for a second, third, or fourth puncture, as  a means  of relief
only.
                Symptoms Consequent on the Puncture.
    These  were very similar to those reported in my former paper.  The
pain of the puncture was the chief trouble, and this, as  it was  momentary,
Avas but little noticed by the majority.  Stricture  across the chest Avas occa-
sionally noticed towards the end of the  operation.   The cough was  aug-
mented in many.   This I regarded as a favorable sign, as it usually indicates
that the compressed lung is beginning  to expand.   In one case this symp-
tom was excessive, it having lasted twenty-four hours almost without inter-
mission.   In this case the lung  arose instantly from its  compression.  One
had vomiting of her dinner, the operation having  been done in  the after-
noon.  In all, where fluid  Avas  obtained, the oppression was someAvhat re-
lieved ;  in one, impending suffocation was prevented.  Most of the patients
were exhilarated by the success of the operation, as  in  our  previous set of
cases.  In one, there Avas a slight oozing of blood from the point of- punc-
ture, which, however, was easily checked.
    The pulse remained tranquil, as much as it was before the operation.
    The digestive functions were improved.  In all, where much fluid Avas ob-
tained the appetite was improved with singular rapidity.   One person asked
for food before we left the house.          ,
    The urine Avas augmented frequently by the operation, a fact which I
noticed often Avhen analyzing the first set of cases.
    In none was the fever augmented, or a febrile paroxysm excited.
    The physical signs altered slowly in some  cases, in others very rapidly.
The patient in case 15, having been ill  a few Aveeks, presented the phenom-
enon  of the lung completely expanded and filled  with rales the  next day
after the removal of five pints of fluid.  Generally, hoAvever, a  more slow
process was carried on, the lung expanding in  the first few hours only along
the vertebrae and at the apex, and thence more or  less  gradually rising  to
meet the  parietes of the chest; the parts under the axilla being, of course, 
IN  PLEURITIC EFFUSION.
33
the last to fill out.  In some  instances that  state of the lung described by
Gardner,* remained for months, the patients being  nearly free  from  all
rational symptoms of disease, save, perhaps, a tendency to dyspnoea.   Cases 4
and 14, are examples of this.  Cases  22, 23, may become so.
    The character of the fluid drawn from the chest varied, as in our other
category  of cases.  By a reference  to the tabular  statement, it will be seen
that from forty-seven punctures, the following results were obtained :
                                 Table  2.
          Nothing,........................................................5 times.
          Serum, a few drops only (2 cases),................................. 4  "
          Serum in large quantities,........................................16  "
          Pus, or purulent,............................  ....................17  "
          Bloody,......................................................... 5  "

    The  quantity of the fluid varied  considerably; three ounces being the
smallest,  one hundred  and seventy ounces being the largest.  In this latter
case it was pure pus.
    The influence of the character of the fluid, the length of the disease pre-
vious to  the operation, and the existence or  non-existence of previous dis-
ease, may be learned by the folloAving series of tables.

                                 Table  3.
Chaeactkr of the fluid in the Chest.          Sebum.         Pus.       Bloodt.       vTotal.
Recovery from pleuritic effusion,................7 cases,........5 cases,........Urease,.......1J! cases.
Death afterwards, consequent upon the effusion                          /
     and previous disease,.....................3 '•  ........4  " ......J..............jf  "
Friction-sound heard, but death a few weeks
     after from disease of brain,................1  "  ................................... 1  "
Under treatment, doing well,...................1  "  .................................... 1  "
Under treatment, with prospect of months of
     illness,.................................................2  " ..................... 2  "
                                                                     24 cases.
  ^■Hflfiems, therefore, that the presence of serum is more favorable for the
prognosis than is the existence of pus.  This only confirms  our preconceived
notions, but it is rather different from the opinion I advanced in my previous
paper, the facts contained therein not allowing me to hold the opinion I
now advance.
    The next  important element  in the prognosis, is the  length of  time the
disease has lasted previous to the operation.   The folloAving table will show
this.
                                 Table  4.
                                        Sebum.            Fua.         Bloodt.
Average time before puncturing J recovery..........2| months,.........2 months,........
   in cases  of,             I death,............3  months,.........A\ months,.........3 months.
    Whence it appears that whether pus or serum exists, an early operation
is more favorable than a later one.
» British and Foreign Medico-Chirurg. Review, April 1853, Art. XI.
                  5 
34              BOWDITCH ON  PARACENTESIS THORACIS
   The influence of the existence or non-existence of previous disease may
be illustrated by the following.
                              Table  5.
                                            Of those who had
                        no disease immediately preceding   |   cough, and were probably
                              the effusion,                   phthisical,
Recovered from the effusion,....................10...................................4
Died with effusion remaining,...................  0...................................<5

