PLEURITIC EFFUSION: ITS TREATMENT. 
A PAPER 
READ BEFORE THE 
tainc jledical Issotiation, 
JUNE 12, IBS 9, 
BY HERBERT F. TWITCHELL, M. D., 
OF FREEPORT. 
PORTLAND: 
STEPHEN BERRY, PRINTER. 
1889. PLEURITIC EFFUSION; ITS TREATMENT. 
A PAPER 
READ BEFORE THE 
lain* j|p(lical 
JUNK 12, 1889, 
HERBERT F. TWITCHELL, M. D., 
OF FREEPORT. 
PORTLAND, 
STEPHEN BERRY, PRINTER. 
1889. PLEURITIC EFFUSION: ITS TREATMENT 
Mr. President, and Gentlemen of the Association : 
The subject to which your attention is called is of unusual 
importance to all practitioners of our state, because of the 
frequent occurrence of pleurisy with effusion in this latitude. It 
is a disease, too, the treatment of which is likely to be attended 
by a success that is brilliant, or a failure that is lamentable. 
There are few pathological conditions engaging the skill of the 
physician, that render him more personal satisfaction or lasting 
regret, according to the result of his treatment. 
The proper treatment of pleuritic effusions has been a bone of 
contention since the time of Hippocrates; if it has been worn 
thin ere this, we ought the more easily to get at the marrow. 
Believing that all diseases are modified somewhat by the 
climate and locality in which they occur, believing equally that 
the experience of the physicians of our own state, as far as it 
goes, is as valuable as that of the profession elsewhere, we have 
sought, by a method already known to you, to obtain the com- 
bined experience of our Maine physicians in the treatment of 
this affection. 
It is but fair to state that the statistics, which we have re- 
ceived are not absolute ; for they are drawn largely from mem- 
ory, and not from actual records. However, the accompanying 
correspondence gives free expression of opinions, which have 
largely determined the conclusions which have been deduced. 
For the purpose of this paper, it seems necessary to consider 
effusions under two heads only, hydrothorax and empyema. 
Of the 490 cases of effusion collected, 339. or more than 69 per 4 
cent., are cases of hydrothorax ; 131 affected the right side, 164 
or 55>£ per cent., the left, while 44 were not located. There 
were 319 recoveries and 16 deaths; the remaining 4 cases went 
on to empyema. This shows a little more than 95 per cent, of 
recoveries under all methods of treatment; 192 were treated by 
medical means alone, with 178 cures, and 14 deaths ; a recovery 
of per cent., against 147 cases treated by aspiration, with 
141 cures and 2 deaths ; a recovery of 98T6(J per cent. The 
four other cases, which became empyemic after this treatment, 
are not included in the percentage estimate of aspirations, for 
the reason that similar cases are not included in the estimate of 
those treated medically. 
The time required to accomplish a cure averages about three 
and one-half months by either method. The most frequent and 
fatal complication reported is phthisis, occurring sometimes as 
cause, but more often as effect of protracted, badly managed 
cases. Pneumonia is also mentioned frequently; Meningitis, 
typhoid fever, and other acute affections rarely. Further details 
are contained in the subjoined table. 
TABLE OF SEROUS EFFUSIONS. 
Method 
of 
Treatment. 
Number of Cases. 
Left Side. 
Right Side. 
Not Stated. 
Cured. 
With Deformity. 
Changed to Empyema. 
Died. 
Percentage of Recov- 
eries. 
Complications 
of 
Fatal Cases. 
Average 
time 
for 
Cure. 
Medical, 
192 
85 
72 
35 
178 
0 
* 
14 
92* 
2 pneumonia. 
1 phthisis. 
1 meningitis. 
4 badly treated. 
3 2 
°rir 
months. 
Aspiration, 
147 
79 
59 
9 
141 
2 
4t 
2 
98* 
1 phthisis. 
Q 5 
months. 
Summary, 
339 
104 
131 
44 
319 
8 
16 
95+ 
7 cases. 
