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7 JAN 74
EMPYEMA OF LONG STANDING.-REMOVAL IN THE COURSE OF TWO DAYS, BY PARACENTESIS, OF NINE QUARTS OF PURULENT FLUID FROM THE THORAX.-DEATH FROM PURULENT INFECTION.
BY JOHN W. OGLE, M.D.
ALEXANDER F., aged 33, a clerk, six feet in height, was admitted into St. George's Hospital June 12th. He was born of healthy parents, and had always been hale and strong until he was 25 years old, when, after much exposure, he caught "cold," to which he ascribed his illness. The "cold" was followed by hæmoptysis, which lasted several weeks. He subsequently became much troubled by palpitation of the heart, dyspnoea, and constant cough, which greatly reduced him; and for three years he had been quite unable to lie on the right side; and during that time his legs had been anasarcous. For eight months he had had insufficient food.
SYMPTOMS ON ADMISSION.-He was very emaciated, and his cheeks, lips, and nose were very livid. His breathing was short and rapid (being 36 per minute), and laboured: and the respiratory movements were almost entirely confined to the right side of the chest. He lay turned over to the left side. The chest was remarkably "barrel-shaped," and the ribs on the left side
bulged out much more than those on the right, the intercostal spaces being prominent. The left half of the chest measured three inches more than the right half (the proportion being 17 to 20 inches). On percussion and auscultation it was found that whilst the respiration was puerile over the entire right side (excepting at the lower portion posteriorly), the whole of the left side was quite dull on percussion, and entirely devoid of respiratory murmur, the vocal resonance being absent. The heart was pushed over to the right side, so that its impulse was felt the strongest about one inch to the right of the right nipple: it was beating at the rate of 225 per
The urine was scanty, loaded with lithates, and very albuminous.
The patient was supported by wine and nourishments, and on the day following admission two quarts of purulent but fotorless fluid were drawn off by the aspirator from the cavity of the left pleura, the needle being introduced between the sixth and seventh ribs. This gave the patient immense relief, for whereas prior to the operation the respirations were 45 per minute, in twenty minutes afterwards they were only 30. Before the operation the temperature was found to be 97.6° and very shortly afterwards it was 99.6°. The palpitation of the heart was also greatly ameliorated by the operation. Much fluid was still left in the pleural cavity. On the 14th the pulse was 220 per minute. On the 15th the temperature was 98.2° at 9 A.M., and 98.6° in the evening. On the 16th, note was taken that the patient could sleep and breathe with comparative ease, the cyanosis having almost entirely departed. On that day the temperature was 98.6° at 9 A.M., and 99.6° at 9 P.M.
On the following day (the 17th) there was increased dyspnoea and palpitation, and ether and digitalis were given with great relief: but still the patient was unable to lie on the right side. The urine was, as before, very albuminous. The temperature was 99.8° at 9 A.M.
From the above date to the 27th, frequent examination showed the existence of the following state of things. The whole of the left side of the chest was dull on percussion. Vocal resonance was deficient, and vocal fremitus quite absent
No expansion of lung could be detected. The apex-beat of the heart was felt chiefly beneath the ensiform cartilage, but a second kind of beat was also recognised directly below the right nipple. The dyspnoea was not very troublesome, but attacks of palpitation were so; and during their occurrence the pulse became extremely irregular, so that it could not be counted. At other times the pulse was, generally, about 108. The urine remained scanty, but had ceased to be albuminous. Fluid in the abdominal cavity was detected. As the symptoms suddenly became more urgent, paracentesis was again performed by the house surgeon, Mr. Morgan (an ordinary trocar being used), an incision being made between the fifth and sixth ribs; and slowly and by degrees no less than seven quarts of purulent fluid (of the same nature as that removed by the aspirator) were drawn off. Mr. Morgan then passed through the incision a long bent probe, made it point between the ribs at the bottom of the thorax (the ninth and tenth), cut down upon it, and passed through the lower opening with a drainage-tube attached. Owing to this procedure the dyspnoea was greatly relieved, and the palpitations ceased: the anasarca in the legs also Subsequently, the apex-beat of the heart was felt about one inch to the left of the right nipple. Owing to the admission of air, the left side of the chest became very resonant, and the subcutaneous tissues around the wound were emphysematous. The patient much improved; his appetite was good, and he took meat and other nourishment, and four ounces of brandy daily, also bark and mineral acid.