    From  this  table Ave infer, Avhat, in fact, we kneAV before, that pleuritic
effusions, uncombined Avith serious pulmonary disease, do not usually destroy
life.   I cannot  but think, hoAvever, that in case No. 2  the operation  may
be said to have saved life, for a time, at least.   In case  15 I have no doubt
suffocation Avould have taken place, had not the operation been performed.
    Another interesting inference is suggested by this table, viz., we observe
that of 10 avIio had organic diseases, 4 were cured of the pleuritic effusion:
6 died. Noav, the puncture Avas the  sole cause of the cure of these four, for
the lung expanded in all of them within twenty-four hours or a few days after
the operation Avas done.  No  other cause  operated, and therefore to the
thoracentesis Ave must attribute the cure.  Is  there any physician that can
say as much of any other method of cure under similar circumstances ?  Is
there  any  remedy Avhich  will cause an  absorption of five  pints of fluid  in
twelve hours, and alloAv a lung  that has been  compressed for months to be
thoroughly filled with air in twenty-four hours ?
    In confirmation of  these remarks, and  to give the reader  a more defi-
nite idea of the amount of influence  the puncture had towards the  cure or
relief of the effusions,  I  submit the following data taken from my  own
cases, compared with similar data obtained by the courtesy of  Mr.jftM^, Savvr*
at present house-pupil of the  Massachusetts  General  Hospital,  from  the
records of that institution.  In preparing my. own, I have taken, first, all
those  cases in  which the lung, after having  been  for weeks, or  perhaps
for months compressed, has  suddenly expanded, within  twelve or twen-
ty-four hours after  the  puncture;   second,  those in which the  stimulus
above spoken of was given to the various functions of  the body, so that all
the rational signs grew decidedly  better from  the moment the fluid was
evacuated, while the long-compressed lung dilated but slowly.
    In the first, the lung expanded immediately, or within twelve hours after
the puncture. In the second, the lung, on average, in 32*  days, or 44 weeks
after the puncture.
    I think no one can doubt that paracentesis cured the disease in the first
class of cases.   In proof that  it  aided very  materially toward  the same 
IN  PLEURITIC EFFUSION.
35
results in  the second class.  I  present the subjoined table of comparison
betAveen  my cases and those treated at the hospital.*
                                Table 6.
                                Hospital casks.             My cases.
                           ,-----------------*-----------------, ,-----------------A-----------------^
                           Whole length I After entering I  Whole length I     After
Length of time the disease lasted.   of the disease. |   hospital.  | of the disease. | Thoracentesis.
Average duration  in  cases )
  of complete filling of one >  12 +weeks.  6| + weeks.   13 weeks.     3 weeks.
  pleural cavity,          \
 do.  do.  partial  do.  do.  12   "      6£    "     9i   "       4   "
    Supposing all these data to be absolutely correct, I  might  draw from
them the following  propositions.
    1st.  One pleural  cavity being full of fluid.—a. Thoracentesis  shortens
the disease more than one half.
    2d. One pleural cavity being partially filled.—b. Thoracentesis shortens
the disease more than one third.
    I  do  not, however, present  them  as  absolutely correct, but merely as
approximations to the truth.  But I do not see that any one can deny, that
puncturing the chest does  very materially shorten, and consequently alle-
viate  the sufferings  of a patient affected with  pleuritic  effusion.   As if  in
confirmation of this view,  we see that although it appears,  in  my  cases  of
complete filling of  the  pleural  cavity, that  the whole duration of the dis-
ease was  perhaps as  long as it was in the hospital cases, nevertheless there
was this great difference of time after the two  treatments were commenced,
before the effusion was removed ; viz. those treated by paracentesis getting
well in half the time required by the hospital  treatment.  I do not believe,
however, that thirteen weeks shows the duration of the disease  as  it will
be when  tapping is  resorted to with  as much freedom as  we  resort  to
calflmel, blistering,  &c.   For this period of thirteen weeks  is really owing
to one case, which had  lasted seven  months  before  a puncture  was  made.
Excluding  this case  from the  calculation,  we  shall get  *7f weeks as the
average  total duration  of cases  of pleurisy treated  by  paracentesis,  in
connection with other remedies.  I will go still farther, and  avoAV my belief
that  ere long, Avhen we shall puncture early after an effusion has occurred,
the disease will often be relieved in a much shorter time even than 7£ weeks.