* For obvious reasons no estimate can be given. 
t Two died and two recovered under subsequent treatment by free drain 
age. They are not included in the calculations of percentage. 5 
A glance at these statistics indicates the advantages of aspira- 
tion as a method of treatment; while a careful consideration of the 
attending facts in a still stronger light 
Consider, then, that the rarhcal table represents nearly all the 
cases of slight effusion and those yielding most readily to treat- 
ment; while the cases of excessive effusion, and most of those in 
which medical means proved unsatisfactory or failed altogether, 
are only considered in the table of aspirations. Cases of serous 
effusion, treated medically till they become empyemic—a process 
which nearly all empyemas go through—are not considered in 
the first group of figures, while those treated by aspiration before 
this change occurred appear in the second group with startling 
distinctness. The simpler method of medication naturally cures 
the most favorable cases, while it sifts out the unpromising and 
obstinate for a more radical method of treatment. 
The opinions expressed in the correspondence accompanying 
these statistics show that the profession in our state is divided 
unequally upon three methods of treatment, the majority ad- 
vising medical treatment exclusively, recommending aspiration 
only as a last resort, if at all. 
The second class, nearly equal in number to the first, advise 
medical treatment for several weeks—generally from six to eight 
—then if the case is not progressing favorably, or whenever dysp- 
noea becomes urgent, a resort to aspiration. The third class 
has the smallest representation. While recognizing the neces- 
sity of medical treatment, they believe in aspiration of all cases 
where as much as sixteen ounces of fluid have remained for 
nearly one week without showing a tendency to diminish. 
All agree practically upon the medication that should be pur- 
sued. It consists in the use externally of blisters or iodine : in- 
ternally of iodides, diuretics, cathartics and tonics. 
As to the management of acute pleurisy, so as to prevent effu- 
sion, there are slight differences of opinion. Some use blisters 
from the first, others wait for the acute symptoms to subside. 
Many use, but more condemn, such arterial sedatives as aconite 
and veratrum; a»d opiuija, quinine, digitalis, and the simple anti- 
febrifuges are in general use. The practice of strapping or bandag- 6 
ing the chest is only mentioned by a few. Not to weary you 
with further differences of opinion, we have taken the liberty 
to deduce from all opinions the following definite outline plan 
of treatment, when, given a case of acute pleurisy, we hope to 
bring about resolution without the occurrence of effusion. 
If the patient have a strongly acting heart, give ten grains of 
quinine or antifebrin, and one-fourth grain of morphine, to be 
repeated the first forty-eight hours as needed: aconite, for the same 
period of time, two drops every hour. Some object to the use 
of this drug, while its advocates refer to Bartholow, who says, 
“For the treatment of acute pleuritis, previous to the stage of 
effusion, no remedies are more effective than aconite and opium.” 
In case of feebly acting heart, the quinine should be reduced, an- 
tifebrin omitted, and digitalis substituted for aconite. 
It seems to us that the objections to the use of digitalis in 
acute inflammations are not well founded; for its known phys- 
iological action upon the blood vessels is to a considerable 
extent antagonistic to the theories of inflammation. Broadly 
speaking, digitalis assists in sustaining the circulation, and to 
that extent prevents the deposit of inflammatory products. 
In all cases apply immediately a large fly blister. We believe 
with a prominent member of this society, that “all time is lost 
time, which is spent in waiting for inflammation to subside.” 
Would those who advise us to withhold blisters in this disease 
till the acute stage is passed, advise the same delay when acute 
endo/gf.peri-carditis arises in the course of rheumatic fever? 
Yet t&cse membranes, so similar in structure and function, can- 
not differ widely in pathology. 
The kidneys should be moderately stimulated by digitalis, 
acetate or bitartrate of potash, and the bowels should be freely 
moved by the use of saline cathartics. Mercury is no longer 
used as a routine remedy excepting as a purgative. The move- 
ments of the chest should be limited by a broad bandage, or by 
strapping. The patient should be kept perfectly quiet till the 
danger of effusion is passed. Diet should be sufficiently nutri- 
tious from the first, to sustain well the powers of life, and later 
to improve the general condition. 7 
When a case presents itself where effusion has already oc- 
curred, a slight variation from the above plan, if persisted in, 
will, in nearly all cases, according to the advocates of the medi- 
cal treatment, suffice for its removal. Externally, blisters are 
repeated every few days, while the remainder of the side is 
painted with iodine. Internally, the salines are assisted by 
croton oil, elateriura, or jalap. Pilocarpine may occasionally be 
exhibited with advantage ; but the diuretics are considered the 
most important eliminants. lodide of iron, potash and ammo- 
nium are used systematically, and in the order of frequency 
named. It seems to us that iodide of ammonium has not been 
given the prominence which it merits. We have found, by per- 
sonal experience, not only in pleuritic effusions but in many 
kinds of obstinate indurations, that it is a very potent resolvent. 
