MONTHLY CYCLOPÆDIA OF PRACTICAL MEDICINE MEDICAL BULLETIN Vol. XXX, Old Series. PHILADELPHIA, F. A. DAVIS COMPANY, PUBLISHERS, 1908. 1510 THE BRADSHAWE LECTURE. ON THE PLEURAE: PLEURAL EFFUSION AND ITS TREATMENT.1 Delivered before the Royal College of Physicians of London, November 5, 1907. BY SIR JAMES BARR, M.D., LL.D., F.R.C.P., F.R.S.E. Senior Physician, Liverpool Royal Infirmary; Visiting Physician, Haydock Lodge and Tuebrook Asylums. (Concluded from December issue.) TREATMENT. Cases of dry pleurisy require very little treatment except some counterirritation, a diaphoretic, a purgative, and perhaps a sedative to relieve pain, or some strapping of the chest to limit the amount of movement. I wish to take this opportunity of emphasizing the principles which underlie my methods of dealing with effusions into the pleural cavities. At the present time this is the more necessary, as I find that I have got a few imitators, who have never seen me treat a case, but who think the whole method consists in withdrawing more or less of the effused fluid and injecting a little adrenalin solution. I am not surprised when I hear that they do not attain the success which I may say almost invariably follows my efforts. In the treatment of pleural effusion the question often arises, When should you withdraw serum? This is rather an important question, and one which is more easily asked than answered. You know that if the effusion be not very great it often gets absorbed after the febrile stage passes off, with or without any special medication. Many devices have been advocated to hasten the 1 1 Published simultaneously by Sir James Barr in the British Medical Journal and the Monthly Cyclopædia. absorption, with more or less success. Being naturally of a conservative frame of mind, I do not care for meddlesome interference with natural processes, consequently I sometimes give Nature a longer chance than is perhaps advisable. The effusion is a natural process, which, if it continue till after the inflammation has subsided, lessens the risk of pleuritic adhesions; it also keeps the collapsed lung quiet, which is very desirable if there be any active tuberculosis in the lung. A very large proportion of cases of pleurisy are tuberculous, and the early withdrawal of fluid causes vascular turgescence of the lung, often hastens the dissemination of the tubercle bacilli, and kills the patient. Before I began the substitution of one fluid for another by the introduction of air into the pleural cavity, I was much more chary of early tapping than I am at present. I can now remove the whole of the effusion, even in tuberculous cases, at an early stage, with perfect impunity. A considerable number of deaths have followed the complete withdrawal of effusion in elderly persons with rigid chest walls. The danger in such cases arises from establishing too great a negative pressure which leads to hyperemia and oedema of both lungs; this can be obviated by the introduction of air. I now recommend the complete withdrawal of the effusion in all cases, but before any great negative pressure is established, and before the patient feels any discomfort, I stop the siphon and introduce about an equal quantity of air to the amount of fluid which I have withdrawn. I then re-establish the siphon and complete the withdrawal of the effusion. When all the liquid is withdrawn I inject 4 cubic centimeters of adrenalin solution (1 in 1000) diluted with 8 or 10 cubic centimeters of sterile normal saline; and, if I think it necessary, I introduce more sterile air, so as to make the total amount equal to half or three-fourths of the bulk of the fluid withdrawn; the larger quantity of air is introduced in tuberculous cases. By this method the patient suffers no discomfort except from the slight thrust of the trocar. I prefer the siphon to the aspirator because you can readily regulate the force of the suction, and as your tube only reaches to a receptacle on the floor practically your negative pressure never exceeds 1 pound to the square inch; this force is greatly exceeded by the aspirator, and the greater the negative pressure the greater the risk of secondary hyperæmia or oedema. It is an advantage to introduce a manometer in the air tube, as you can thus avoid producing any positive pressure in the pleura. Of course all aseptic precautions are taken. (I now exhibit my apparatus for this treatment.)7 The adrenalin solution is introduced to contract the blood-vessels and lessen the secretion. According to Schäfer, Elliott, Brodie, and Dixon, adrenalin only 'Manufactured by R. Sumner and Co., 50A Lord Street, Liverpool. acts on unstriped muscular fiber which is innervated by the sympathetic; the pleural vessels belong to the systemic system and are thus innervated, but its effect is not very prolonged, consequently you cannot expect it to lessen the secretion for any great length of time if there be a great negative pressure in the pleura. Although I had very good success from its use before I commenced the introduction of air, I soon recognized the limits of its usefulness. When you remove four or five pints of serous fluid from the pleura there is a potential or actual cavity left which cannot be filled by a drachm of any fluid. Such a cavity cannot exist in the human body with a surrounding atmospheric pressure of 15 pounds to the square inch. It is filled by: (a) The carbonic acid gas which escapes from the serous fluid; (b) by the more or less expansion of the collapsed lung; (c) by the return of the mediastinal contents which were pushed or drawn to one side, and the further expansion of the other lung; (d) by increased quantity of blood in the chest; (e) by elevation of the diaphragm; and (f) by falling in of the chest wall. All these events may not suffice to fill the cavity if the amount of fluid withdrawn have been very great, and the lung be so collapsed and bound down that it cannot expand. In this case the negative pressure is very great, and under such circumstances it would be absurd to expect adrenalin or anything else to permanently check the secretion. When the use of adrenalin is supplemented by the introduction of air, the negative pressure is lessened or abolished, and the lung gradually expands as the air gets absorbed. By this combined method you can operate early in any case, even during the febrile stage, and under no circumstances should you allow the fluid to accumulate to such an extent as to completely collapse the lung; you should tap before the patient suffers any respiratory distress. By the removal of the effusion you often remove an enormous number of microorganisms, and by the introduction of sterile air you substitute a light innocuous fluid for a heavy and deleterious one. Dr. W. Ewart of London has recently been injecting adrenalin solution into the pleural fluid preparatory to drawing it off, and he has had good success in thus stimulating the absorption of the effused fluid. I always like to treat the individual rather than his disease, consequently I try to avoid routine, and I make such modifications in treatment as will suit each individual case. When the pleurisy is practically cured you will find plenty of scope for ingenuity in trying to restore the function of the lung to its pristine vigor. I have no time to enter into the numerous respiratory exercises which I from time to time recommend, but there is one which each of you can try on himself, the marked effect of throwing one serratus muscle into and the other out of action. You can also study my observations on the conditions of |