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FIFTEEN EASES OF HYDROTHORAX—(SIXTHSERIES.) , ». uT * ••
F. PEYRE PORCHER., M. D., CPIARLESTON, S. C.
The preceding series were restricted to the considerationof cases in which paracentesis of the plural cavity, thelungs, or the pericardial sac was employed.
As I do not desire to record or describe the surgical pro-cedures only, which are unimportant in comparison withthe diagnosis and detection of the presence of fluid, I willinclude in this series every case where fluid was discov-ered, ante or post-mortem, during a service, it will be ob-served, of but a few months, and in only one division ofa hospital of very limited capacity. This will demonstratethe unsuspected frequency of pleurisies with effusion inthis country. A few cases treated at the same period byone or two of my colleagues are added.
From a consideration of the entire series (numbering 69cases,) I am again compelled to say that the conclusion isforced upon us that throughout the country a vast numberof cases escape detection and treatment, either medical orsurgical. If this be true, the question arises whether sucha conclusion is flattering to the profession as a body.
Case I. Serous fluid degenerating into pus; paracen-tesis ; introduction of drainage tube.
I. Morrison, colored, set. 33, difficulty of breathing uponexercise, with dropsy of feet, logs and abdomen. The dull-ness extended above the nipple of right breast, and pos-teriorly to the same level ; slight roughness of first soundat base of heart, but could not detect prolonged first soundover mitral, as reported by others who had examined him.
Diagnosis.—Fluid in right thoracic cavity.The hypodermic needle having been introduced an inch
below the point of the scapula, the presence of fluid wasestablished.
Fifteen Cases of Hydrothorax —F. Peyre Porcher, M. Ft.
It is stated as follows in hospital book: “ June 1, patientaspirated, and two quarts of fluid of a vermillion color,removed by Dr. Porcher. Patient lias been feeling bettersince the aspiration, and the act of respiration is muchmore easily performed.”
After a time, as there was immobility of the unsoundside, with no reverberation of voice, and hectic symptom,and an evening temperature of 100 degrees occurred, it wasdetermined to repeat the aspiration The needle wr as in-serted at the ninth intercostal space at the back, fourinches below the spine of the scapula, and about one quartof purulent, or sero-purulent fluid was removed.
July 16—Patient better, but the movement of fluid couldbe detected upon changing the position of his body. A trocarand canular was inserted, and two and a half quarts of puru-lent fluid withdrawn. The opening having been widenedwith a bistoury, a drainage tube was introduced and allowedto remain.
To show how successful may be the treatment of empy-semia, I insert the following from a recent journal:
“ The question of the after treatment of empyaemia isone of great practical inter est, and the experience of Prof.Hoelsti (Rundschau, SH. 1889) is well worth attention. Ofthe 27 cases operated on, only one died, and that from pul-monal and cardiac complications ; three left the hospitalwith fistula, and the rest were cured. In all the cases oper-ated on the pleural cavity was not washed out once. Themain point to emphasize in every case was free drainage,which was best accomplished by the resection of a rib, pre-ferably the sixth, and to avoid the mistake of removingdrainage tubes too soon.”
Case 11. S. Camoens, colored, female, set. 50; enteredJune 19, 1888. Extremities dropsical, absence of respira-tion and dullness at base of right lung, corresponding dull-ness at base posteriorly and akso in front of left lung. Therewas no decided pain in the chest, or abnormal sounds uponascultation. She had been ill for months before admission,and died June 21.
Autopsy: Cheesy matter under sternum ; pericardial sacadherent to heart, and degenerated, with a purulent ab-scess ; tubercular deposits upon ensiform cartilage; heartextremely fatty; fluid in right pleural sac compressing theright lung upon the spinal column ; fluid also in left cavity.
Cause: Former pleurisy and pericarditis, followed by
Fifteen Cases of Hydrothorax —F. Peyre Porcher, M. D. 3
inflammatory exudation. This woman must have sufferedfrom the presence of intrathoracic fluid long before heradmission, and doubtless it should have been detected andremoved.
Case 111. Illustrating unusual difficulty in diagnosis ofintrathoracic fluid:
Csesar Brown, colored, set 59, admitted July, 1888.There was no fever, slight swelling of the feet, but noalbumen in the urine. He was tapped with the hypoder-mic needle on the right and left side to test for the presenceof fluid, because, although there was some vocal resonanceand no fever, there was impaired respiration, and partialdullness at base of lungs, anteriorly, posteriorly andlaterally.
His liver was greatly enlarged, and the spleen also—orat least the left lobe of the liver gave dullness over thesplenic region.
He was carefully examined, July 18, with a diagnosis ofcirrhosis of liver, and fibroid phthisis with intrathoracicfluid. No satisfactory respiratory murmur was found inany part of his chest—only sub-dullness; so that the explo-ratory tapping was justifiable. Prof. Guiteras agrees as tothe cirrhosis, and, notwithstanding negative results, is ofthe opinion also that fluid does exist in the thorax.
Case IV. M. Townsend, set. 40, colored, admitted July8, with the diagnosis: “ Fluid in pericardium and dilata-tion of the heart; the dullness over this organ being five tosix inches in area.”
Death occurred a week after admission, without treat-ment. It was intended to use hot baths and hypodermicinjections of pilocarpin whilst in the baths, which hadproved very efficient in our hands in other cases of dropsyfrom disease of the heart. The post-mortem revealed thecorrectness of the above diagnosis; some fluid also beingfound in the right thoracic cavity.
Case V. Leonora Bell, colored, set 45. Fluid in chestand ectopia cordis; heart displaced to the right, two inchesbeyond the sternum. Sick four months before admission ;oedema and pain of left breast; both hands swollen ; slightgeneral anasarca; no signs of valvular disease.