    *  This table is founded on data drawn from fifty-four cases of pleuritic effusion,
found recorded in the  books of the hospital, between Jan. 4, 184*7, and Sept. 9, 1853.
In it I have made use of those cases only, in which the disease could be  traced by
the rational and physical signs to its termination in the hospital:  or, if the patient
left the hospital before recovery, but after a long residence at the institution, I have
added the sign + to the number of months the case was under the care of the insti-
tution.  From my own cases, I have only taken those of a similar character, viz.
Nos 1, 1, 8, 11, 12, 15, 18, 20, 21.
    VOL.  I. NO. 2.                    1 
3(5             BOWDITCH ON  PARACENTESIS  THORACIS
If this be  so, are we not morally bound to perform this operation early in
all  serious  cases; that is, in all where there is any considerable amount of
fluid, enough, for example, to cause flatness in the lower half of the chest ?
I am well aware that I shall be met with arguments drawn from the danger
of the operation.  I consider this argument as null, when  applied  to the
exploring canula and suction pumps used in all  my cases.   I believe this
fear is a phantom  that  has descended  to us from a bygone race of men,
who were  as intelligent, it  is true, as any of the present  day, but whose
means of diagnosis of thoracic disease were infantile when compared with
our own.
    In what cases should an operation be performed ?
    In my former paper I stated fully the cases in which I should hereafter
advise an operation.   As I  have seen no reason to materially change my
mind since that time, I shall  transcribe  some passages merely.  I  wrote
then :

    1st. There cannot be a doubt that it  should be performed in all cases,
either acute  or chronic, in which there is dyspnoea sufficient to threaten
death.
    2d. I believe that the case of the little  child  about Avhom I was con-
sulted in 1849, proves conclusively that the operation should be  performed
where the pleura is distended with fluid, even if the dyspnoea is not perma-
nent, but only paroxysmal, the patient  being in the interval comparatively
easy. Life might have been saved in  that case, if the puncture had  been
made : but the little patient  seemed so well, that we decided to defer it till
a more serious symptom  should occur.  It will be remembered that  that
very night the patient died in a sudden attack of dyspnoea.
    3d. I think that we ought to operate in a somewhat chronic case, where
these paroxysms occur, even if the chest be only partially filled with fluid.
I saw a man who had been ill about three months, and had evidence of fluid
filling one-half of one pleural cavity.   It was thought best to try remedies
before puncturing.   In three or four days he suddenly expired in an* access
of dyspnoea.
    4th. In all acute  attacks, where the remedies employed do not seem  to
produce ready absorption, the operation should be performed.   Dr. Hamil-
ton Roe says  that three weeks is the longest time we should allow the fluid
to remain in the chest *  I agree with him fully.
  . ,51*\ JnTallv effusions> where one side of the chest  is full and distended
with fluid, I shall advise it, even if there be no  great  dyspnoea or other
serious symptoms ; a, because it is not uncommon for one having a pleura
distended with fluid, to die;  b,  because the operation can do no harm ; c, it
may prevent  a tedious illness; d, because it may oppose tendencies  to the
development  of tubercles; e, it will probably prevent future  contraction of
the chest,- finally, because in that way an external opening and a harassing
hstulous discharge may be avoided.
    6th  Case VIII proves that, although in a very acute case the puncture
may not  prevent the  re-accumulation of the fluid, nevertheless, the opera-
tion may be of great service in relieving the prominent symptom of dysp-

                     London Lancet, vol. ii., 1844, p.  190. 
IN PLEURITIC  EFFUSION.
37
ncea, and in helping on the more rapid cure.  It may, therefore, become a
question  whether even  a  small quantity of fluid  should not be  removed
within a week after the first attack of  acute  pleurisy.   Time and future
cases  must decide this.  Upon this part  of my subject, I cannot refrain
from quoting the remarks of the reviewer  above alluded to.  " The Avhole
argument turns on the  facility and  safety  with which paracentesis can be
performed, and although the cases are not  sufficiently numerous to allow us
to recommend it  as in all cases practicable and useful, yet they warrant us
in stating, that this operation  is one of Avhich practitioners  have too much
dread ; and that, when  skilfully performed, it may be practised with  very
little hazard to the patient, and with a result, in the majority of cases, that
is satisfactory to the practitioner." *
    Objections to the  Operation.—There are two classes  of objections  (vii.,
theoretical and practical) brought  against the  operation  of paracentesis
thoracis.  I confess they are very formidable, nay, insuperable, when applied
to it as recommended in most books of surgery.   It leaves an open, gaping
wound, through which may rush the external air with each movement of the
thorax.   I will not  say that  this method may not be useful in some in-
stances.  Doubtless it has been, and it may be so again.  But  the modern
European method by trocar  and canula,  as  performed  by Trosseau and
Hughes, &c, and especially as it  has been modified  and improved by Dr.
Wyman, is one of the simplest and  safest  of all operations.  Still there are
objections, theoretical and practical, brought against  it.   Let us  consider,
then, their value.
    1st, It is said  that the  chest, being  a bony cavity, cannot contract;
ergo, you never can get out the fluid, or you do so at the  risk of injuring
the lungs ; the objector forgets  that the diaphragm and intercostal muscles
prevent the thorax from being a bony cavity, and do allow of some contrac-
tion.   Still further, by means  of the suction-pipe, we draw out the fluid, and
thus form, perhaps, a vacuum in the pleural cavity.  The compressed  lung
dilates :  the  other lung likewise admits more air and crowds into  the empty
space.
    But, 2d,  The objector adds, by forcibly compelling the lung  to dilate,
you run the risk of seriously  injuring it.  Hoav do you  know this, save by
experiment %   Now, experiment proves that nature always gives us notice, by
the suffering of the patient, hoAV far we may go in the operation of suction.
I have  myself operated twenty-three  times,f and Dr. Wyman  has done so
many more times, and  in no single instance has any permanent evil resulted
from this cause.   We have always desisted the moment any complaint was
made by the patient.
    3d, "it is said, you  cannot draAV out  all kinds of fluid.   Very true,  there
 may be such cases, I have met Avith  them ; but, I think, they will be less
 numerous as Ave become  more accustomed to  the operation, and it is done
 more properly .J  Besides, we can always,  if necessary, have recourse to the
old operation, if' the trocar fails.
    4th, But you will let the  air into the pleura.  This, to some minds, is a
serious theoretical bugbear.   The admission of a small quantity of air does
 not necessarily cause trouble, unless it be  frequently repeated, as in cases of