The great importance of improving the patient’s general condi- 
tion is recognized by all, and finds expression in the use of 
alterative tonics. 
Such, in brief, is the skirmish plan of the battle. What a 
comfort to feel, in case of repulse, that we can summon to our 
aid the almost invincible aspirator ! That it may with advan- 
tage be employed earlier in the fight, we hope to show in the 
closing of this paper. 
EMPYEMA. 
Empyema, when not traumatic, or possibly of spontaneous 
origin in children, occurs as a sequel to neglected or badly man- 
aged cases of hydrothorax, and rarely from the depravity of the 
patient’s condition. The chief advancement in its treatment, 
has been in the direction of obtaining a more free and contin- 
uous exit for the pus, till now abundant evidence has accumu- 
lated to prove that/ree drainage is by far the most successful 
method. The following statistics from our state verify this 
statement. We have been furnished with reports of 151 cases, 
76 affecting the left side, 54 the right, and 21 not located. Of 
these, 97 were reported cured and 8 partially cured ; while 6 
others recovered from the empyema, but died in a few years of 8 
phthisis. This gives recoveries from the immediate disease of 
73/ i per cent. Of the 40 immediate!}1- fatal cases, 14 were 
complicated, 5 by phthisis, 3 by pulmonary fistula, 2 by inflam- 
mation of the lung tissue, and 4 by organic disease of the abdom- 
inal organs. 
The method of free drainage was employed in 124 cases, yield- 
ing recoveries of 78 per cent. Aspiration was employed in 11 
cases, yielding recoveries of less than 64 per cent.; while of 16 
cases treated with the trocar, or left for spontaneous opening, 
more than one-half died. The time required to accomplish a 
cure averages six and one-half months. 
Method of Treatment. 
Number 
of 
Cases. 
Recov- 
ered. 
Died. 
Percentage 
of 
Recovery. 
Free drainage, 
124 
97 
27 
784- 
Aspiration, 
11 
7 
4 
634- 
Spontaneous evacuation, 
9 
5 
4 
554- 
Trocar puncture without drainage tube, 
7 
2 
5 
284- 
Summary, 
151 
111 
40 
73 % 
TABLE OF EMPYEMAS- 
The means for obtaining free drainage almost universally used 
in our state, is simple incision, carrying a rubber drainage tube. 
The point selected by 85 per cent, of our physicans to puncture the 
chest, for aspiration as well as for incision, is the sixth interspace 
on the right side, the seventh on the left, in the mid-axillary line. 
Formerly it Was thought that the opening should be made in 
the lowest intercostal spaces, as being more dependent and 
thereby giving better drainage ; but an opening in this situation 
aside from the dangers of the operation to important structures, 
would be liable to obstruction from approximation of the costal 
and diaphragmatic pleurae, or from agglutination by plastic 
lymph, which finds a ready lodgment here; while a considera- 
tion of the conformity of the chest cavity, as well as clinical ex- 
perience," shows that an opening in the fifth, sixth or seventh 
interspace is really the most dependent for a patient in the re- 9 
cumbent position. The drainage tube should enter the cavity 
far enough to ensure unobstructed exit to the pus. In acute 
cases a single opening may suffice for a cure, where the pus is 
contained in one compartment, when it flows out freely at the 
time of the operation, and especially if the patient is not show- 
ing signs of septic absorption; but in chronic cases, if septic 
symptoms be present, or when adhesive bands have formed 
multiple compartments, and in pneumo-hydrothorax, one or more 
counter openings may be required; for success will be assured 
only when all the matter can find a ready escape. When a cask 
is to be tapped we are all familiar with the advantage of a 
counter opening. The empyemic chest presents a fair simile 
when free expansion of the lung is prevented by adhesive bands. 
