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No. 1.


respiration, elevation of temperature, dry, ORIGINAL ARTICLES.

tight, painful cough; these symptoms, ac-
companied or followed by dullness or flat-
ness upon percussion, following the line of
an Ellis curve, absence of vocal fremities or

breath sounds, subolavicular skadiac reso-
Purulent Pleurisy - Its Early Detection
and Treatment.

nance and displacement of the heart, the

diagnosis of acute pleurisy with effusion is By C. H. WALLACE, A.M., M.D.,

established almost deyond a doubt; and the PROFESSOR OF PATHOLOGY AND CHEMICAL MEDICINE IN THE persistence of the fever-101 to 104 — beyond

a fortnight with physical evidence of in

crease in the quantity of fluid, furred, red The subject I have chosen for my paper tongue, hectic sweats, especially in sleep, is extremely trite, and I can add nothing of failure in strength and loss of flesh, edema novelty to it; however, it is a disease of uni- of the thoracic walls, are sufficient evidence versal interest to every physician, and its for the suspicion that the effusion is puruearly detection, treatment and management lent in character. However, these sympis of vital importance to the patient. toms do occur in part and sometimes in toto

If by my effort I elicit a discussion which in fibro-serous pleurisy, and the exploratory will have the effect of making clearer the puncture is the only method of positively esdifferential points of diagnosis in obscure tablishing the diagnosis. The simplicity cases, and the importance of always regard- and painlessness, and the innocence of this ing it as a surgical affection demanding im- procedure under proper antiseptic precaumediate attention, the purpose of my paper tions, in my opinion, renders its resort obwill have been accomplished.

ligatory upon the medical attendant in every Empyema has been recognized and treated case of pleural effusion which does not by paracentesis and pleurotomy since the within the first two or three weeks show time of Hippocrates, but not until a com- physical signs of absorption and improveplete description of the pleura as a serous ment in the general condition of the patient. membrane, and its anatomical relations to Furthermore, its use is of equal importance the lungs and other vicera, and physical in obscure cases, where the fluid is encysted modes of exploration by Lænnec, was the by reason of pre-existing adhesions or has real foundation of our present knowledge become divided into lakes by recent adlaid; and it has been only in recent years hesions, or has become commingled with that this affection has been thoroughly in-air from communication with a tubercular vestigated and elucidated by means of the cavity, or the generation of gas by the dehypodermic exploring needle of Pravez and generation of the pus itself. This condiAlex Wood. The physical signs of purulent tion of affairs will produce a conglomeration effusion are essentially the same as in fibro- of physical signs that will mystify and misserous effusion, and in typical cases the dis- lead the diagnostician, however skilled and ease is recognized with comparative ease by experienced. an experienced ear. In a patient complain- CASE 1. W. H. was admitted into asylum ing or having complained of pain or stitch No. 2, May 5, 1887, suffering from acute dein the side, irregular and jurky rythm in lirium mania. He was eighteen years of

age, unusually strong and robust, with a past three weeks. There is no apparent good family history. After several months diminution in the amount of discharge, and of delirium he gradually became quiet, but only slight evidence of closure of the pleural with permanent mental enfeeblement from sac by expansion of the lung, as shown by the duration and intensity of his excitement. physical signs and shortening of the sinus.

January 16, 1888, eight months after ad- A change was now made in the wash solumission.-Has suffered from nausea and tion from boracic acid to bichloride of vomiting for the past week, and this morn- mercury, then straw-colored iodine water. ing complains of great pain in his right These solutions were both abandoned after side. Examination: temperature 103, pulse a few trials on account of the shock, pain 110, respiration 30. Dullness upon percus- and paroxysms of coughing they occasioned, sion upon right side below the fourth inter- and resort was had to warm water. costal space, skadiac resonance at apex; July 1st, five months after operation. The absence of vocal fremities and respiratory activity of his nutritive functions have murmur over lower two-thirds of lung, and materially lowered during past four months. puerile breathing in the opposite lung. The Irrigation with the warm water has been diagnosis of acute pleurisy with effusion kept up daily, even after removal of drainage was made, and he was ordered salines as in- tubes, they having been completely withdicated, and kept in bed.

drawn some six weeks after operation. PaJanuary 27th, eleven days after attack.- tient has been kept much in open air for Patient not doing well; perceptible failure in past three months. His expectoration has strength and loss of flesh; temperature 100 récently become thick and profuse, and exto 10272, pulse feeble-90 to 100; physical amination of it by Dr. Hoyt, the pathologist, signs much changed. Ronchi creaks and revealed tubercular bacilli. Irrigation was rales heard over entire lung. Area of dull- abandoned from this date, and cod-liver oil ness now limited to lateral portion of lower was added to his tonic treatment. His gentwo-thirds; resonance being increased near eral health showed signs of improvement medium line, both anteriorly and posteriorly; within the next week; his appetite became and fremities and respiratory murmur also better, expectoration diminished, the disto be heard at these points. For the pur- charges materially lessened and the sinus pose of determining the character of the shortened. fluid, I made an exploratory puncture with August 22d, five weeks later.-Expectoraa fine needle, but to my surprise failed to tion scant and microscopical examination get fluid. So well satisfied was I with the reveals only an occasional bacillus in the correctness of my diagnosis that I deter- field. The sinus has closed, and has gained mined to try again. This was repeated thirty pounds in weight. He soon regained until the seventh prod; I was rewarded for his usual health and is now living, a fine my perseverance by getting fluid, purulent specimen of physical manhood. in character.