    *  London Lancet, vol. ii., 1844, p. 301.
    \  Jan. 18, 1854.  Up to this date, fifty times, with the results as above,
    %  The result since, in  my own practice, has confirmed this.
wmmmm^uMtMX'*-,— 
3g             BOWDITCH  ON  PARACENTESIS THORACIS
pneumo-thorax, and of puncture of the thorax, according to the old opera-
tion.  I have seen air accidentally pumped into the chest, instead of fluid
being draAvn out!  And this caused no injury.  The patient never knew of
it by his own sensations.   I do not believe it excited any inflammation.  I
am not  alone  in this opinion.   Other  operators  believe the  same;  for
they have observed the same accident, with similar results attendant there-
upon.
    5th,  You run a great risk of  exciting pleuritis by the puncture of  the
delicate pleural membrane.   It is  a sufficient answer to this objection that,
at the autopsy of cases  in which persons have died from  other diseases,
after a puncture Avith a fine trocar, no  evidence of inflammation from that
cause has manifested itself.  Case I., given above, also  proves it,  by show-
ing  a  similar non-purulent fluid drawn out on two successive  operations.
Dr. Wyman  has noticed this frequently.  I have never known pleuritis to
ensue.*
    6th,  You may injure the lung, or strike some other important organ.
    Very true ; but, 1st,  I deny that  a puncture of the lung is so very dan-
gerous.  It has been done.   It was done in a case, as  Dr. Wyman believes,
under  Dr. W.'s  care.  I have done  it.  I have seen  another  do it, and,
moreover, use the suction-pipe while the  trocar was  in the lung.  In no
case has any evil resulted.   The sputa were, in one case, slightly tinged with
blood soon aftenvards, but no unusual pain or distress resulted to the patient.
But, 2d, these are exceptional cases.   If  our diagnosis be  conscientiously
and thoroughly made, we need very rarely injure  the pulmonary  structure.
If we injure  any other organ, it will  generally be  owing  to our own care-
lessness.
    7th,  The intercostal vessels or nerves may be injured by the  trocar.
    This is possible, but not probable.   1st, It Avould be difficult, in fact, to
strike and seriously injure the artery, because the  trocar is  so small that a
small artery would most  probably  glance aside.  2d, The spot for the oper-
ation may be chosen where the vessels are the most minute.   '3d,  The ope-
rator, of course, will thrust the instrument as near to the upper edge of the
rib as is possible.  4th, Finally, among all the operations performed within
the past three years in  Boston and  its vicinity, no serious  result has hap-
pened to the artery, although, in  one case, I observed some slight  and tem-
porary haemorrhage  after the withdrawal of the trocar.
    8th, One objection brought against the operation  is the following, viz.:
That all cases of chronic pleurisy will get well  after a time, unless  the
disease be dependent on  more serious  lesion of the lungs, or  other remote
organs.   In  answer, I would say  that, according  to my experience, in part
already  given  above,  it  is not true  that a person affected  with chronic
 pleurisy, as an idiopathic disease,  will eventually get well.   He  may die, as
Ave have seen, in various ways ; which result a puncture and extraction of
the fluid may prevent.   But, still  further, is it of no use to  shorten the dis-
 ease by  months ?  Is it of no service to prevent fistulous opening,  and those
 terrible  distortions of the chest consequent on the cure of long  pleurisy?
 Moreover, suppose that tubercular or other disease exists, is  it of no service
to raise  our patients from  their bed, to give freedom of breath, and to actually
 lengthen lite, as was done in cases II. and VII. XV. XX. ?