An excellent and safe method for making the counter puncture 
has been given by Dr. Satterthwait, in the Medical Record of 
November 17, 1888, although the method of thorough drainage, 
belongs essentially to Chassaignac. A metallic seton-carrier, 
about thirteen inches long, threaded with several strands of silk— 
which Dr. Satterthwait prefers to a tube—is passed through 
the first opening into the chest, downward and backward, till it 
projects between the ribs at the lowest part of the pus cavity. 
An incision is then made upon the point of the probe, the silk 
drawn through and left in position for drainage. The percent- 
age of recovery given by those who practice this method is cer- 
tainly remarkable, although the treatment was applied to the 
most unpromising cases. 
In empyemas of long standing, which have been neglected or 
badly treated, it is sometimes found that the lung will not ex- 
pand, and the chest wall must therefore be made to contract. 
In these cases it may become necessary to excise a portion of 
one or more ribs, an operation first performed by Celsus and 
afterward made popular by Estlander. One of the modifica- 
tions of this operation is especially interesting to this society, 
having been suggested and practiced by one of its leading mem- 
bers. In his practice it has yielded very satisfactory results. 
It consists in excising the sternal end of the rib at its juncture 
with the cartilage. 10 
The practice of washing out the cavity is advised by a num- 
ber of our correspondents, while the majority consider it unnec- 
essary. It will be found beneficial in cases characterized by 
unhealthy, offensive discharge, and septic symptoms. The in- 
jected fluid should be sterilized water, 105° Fahr., containing 
carbolic acid, boracic acid, iodine, or other antiseptics in solution. 
Are there any cases of empyema amenable to a less radical 
treatment than free drainage ? Years ago Dr. Bowditch, of 
Boston, proved that some cases could be cured by aspiration, 
and a few cases are also reported in the above statistics. We 
ask your indulgence for a somewhat careful report of a case in 
point, which we believe to be of unusual interest. 
Walter 8., four and one-half years of age, resides in Pownal, Me., 
in a somewhat insalubrious locality. He is the youngest of a large 
family, all of whom are subject to sore throats, swollen glands, 
auricular abscesses, or other of the various manifestations of 
congenital strumous diathesis. Walter was only ten months 
old when his father died of some obscure wasting disease, sup- 
posed to be cancer of the stomach. For two months after birth 
the child suffered with scalled head. He is now of slight frame, 
light doraplexion, weak eyes, delicate skin—markedly a “ gelatin- 
ous offspring of albuminous parents.” 
I was called on the afternoon of March 10, 1887, and found 
him in a semi-conscious condition, respiration 60, temperature 
105.2, and with a pulse that could not be counted, for rapidity. 
Distinct dullness on percussion and bronchial breathing over the 
lower part of the left lung behind, led to a diagnosis of pneu- 
monia, the more readily as an extensive epidemic was then pre- 
vailing among children. He did not complain of any pain 
whatever. Sinapisms of mustard, followed by continuous poul- 
ticing, was ordered externally ; ipecac, aconite, and spirits of 
nitre internally. The following morning the pulse was 120, 
respiration 30, and other symptoms correspondingly improved, 
excepting that the physical signs of consolidated lung remained 
the same. Directions were given for a continuance of the 
external applications, and for one grain of carbonate of ammo- 
nium every hour. Two days later, in responding to a sudden 11 
summons, I found the patient unconscious, eye-balls turned far 
upward and not parallel, pupils oscillating and unequal, head 
thrown far backward, burrowing into the pillow, while he mo- 
mentarily uttered piercing screams. Pulse rapid and respira- 
tion irregular, but not otherwise noted. Paresis affected the 
body, extremities and sphincters. The facial expression indi- 
cated great suffering. 
A diagnosis of meningitis led to a most unfavorable prognosis. 
However, the following vigorous treatment was instigated, and 
faithfully carried out by the mother. The head was elevated 
and constantly enveloped in ice water packs, while dry heat sur- 
rounded the feet. A fly blister was applied behind each ear, 
and mustard to the back of the neck. The bowels were moved 
by a vigorous calomel purge, while ten grains of bromide of 
sodium once in four hours, and one and one-half grains of iodide 
of potassium every hour, were ordered for continuous treatment. 
