Prognosis.—The outcome depends on the cause of the bleeding, its amount, and the possibility of reaching the bleed ing point by surgical means. In matic cases there is early coagulation; the serum is rapidly absorbed; but the clot is long in disappearing. If infection occurs, suppurative pleurisy follows.
Treatment.—This is purely expectant unless the bleeding-point can he located and secured. Great caution should be exercised in operating when the source of the bleeding is not known. If there is urgent dyspno2a some of the blood should be removed by aspirating.
Any patient who has suffered from simple pleural luamatoma not demon strated as tubercular should be sub mitted to severe hygienic measures and close surveillance of the respiratory ap paratus. Alesnil (These de Paris, '94).
Chylothorax.
This condition is often designated by the name "chylous pleurisy," but incor rectly, as there is no inflammatory process present. A similar collection may exist in the peritoneum.
Symptoms.—The symptoms are such as are caused by non-inflammatory effusion. Pain may be caused by distension of the pleural cavity. Aspiration of the fluid determines the diagnosis, but there may be difficulty in withdrawing the fluid. is usually caused by ob struction of the thoracic duct or the receptaculum chyli, but may be due to rupture of either of them. In many cases the seat of lesion cannot be found at the autopsy. The obstruction may be caused by a cancerous growth or a tuber culous deposit.
In case of chylous pleurisy at the ne cropsy the abdomen was found to con tain about 5 ounces of milky fluid and the right pleura 2 pints. In the left pleura there was a pint of turbid serum, with some fat held in suspension. The thoracic duet was dilated in its whole extent, and was blocked at its outlet by thrombosis of the internal jugular and subclavian veins limited to that spot. The liver appeared normal. The general glandular enlargement was due to infil trations with carcinomatous deposit sec ondary to scirrhus of the pylorus. Tur 'ley (Lancet, May 20, '93).
Prognosis.—The outlook is very un favorable, but the course depends much on the nature of the primary lesion. Probably none recover, death usually oc curring in six to ten months.
Treatment—The fluid should be re moved by the aspirator as often as its accumulation causes pain. Nothing more seems feasible.
New Growths of the Pleura.
Most of the new growths occurring in the pleura are secondary to deposits else where. The majority arise by direct in vasion from a primary lesion in the lung, but they may follow disease elsewhere, especially of the mammary gland.
Of the primary growths, carcinoma is the most common, but sarcoma and fibroma also occur.
Symptoms.—The clinical history pre sents great variety. Pain may be absent, slight, or severe. Loss of strength and flesh occurs, but emaciation is rare. Usu ally there is dyspncea and cough. In diffuse cancer of the pleura secondary to primary cancer of the lung the pleural symptoms may so predominate that the lung disease is lost sight of. There is marked dullness and weak fremitus and breath-sounds. In the majority of cases the signs point to marked pleural effusion with displacement of the heart and en largement of the side. In some cases, however, marked retraction takes place.
The course is usually rapid, death oc curring in a few months.
Diagnosis.— New growths of the
pleura can rarely be distinguished from other forms of pleurisy—chronic tuber cular, especially—until well advanced. The effusion is usually blood-stained, and the characteristic elements may be found with the microscope.
Case of pleural effusion in which the exudate was examined, a diagnosis of spindle-celled sarcoma of the pleura made, and diagnosis was confirmed post mortem.
The exudate contained groups of typ ical spindle cells, as differentiated from the flat cells of the endothelium com monly found in pleural exudate and also differing from the irregular spindle cells found in plastic pleurisy. R. S. Warthin (Med. News, Oct. 16, '97).
Morbid Anatomy.—The primary car cinoma is usually of the endothelial type. In most cases there is much thickening of the pleura, more of an inflammatory character than of new growth. The origin of the growth is uncertain, but probably from proliferation of the epi thelium of the primitive body-cavity. The pleural cavity usually contains much bloody fluid. There may be me tastasis to other organs, and the growth may appear in front of the ribs and filtrate the superficial structures. This was the case in a man whom I saw last year. His left chest was contracted and a large area of its anterior surface much indurated by cancerous deposit. Treatment.—As the condition is abso lutely unamenable to treatment, nothing can be clone but relieve the distressing symptoms as far as possible. Paracente sis is usually followed by rapid reaccu niulation of the fluid.
Echinococcus of the Pleura.
This affection is very rare, being met with primarily in the pleura in probably less than 1 per cent. of all cases; as a secondary infection, especially from the liver and lung, it is somewhat more fre quent.
The cyst is usually single, growing in ward from any part of the pleura. It compresses the lung and gives rise to the signs of a circumscribed pleural effusion of which the outline may be irregular. In a few cases it grows outward and causes bulging of the chest-wall and may perforate it, causing a chronic fistulous opening.
The cyst-wall is formed externally of the much-thickened and dense pleura and internally by the laminated mem brana propria of hydatid cysts. The fluid contents are clear, though rarely r they may become purulent from second ary infection.
As in hydatids of the liver, so here, the health may continue good. Pain, however, may be an early and persistent symptom. Pressure symptoms are added as the cyst enlarges, and the lung be comes compressed and the heart dis placed. The temperature is normal un less inflammatory symptoms develop. Anemia and loss of flesh may become marked. Occasionally there is tumor rhage into the pleural cavity.
Diagnosis.—The diagnosis is usually difficult. The true nature of the condi tion may be suspected from the evidence of a growing cyst without fever. There may be pain and loss of flesh. Tactile fremitus is absent. Circumscribed pleu risy and new zrowth will cause similar symptoms, but may be differentiated by puncture and careful examination of the fluid for hooklets.
Treatment.—If left to run its course it usually terminates fatally. In the treatment simple aspiration is rarely suf ficient, while free incision with liberal resection of ribs, if done early, rarely fails to effect a complete cure.