    * Sin°e ^ ™* "*£****> I have noticed in one case, in which  several punctures
 were made, that the fluid becamemore purulent at each successive operation. 
IN PLEURITIC  EFFUSION.
39
    Again;  I  believe that  this operation Avill be  used Avith advantage  in
acute disease,  and may, likeAvise, shorten its course.  Case VIII. sIioavs this,
where the patient, on the twenty-third day, Avas  up and preparing her din-
ner, and the effusion subsiding.  Case VII. is a still more striking example
of this ; i. e., if we regard the pleurisy as having commenced when the pain
in the side began.  If this be so, then  the cure was complete in a very few
days after the operation.
    9th, Finally, some object to the operation because of the  uncertainty of
diagnosis.   You may operate in a case of cancer of the  lung, or  gangrene,
or some other disease than pleurisy.
    I can conceive of such an error being made in  some very rare cases, but
I  do not believe that such  cases will be likely to  happen very often; and,
moreover, as I have already said, I think that a slight puncture of the lung
with a  small trocar is of very trivial  moment.   We  may, therefore, very
justly put aside this objection  as one of little vahie against the operation.*
    But shall  we confine ourselves to a simple puncture and a withdraAval of
the fluid ?   In my previous paper I alluded to the operation by the scalpel,
as a barbarous one.   I would modify my statement; I believe there are  cases
in which a permanent opening would  be of service.  In  cases, for instance,
where repeated punctures have been made with as repeated re-accumulation
of the  fluid, a fistulous opening may be needed.  Case  24 may  be  one in
which it would be well to make such an opening.  But even in  such case,
frequent puncturing might answer the  same end.   And suppose Ave  have
decided to have  a permanent opening, why not operate with  a large trocar,
or leave it  in the wound for a few hours or  even days, as is actually done
 by Barth and Windrict ?
    But shall we merely remove the fluid ?  I think not.   The  recent ob-
vations and experiments of MM. Boinet and Aran in Paris prove conclusively
not merely  the safety, but the  advantage in some instances, of injections of
tinct. iodine.   Both of these  gentlemen give cases f  of great interest, in
which the iodine seemed to improve the secretions of the pleural  cavity and
help the cure.
    Finally, although  thoracentesis in pleuritic effusions has not  always
 effected all the good I could have wished ; although, in some instances, it
 has seemed to do little more than give temporary relief; nevertheless, I am
 convinced, from the experience I have gained from the preceding  cases, that
 in some instances it saves life, that in a vast majority it gives infinite relie
 to distressing symptoms, that  in none does it cause any harm.  I sincerely

    * At times, too, a mistake may arise from the lung remaining, as described by
 Dr. Gairdner, of Edinburgh,* condensed after the effusion has been absorbed or re-
 moved ; in consequence of which state of the parts, there may be absence of respi-
 ration,  flatness on percussion, diminished motion of the  ribs, &c.   All these signs
 may lead into  error.  I am now inclined to believe that I made that mistake in case
 VI. possibly I  did so in case XXV.  No evil followed in either case. The patients
 scarcely noticed that the puncture had been made (1853).
    f Archives G6nerales de Medecine, May, 1853. Union. Medicale, Aug. 1858.
    * See British and Foreign Med-Chirurg. Review, as cited above.
t30u^—^mamaaw&£j£^ VlMi 
40
BOWDITCH ON  PARACENTESIS THORACIS
hope, therefore, that these facts may serve  to overcome the prejudice exist-
ing in the minds of the  profession, to the operation, at least, as it has been
performed on the subjects of this paper.   For myself, unless  my present
views change very materially, I shall feel that I am guilty of a  neglect of a
duty to my patient, if I  do not urge the  operation, in any case, after the
existence  of effusion has  been manifested a feAV weeks, and when remedies
do not seem to effect its  cure.  I shall feel bound to use  it  in  any case of
large effusion, however short a time it may have existed.  I shall, in other
words, regard thoracentesis as I regard other remedial  agents, to be used as
freely as I use them, viz., whenever I think necessary.
    In connection with, and as a most fitting conclusion to these remarks, I
cannot forbear quoting from a  letter which I received from a gentleman
Avell knoAvn in this country and in Europe, and who has had as much expe-
rience on this subject as  any other individual on either side of the Atlantic.
Under  the date of June  2d, 1852, he writes, " It has indeed surprised us as
well as yourself, that so simple, so harmless, and  so beneficial an operation
(Avhen proper precautions are taken, by competent observers), has been so
little regarded in America or England, where it most strangely continues to
be esteemed as a most important and serious one."  " It may be interesting
to you  to know that I have myself been  present at, directed, or superin-
tended, at least eighty, and, I quite believe, one hundred operations of para-
centesis thoracis," [by puncture with an exploring  trocar and the subse-
quent  introduction  of a larger  one, and without the use  of any suction
pump.—H.  I. B.], " and I  never  knew  it, in  any of those cases, do  any
injury; that in a vast majority of these instances, it has been attended with
marked benefit;  and that in many, where a cure was possible  it has been
the important element in effecting that cure."