CASE 2. A. B. was admitted to asylum February 2d, three days from this time, No. 2, June, 1890, suffering from melanunder ether I performed pleurotomy at the cholia. Nothing known of family history. site of the last puncture in the seventh inter- General physical condition good. costal space, relieved the pleura of about January 2d.—Six months after admission one and one-half pints of sweet pus, intro- he sickened. Examination revealed a mornduced drainage tubes, transfixed with safety ing temperature of 101, pulse 98, respiration pins, irrigated with warm boracic acid solu- 24. He complained of pain in the left side, tion, by means of a fountain syringe, and and had dry, superficial cough, friction rales dressed with bichloride gauze and oakum. and diminished breathing over the lower

March 1st.–Patient not doing well; fre- portion of left lung. quently vomits food, especially after irriga- January 6th.--He had all the physical tion, which has been kept up daily for the signs of effusion as high as the fifth interfetid pus.

costal space, with a temperature ranging ing, and always more or less pain, it is disfrom 101 to 102.5.

persed with and tubes removed. tuuary 16.--Has complained daily of March 17th.-His general condition has

and has occasionally vomited his slowly improved since last note; expectorafood ivr the past fortnight. Physical signs tion much diminished and the discharge give evidence of increase in effusion. Heart much lessened; again examination of sputum is now considerably displaced, his fever has is negative. He is permitted to sit up. persisted, tongue dry and red, appetite poor, April 1st.-Doing well; sinus has closed. hectic sweats on falling asleep, and absence His recovery was uninterrupted from this of bacilli's sound. These symptoms point date. to a purulent effusion.

May 21st.—He was sent to his home in February 2d.-Has gradually failed since the country, where he would reap the benelast note. Made exploratory puncture with fits of out-door life. small aspirating syringe, and found fluid He has been returned to the asylum within purulent as suspected. Withdrew about one the last year on account of his mental conpint at this time with aspirator, preparatory dition. He is now in good physical trim, to pleurotomy.

and has no indications of tuberculosis. Two February 4th.-Under ether I made an in- years since operation. cision in the seventh intercostal space, in CASE 3. C. W. was a baker by profession. the middle axilliary line, at the site of the He was a frail, stoop-shouldered man, thirty previous paracentesis. The cavity con- years of age, with a paternal predisposition tained something more than a pint of non-to tuberculosis. After an exposure from a

walk in the country a stormy night, he was I inserted two drainage tubes, transfixed seized with rigors, followed by fever, genwith safety pins, and washed out with warm eral muscular pain and some stiffness of boracic acid solution and dressed with bi- joints. He was diagnosed as having rheuchloride gauze, cotton and oakum. The matism by his medical attendant, and treated cavity was irrigated daily with boracic acid accordingly. He had suffered from acute solution. Nothing noteworthy took place articular rheumatism in former years. In a in this case until February 10th, two weeks week he developed chest symptoms upon the after operation, when he again complained right side, and was diagnosed by a second of pain in his side. His temperature ran physician as having pneumonia. I saw him up to 103, and coarse rales were to be heard the following day, when, to my mind, he over the lower portion of the lung. The had well-marked physical signs of effusion. fact that for several days prior to this at. I verified my diagnosis by an exploratory tack the wash solution had returned almost puncture. The effusion rapidly attained exclear, and removal of tubes showed them to tensixe proportions, as evidenced by disbe patulous, lead me to suspect adhesions placement of heart, stomach and diaphragm, had taken place, surrounding an island of and accompanied by intense dyspnea. I at pus which was being absorbed. He went this time (two weeks from onset of sickness) from bad to worse from this date.

performed paracentesis and relieved him of February 28th.-He is much emaciated thirty-two drams of serous fluid. Absorpand is too feeble to assist himself in any tion rapidly took place, and about the time way; has fine rales over the other lung, physical signs showed almost complete dishectic flush upon cheeks and daily exacer- appearance of fluid, he was again seized bations of fever. Cough has become ex- with rigors, pain in the opposite side, folceedingly annoying, and expectoration more lowed by rapid effusion. At the end of three frofuse; however, examination of sputa by weeks from his second illness, there being Dr. Hoyt gave negative results. Inasmuch no signs of absorption, I did a paracentesis as irrigation not unfrequently resulted in upon the left side; however, not with similar mild shock and paroxysms of intense cough- good results as upon the right. There was

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