Notwithstanding these measures, the symptoms continued un- 
abated for twenty-four hours. Then the outcries diminished 
and the eye-balls assumed a more natural position; while thirty- 
six hours later the child was restored to partial consciousness, 
and the pupils to a nearly normal condition. Por a long time 
the head remained unnaturally extended; but all other cerebral 
symptoms had passed away by the end of a week. I will state 
here, in connection with the above symptoms, that ten days later 
a small abscess formed behind each ear where the blisters had 
been applied, and one week later still, purulent matter was 
discharged from each middle ear. 
The pulmonary symptoms now reclaimed attention, and it was 
found that the respiration was still about 40, with a pulse of 150 
per minute. There was marked dullness over nearly all the left 
side behind, and some rfiles at the top of the dull area. I 
ordered poultices and systematic painting with iodine externally, 
one grain of iodide of potash, with one and one-half grains of 
iodide of ammonium, internally every hour. The child improved 
gradually till the end of the month—three weeks from the on- 
set of the disease. The respiration was now 32, pulse 120, and 
temperature 99°. The upper portion of the lung was clear 12 
nearly as low as the angle of the scapula. The slow process of 
resolution suggested pluritic effusion; but as the two sides 
seemed alike in measure and fremitus, and as the heart-beat was 
in the normal position, the idea was dismissed. For the next 
ten days there was little change ; and two days later the patient 
was decidely worse. The chest was exposed, and a glance only 
was required to show a condition of hydrothorax. Assisted by 
my colleague, Dr. Spear, I aspirated at once—just one month 
from the onset of cerebral symptoms—and obtained thirty ounces 
of nearly odorless, rather thin, creamy looking pus. Respira- 
tion at once diminished from 40 to 30, and the apex of the 
heart resumed a nearly normal position. A large fly blister 
was applied to the chest. The child improved rapidly for a 
month and then unfavorable symptoms returned. 
By advice of Dr. Dana and Dr. Weeks, who examined the 
patient at their Bowdoin clinic, we performed a second aspira- 
tion, just five weeks from the first, obtaining twelve ounces of the 
same kind of pus. Three times during this operation the flow 
of pus through the aspirator was interrupted by jets of gas, 
which caused the whole instrument to vibrate. It seemed to 
come from the surface of the pus; for the needle point did not 
touch the lung, nor did the patient cough. The apex beat of 
the heart returned under the xiphoid cartilage only, showing 
that some adhesions had formed. In pursuance of advice, I 
determined to instigate free drainage as soon as the child ceased 
to improve. To my surprise, however, nothing interfered in 
his progress to health. One week later there was a concavity 
in the antero-lateral aspect of the chest about as large as my 
hand. Three weeks later still, the chest was in normal shape, 
and the heart and lung had resumed their proper position and 
function. Two years have now passed, during which the child 
has been in perfect health, and there now remains nothing 
about him to indicate his former disease. 
We see in this case the tendency of serous inflammations to 
pass from one serosa to another and to complicate inflammation 
of other tissues. Another striking example of this tendency I 
have seen in a case when abdominal effusion was followed by 13 
pleuritic, and then by consolidation of each lung. The case also 
shows the wonderful recuperative power of children; but it is 
of especial interest in this connection, as showing the possibility 
of, and the circumstances under which we may expect to cure, 
empyema by aspiration. It is in the young, then, that we are 
most likely to obtain this happy result; for they frequently 
manifest a tendency, as shown by this case, to spontaneous reso- 
lution from suppurative processes. Their ribs and cartilages 
are elastic, permitting the chest wall to fall in, if necessary, and 
obliterate the cavity, an important mechanical factor in the 
process of cure. 
Cases amenable to this treatment must also be of recent origin 
and free from septic manifestations. That this mode of treat- 
ment should only be selected in suitable cases is proven by the 
fact now well established, and too often illustrated in our corre- 
spondence, that fatal results are frequently due to delay in pro- 
curing free drainage. 
J. L. Cohen, treating of purulent effusions, makes this state- 
ment : “ A cure without a free discharge of the fluid, which can- 
not be obtained by the aspirator alone, is an impossibility.” 