    Appendix.   Since  finishing this paper, I have perused an article in the
Archives  Generales de M6dicine, for October, 1853.*   As it supports views
similar in many respects to those  advanced in the foregoing article, and is
of such recent Parisian date, I propose to make  a brief analysis of it.  It
gives details of four cases of acute pleurisy;  in all of them, thoracentesis
was performed.   Three were cured by it  as the chief remedy.   In one there
was a relapse and illness for an unknown series of months.  In those cured,
the average duration of the disease before  the puncture was 13$ days; the
duration after the puncture was 17 days.   In other Avoids, a period of 30§
days was  the length of time the disease  ordinarily existed.  (See Table 6.)
    After  these cases, the author discusses the various methods used in punc-
turing, and  decides  in favor of the trocar and canula, with the moistened
tube attached to  the latter, the end of which, after the removal of the  tro-

   * De l'Utilite de la Thoracentese.  Par B. Schnkpk, interne des hopitaux, Laureat
de la Faculte" de Medecine a Paris. 
LN PLEURITIC EFFUSION.
41
 car, being placed in water prevents the entrance of air, and acts  like a
 syphon, in gradually drawing off the fluid.   He alludes to the fact that  in
 Germany the canula is, at times, left in the wound for some days, and with-
 out difficulty.   M. Barth has done so.   He speaks of tho fear of the opera-
 tion formerly entertained by  Louis, Arndal, Skoda, &c, and says that  at
 present these gentlemen approve of the operation.   In looking at the bene-
 ficial results of the operation, he  records the  sudden healthful  stimulus
 given to all the functions, exactly as it was noticed in our cases.  The ope-
 ration may be used  as a means of relief only.  He regards it as almost a
 specific remedy in acute pleuritic  effusion.   The  author attributes, rather
 hastily, I think, the cough  which came on in his cases, after the  puncture,
 to the irritation of a little  air admitted to the pleura.   Valleix and Barth
 oppose this view, but advance opposite views, as to the real cause, the former
 believing it to be owing to the sudden dilatation of long-compressed vesicles ;
 the latter  holding exactly the opposite  view, and contending  that the fact
 that the vesicles can not expand  is the cause.
     (Our cases sustain neither of these views entirely.  In case 15, the cough
 was more severe than I ever knew in any of the observations,  yet the lung
 expanded immediately throughout its whole extent.   In 20, on  the contrary,
 though the lung dilated, there was little cough.  In cases 13, 23, the  cough
 Avas troublesome while there was no evident sudden dilatation  of the lung.)
    Iodine injections into the pleural sac  are examined.  The cases detailed
 by Aran  and Boinet (see above), are alluded to.   M. Barth has punctured
 five times in one case, and used chlorinated injections. Valleix, also, has
 used iodine with  freedom and without injury.  Soft, warm water is  useful
 at  times.   Raumberger, on the contrary, opposes all such proceedings, on
 purely theoretical grounds, which are proved to be  unsound.
    His resume may be generalized thus: 1st,  The  operation is  not dan-
 gerous ; 2d,  A trocar and syphon tube is the best instrument; 3d, A little
 air in the pleura  aids the flow of the fluid ; 4th, The  results  are, a more
 free and regular respiration, renovation of the  forces, better haematosis, &c.;
 5th. In simple pleurisy, thoracentesis is " the most powerful agent to hasten
 a cure ;" 6th, When symptomatic of other more serious disease, it is an ad-
juvant alone.   (Our cases 4 and 15 prove that puncture cures pleurisy even
 when connected with, if not caused by phthisis.)   8th, It ought to be per-
formed whenever  the dyspnoea  makes  us fear asphyxia, and as  early as
possible from the attack.  9th, It is contraindicated in imminent asphyxia.
(Case 15 proves this assertion to be incorrect.  I cannot but think it wrong;
for  I believe that the more imminent the danger of asphyxia, the  more
important it is  that the operation should be performed.)   10th, A little air
in the pleura does no harm, but is rather useful, as above stated.   11th,
Lesions of the  lung or intercostal arteries, during thoracentesis, are  not
noticed by modern authors.
                             6 
Tabular  Statement of Operations for  Paracentesis Thoracis, performed between  April,  1850,  and Oct.,  1853.