On the 1st of July he complained of losing strength, and of troublesome perspiration, and of headache. The purulent fluid continued to drain out from the canula, which on the 5th was for some surgical reason removed. On the 8th, the following note was taken by Mr. Spitta, acting as house physician :-" Much im
proved. The heart is now situated with its base corresponding to the cartilage of the fourth rib on the right side, whilst its apex may be seen pulsating just beneath the ensiform cartilage. Its action is quite regular. Tubular breathing may be heard at the upper part of the back of the chest. Egophony cannot be detected." On the 9th there was great sweating and some shivering. On the 14th the patient suddenly became worse, and
died with all the symptoms of purulent infection, or bloodpoisoning. In addition to the remedies and stimulants above mentioned, the patient from time to time took diureties and. sedatives, and occasional aperients.
POST-MORTEM EXAMINATION.-The left pleural cavity was found distended equally with air and purulent fluid, the surface being coated by recently formed fibrine, and the pleural membrane very thickened. An old and firm band crossed the upper part of the cavity. The left lung was completely devoid of air, and was firmly compressed against the spine at the upper part of the thorax. It contained numerous small excavations filled with inspissated pus and caseous material, and surrounded by dense fibrous tissue. On the right side the pleural sac was natural. The right lung was emphysematous and congested, containing small nodules of cretaceous deposit. The heart, which weighed twelve ounces, was much displaced towards the right. The kidneys weighed sixteen ounces, but their texture appeared natural. The other organs were natural.
REMARKS. In the above case we possess, as regards the character both of general and physical symptoms, a good typical instance of empyema with consequent pressure on the lung, dislocation of the heart, and congestion of the kidneys. That the affection was of a phthisical origin may be inferred from the hæmoptysis which attended its early stage, and from the excavations in the lung containing caseous matter, &c., found after death.
The case presents several points of clinical and practical interest. In the first place, the lengthened period of duration of the pleurisy is worthy of note, as it would appear that it had at least existed as much as three years; and it was remarkable that during that time no positive help in the way of withdrawing the fluid in the chest had been suggested (a procedure which must for long have been requisite as well as feasible). Again, the good results of the removal of the fluid were strikingly and speedily manifested and it was interesting though not surprising to find that the temperature of the body, which previous to the operation had been below the natural standard, quickly rose after the operation, two degrees. This comparatively low temperature before the operation was, no doubt, owing to the deficient
arterialisation of the blood and consequent failure of heatproducing processes, which resulted from the encroachment on the pulmonary functions that existed before the operation.
Notice should also be directed to the subsidence of anasarca and of dyspnoea and palpitation of the heart, as well as to the removal of the albuminous condition of the urine which ensued upon the relief to the various organs afforded by the paracentesis of the chest.
But especially it should be noticed as an interesting fact, that within the space of two days no less than nine quarts were evacuated from the chest; and it is indeed a matter of astonishment that at one operation seven quarts could be evacuated from one side of the thorax. In addition to this quantity, the pleural cavity (which practically was converted into an immense abscess) continued for some days to pour out purulent fluid through the drainage-tube.
The case, in addition to other things, shows that neither danger nor inconvenience need necessarily follow the removal at one time of large quantities of fluid from the chest; inasmuch as not only were the symptoms at the time ameliorated, but the patient continued to improve for many days after the operations, until, in fact, the symptoms of blood-poisoning, which caused his death,