(International Surgery, Yol. Y, page 816.) 
That this statement is too dogmatic has been proven by Dr. 
Bowditch, as also by seven cases, including the above, which we 
have collected from this state. It should, nevertheless, have 
great weight and make us cautious in our selections for this method 
of treatment.. In nearly all cases, however, aspiration is indi- 
cated as an aid in determining the location and character of the 
fluid, and for the purpose of withdrawing a portion to permit 
partial expansion of the lung, before the whole is evacuated by 
a free opening. 
This, gentleman, Are believe to be the outline-plan of treat- 
ment for this affection, suggested by our correspondence with 
the profession of this state. 
Permit us now, in closing, to claim that early aspiration is 
the treatment above all others for serous pleuritic effusion. It 
removes the liquid at once, thereby permitting immediate expan- 
sion of the lung, and obviating the danger of its becoming bound 14 
back in an unnatural position. In the same way it lessens the 
danger of empyema; for I think you all will admit that the 
longer the pleura is macerated in this pathological fluid, the 
greater the danger of purulent change. The procedure itself 
favors absorption by substituting the elastic pressure of the 
lung for the unnatural pressure of the fluid upon the vessels 
and surface of the pleura. 
Agnew says : “ There is reason to believe that we are gen- 
erally too backward in puncturing the chest for the relief of 
these collections.” 
The operation of aspiration is practically free from danger. 
Can we conceive a more thoroughly antiseptic procedure ? The 
disease may afterward advance to empyema; but are we sure 
that it would not have so resulted in the course of purely medi- 
cal treatment ? If caused by the operation, the fault is in the 
manipulation and not in the method itself. Dr. Bowditch 
reported, that during 24 years and in 270 operations he had never 
seen any injury done by the aspirator. (Practitioner of April, 
1883.) Regarding reported fatal results from the operations, 
Bryant says: “ Evidences are wanting to prove that any relation 
existed between reported cases of death from aspiration, since 
cases are on record in which sudden death ensued in the normal 
course of the disease.” Trousseau mentions numerous cases of 
sudden death from pleuritic effusion, which, he avers, could 
undoubtedly have been saved by early paracentesis. One of his 
colleagues saw a young physician die at the very moment he 
was about to make the puncture. Had the needle been passed, 
what might have been the unjust conclusion ! In the Reference 
Hand-book of the Medical Sciences occurs this sentence : “ Sud- 
den death was formerly not a very rare event in cases of large 
effusions, but is now, fortunately, much less common—thanks 
to the general use of the aspirator.” 
The majority of our correspondents recommend that aspira- 
tion be postponed for an indefinite period of time, unless oppres- 
sion of breathing become urgent. It is now well established 
that this symptom is hardly ever directly dependent upon the 
amount of the effusion. Trousseau lost several patients while 15 
waiting for this symptom to develop. This unfortunate experi- 
ence changed his plan of treatment and led to the following 
definite statement: “Oppression is one of the most deceitful of 
signs. * * * * When the oppression is a sign in addition 
to the physical signs, * * * * it has an important significa- 
tion ; but its absence onght not to inspire too great a feeling of 
security ; for by refraining from interference, we run the risk of 
losing patients, whom the operation would assuredly have 
saved.” 
Aspiration is the method which cures the disease with the 
least discomfort to the patient. The puncture is not likely to 
cause more annoyance than a simple hypodermic injection. In 
fact, many physicians, who object to aspiration because of its 
supposed painfulness or dangers, do not hesitate to explore the 
chest with the hypodermic syringe, a procedure we cannot too 
strongly condemn ; for the imperfect workmanship, or frequent 
and indiscriminate use of this instrument, make it liable to be a 
source of infection. Explore with the aspirator, and then, if 
desired, make a complete operation. We believe with the author 
of the following quotation: “It is not worth while to plague the 
patient by repeated purgings and sweatings, * * * * but 
apart from prejudice, the discomfort of puncture is really less, 
and its results are more sure.” (Eef. Hand-book of the Medical 
Sciences, Yol. V, p. 724.) 
In substance, gentlemen, early aspiration is likely to cure, and 
that, too, quickly, safely, •pleasantly.