No. 1.	Age and date.	Profession.	Previous dis-eases.	How long sick before first operatior.	No. of opera-tions and dates.	Character of the fluid.	Amount of the fluid.	Immediate effects of the operation.	How soon the lungs expanded and heart fell into normal po-sition.	Final result.
	28 April 11, 1850.	House Painter.	none.	5 weeks.	1st, Apr. 17 2d.	nothing. pus.	Six.	relieved of oppres-sion at chest.	not immediately and doubtful how soon—less than 4 weeks.	perfect health after 5 or 6 months.
2.	56. Oct. 1, 1850.	Seaman.	dyspnoea for 6 or 1 y'rs—prob-ably heart disease.	at least sev-eral months	1st, Oct. 1 2d " 12	serum. serum coagulable.	1 xxxvi. |xxxij.	great relief; orthop-noea gone. some " drawing " around chest.	on 5th day, or perhaps sooner; friction sound next day.	death many weeks after-wards with car-diac disease.
3. 4.	28. July, 1850.	Machinist.	rheumat'm; soreness for 3 months in left breast.	3 months.	1st, July 10 2d, " "12 3d, " 14 4th, " 19 5th, Aug 11 Two natu-ral openin's subsequent-ly formed.	bloody. serum. more puru-lent.	few drops. | xxvi. ... a little. Oj-	'easier, pulse bet-ter, relief to dis-J tension and to ] pulsation of the heart to the right ^ of the sternum. marked relief to dyspnoea.	heart fell imme-diately toward left two inches.	gradually failed, and died about the middle of August.
	48. June 4, 1850.	Carpenter.	Had raised blood many times.	10 weeks.	1st, June 9 2d, " 11 3d, " 11 5th, Nov 19 6th, " 21	purulent. nothing. purulent. nothing. pure pus.	few drops. Six-Six.	J great relief. ( stronger. relief.	20 days alter op-eration "respir-atory murmur better," less dull percussion. £ rubb'g sound < at the point oi ( puncture.	gradually got well after many months; chest contracting and lower lobe re-maining con-densed.
 
	1 6-5 July 14, °' 1851.		Girl.	unknown.	unknown.	1st July, 14 2d " 3d "	serum. do. do.	a few drops merely could be drawn.	no effect, neither relief nor trouble.		nearly in artic-ulo mortis, and died soon.
	6.	18 or 20 years.	Young man	unknown.	unknown.	1st, 2d,		nothing.	do.		unknown.
'	7.	29. Aug. 21, 1851.	Spinster.	cough and diarrhoea for many months.	2 weeks.	1st, Aug. 23	serum coagulable.	Sxb.	unpleasant feeling about chest, but soon great relief. Heart fell back 1J inches.	next day mur-mur he'rd every-where ; minute crepitus.	well of effusion in a week—died a year after, of phthisis.
	8. 9.	31. Sept. 3, 1851.	Wife.	pleurisy pain years ago, but well after.	10 days.	1st, Sept. 3	serum coagulating on standing	S xiii.	great relief—no or-thopncea afterwards	next day.	well by 12th day after operation. Patient attended to household du-ties. A few phys-ical signs re-mained.
		20. Oct. 17, 1851.	Clerk.	cough, win-ter previ-ous.	48 days.	1st, Nov. 1 2d, " 3d, Dec. 13 4th, Jan. 14 5th, Feb. 9	yellow, amber-like. a little opaque. more puru-lent.	S xxviii. S xviii. S xxi. Sxxi.	great relief—no se-vere dyspnoea after 1st. Patient desired all the rest when he found dyspnoea com-ing on. Cough bad after them all, stric-ture after last.	lung expanded somewhat at apex—never fair-ly distended.	after many mo's died of phthisis.
	10.	30. Feb. 17, 1852.	Rigger.	cough for a year.	71 days.	1st, Feb. 27 2d, " 3d, 4th,	purulent. t<	a little. §xv. 3 Hi. nothing.	( great relief to dis-\ tress of patient. 1 patient almost in ( art. mortis at time	not at all.	death on 4th, af-ter last opera-tion.
 
Tabular Statement of Operations for Paracentesis Thoracis.—Continued.
fc
No. 11. 12.	Age and Date.	Profession.	Previous dis-eases.	How long sick before first operation.	No. of opera-tions and dates.	Character of the fluid.	Amount of the fluid.	Immediate effects of the operation.	Bow soon the lungs expanded and heart ell into normal po-sition.	Final result.
	59. Dec. 29, 1852.	Soldier.	none kno'n, character dissipated	5 weeks.	1st, Dec. 29	yellow se-rum.	S xxiii.	relief to fulness— able to lie on either side.	ung came up slowly—friction noticed 30th, perhaps before.	death two mo's after with ceph-alic symptoms.
	21. Feb. 27, 1852.	Wife.	cough dur-ing autumn	6 weeks.	1st, Feb. 27 2d, natural opening subseque'ly took place.	thick pus.	Sxli.	great relief to or-thopncea and gener-al uneasy state.	lung had expan-ded somewhat on 5th day; on 11th much more	Derfect health after many mo's.
13.	40. Dec. 30, 1850.	Laborer.	slight dry cough a week before fall which caused his pleurisy.	5£ months.	1st, Dec. 30 2d, Jan. 10	pus. pus.	5 lxiv. S dxx (!)	great relief to dysp-noea and moaning, cough after punc-ture.	lung did not come up readily before death.	death from opi-ate.
14.	24. March, 1853.	Clerk.	cough years ago, but well before acute at-tack.	12 days.	1st, M'ch 20	serum, coagulating	§ xlviii.	relief—dates recov-ery from operation.	next day lung expanded at up-per part; lower never did.	recovered, with condensed low'r lobe after mo's.
15.	45. June 10, 1853.	Wife.	sough for many mo's.	6 weeks.	1st, June 10	do.	S lxxxiii. and 3 vi.	entire relief from threatened suffoca-tion—bad cough— pulse fell—copious frothy expectora-tion.	immediate ex-pansion of major part of lung.	10 days no dif-ference on per-cussion of both lungs; well of pleurisy.
bd
o


3

o
H

o







a 
16.	July 11, 1853.	Laborer.		4^ months.	1st, July 11 2d, Aug. 5 patient asked for operation.	col'd serum, do.	S xxiiiss. I xiii.	respiration less la-bored—comfortable day—little relief.	no physical signs given.	death some days after last opera-tion.
17. 18.	6 yrs. Oct. 20, 1853.	Boy.	*	many mo's.	1st, July 18	pus.	S xiii.	slightly easier.	never.	death mo's after.
	19. July 18,	Clerk.	none.	7 months.	1st, July 19	serum coagulating	S Ixxx.	no immediate trou-ble, and all the functions of the body immediately began to go on well.	murmurs heard to base of lung next day.	perfectly well in about a month or six weeks.
19.	20. July 30, 1853.	Wife.	cough for months.	5 months.	1st, July 30 2d, Aug. 3	pus. pus.	§x. Siv.	strict'e and faintn'ss relieved on lying down; can lie on left side; rel'f to cough.	no marked ch'ge except tubular respirati'n more manifest.	death in two weeks, with tu-berculous lungs.
20. 21. 22.	23. Aug. 30, 1853.	Spinster.	cough for months.	2 months.	1st, Aug. 30	serum coagulating	§ xviii.	nausea, vomiting, little cough—felt as if "had lost part of her side."	heart fell to place—next day crackling thro'-out expanded lung.	in 10 days no effusion remain. ing—equal reso-nance in back. dyspnoea (?)from tubercles re-maining.
	42. Aug. 18, 1853.	Governm't Officer.	rather weakly.	6 weeks.	1st, Sept. 7 2d, " 8	do. do.	drops, Sbv.	a little faint,— great relief to pres-sure and dyspnoea.	crackling imme-diately.	Oct. 6, percus-sion equal both backs and respi-ration pure.
	32 Sept. 28, 1853.	Lawyer.	none.	6 months.	1st, Oct. 2	do.	§ lxxvi.	felt a little weak.	heart fell tow'ds place 1£ inches; murmur heard indistinctly.	grad'l improve-ment from time of operation. Under treat-ment.
* N. B.—The patient had been operated on by Dr. Wyman many times. 
Tabular Statement of Operations for Paracentesis Thoracis.—Continued.

No. 23.	Atro and 1 Dute.	Profession.	Previous dis-eases.	How long sick before first operation.	No. of opera-tions and dates.	Character of tho fluid.	Amount of the fluid.	Immediate effects of the operation. ~	How soon the lungs expanded and heart fell into normal po-sition.	Final result.
	40. Oct. 14, 1853	Laborer.	none.	8-J- months.	1st, Oct. 21	pus.	1 lxiv.	cough considerable —one or two bloody sputa---much re-lieved of weight— able to lie on either side.	lung did not ea-sily come up, air took place of fluid.	lung very slow-ly expanding— still much air, no return of fluid in pleura; under treatment.
24.	21. Oct 20, 1853.	Farmer.	none.	6-£ months.	1st, Oct. 20	pus.	S xxiv.	relieved from pressure.	murmur along vertebra?, and crackling lower down.	improving in strength, <fec. under treat-t.
25.	30.? Sept, 28, 1853.	Merchant.	cough for months.	3 months.	1st, Oct. 1		nothing.	no effect, either un-pleasant or other-wise.