Diagnosis: “ Left chest up to clavicle filled with fluid.”Several friends, Drs. Ogier, M. Michel, E. Ravenel, Legare,
4 Fifteen Cases of Hydrothorax—F. Peyre Parcher, M. D.
and the house physicians being present, paracentesis waspracticed in the left sub-auxiliary region, between the sixthand seventh spaces, and a quart of light serous fluid wasremoved.
Patient died during my absence, August 17. At theautopsy, fluid was found in all the cavities; left lung atro-phied to half a finger’s width, and as usual pressed backupon the spinal column ; costal pleura tuberculous. [Note :
Fluid should have been removed oftener and more thor-oughly-]
Case VI. Saw case with Dr. Guiteras, 1888, with fluidin thoracic cavity; not aspirated.
Case VII. Treated by Dr. P. G. DeSaussure, 1888; alsowith fluid in cavity of chest.
Case VIII. Miss S , white, seen with Dr. Grimke, set 30 ;
complete dullness over left thorax. Used hypodermicneedle without success, as the tube was too fine to admitthe exit of pus, which subsequently escaped in largequantity from a rupture through the bronchial tube.
Case IX. B. Collins, colored, aet. 40, admitted July 20.From notes by house physician as follows : “Complained ofpain in right side with difficulty of breathing. Said shehad had an attack of pleurisy three weeks before. On per-cussion, dullness was found over right lung up to one inchof clavicle. Auscultation showed absence of respiration onthe same side, and a friction sound discernible; some bulg-ing out of chest.”
Diagnosis: Pleuritic effusion. July 22, the needle ofthe aspirator was introduced three inches to the right of theright nipple, between the fifth and sixth ribs, and fully 3Jpints of a pale-straw-colored fluid withdrawn. Patientshowed signs of faintness at the termination of the opera-tion, and an ounce of whiskey was given. As the opera-tion proceeded there was gradual relief from the dyspnoea.
July 23. On percussion, found resonance extending toone inch below the nipple; there was no vocal resonanceupon auscultation. A blister was applied to the back belowthe right scapula Patient rested well last night for thefirst time in three weeks.
July 24. Ordered syr. ferri iodidi, t. i. d., and spirits,Sfiii daily.
Fifteen Cases of Hydrothorax—F. Peyre Porcher , M. D. 5
Aug. 1. Right lung above nipple has partially resumedits functions; the pains from which she had suffered weregreatly relieved by blisters.
Case X. I. 8., aet. 30, 1888; pleuritic effusion; hadspitting of blood ; much emaciated ; loud complementaryrespiration under clavicles, explained b}r the subsequentdiscovery of fluid. The dullness exists above the line ofthe liver and extends as high as the nipple in front of theright lung ; so conclude there is pleuritic' effusion—theresult of a pleuro-pneumonia.
Case XI. J. Smalls, colored, set. 40 ; admitted February5; died a few days after admission, which the autopsy willexplain, as follows : “ Extensive lesions of the thoracic or-gans; cavity filled with fluid, and plastic lymph coagulated ;
lungs compressed against the spinal columns and atrophied;pericardial sac also filled with light, serous fluid. Therewas an abscess of the liver and the spleen was engorged.”[Note—This case should have been earlier detected andtreated, either medically or surgically.]
Case XII. C. Davis, colored, set. 30 ; admitted Febru-ary, 1889, during a partial service by the writer of a fewweeks.
Full plethoric habit, dropsical, with difficulty of breath-ing ;no albumen in urine; feet infiltrated with fluid—form-ing blebs, and serum exuding. A friend wdio was invitedto examine him gave the opinion that the chief trouble wasfrom disease of the heart. My own diagnosis was infiltra-tion of the lungs and dilatation of the heart, with fluid inthe thoracic cavity. Death occurred in a few days.
Autopsy. March 2,1889: —Pericardial sac contained fluid;left pleura so strongly adherent that lung cannot be re-moved without tearing. Lung dark, infiltrated with serousfluid, which pours from it upon pressure. Fluid in rightcavity also. Right lung more spongy and resonant, butwith some engorgement of middle and lower lobes, resemb-ling hepatization, but with much serous juice exuding.Lungs in a desperate condition. Heart dilated ; liver verylarge; kidneys somewhat large; capsules adherent, butwith no material lesion or change; spleen adherent todiaphragm.
Cause of death :—Result of acute pneumonia and plurisy,with inflammation extending to the organs under the
6 Fifteen Cases of Hydrothorax—F. Peyre Porcher, M. I).
diaphragm, which had also passed through stages of severeacute inflammation.
Case XIII.—P. Drake, colored, set. 21; admitted underDr. Guiteras, Oct 21, 1888, with tubercular peritonitis andhydrothorax. Was treated for three months with no im-provement, Died in January.
Case XIV.—J. Leonard, white marine, set. 30 ; admittedJan. 28, 1889, under Dr. Guiteras, with right pleural cavitycompletely filled with serum up to within two inches of theclavicle; was treated with potash iodide and syrup of theiodide of iron, and chest painted with tincture of iodine.Patient left on way to good recovery ; fluid diminishing.
Case XV.—S. Selby, white, male, set. 40 ; was treated inhospital for some time. Upon a post mortem examinationthe left pleural cavity was found full of a sero-fibrinousfluid. The three last cases were reported to me by Dr. Folk,one of the house physicians.
Case XVI.—This case is reported on account of its puz-zling nature, there being complete dullness on percussion,yet an entire absence of fluid :
John Elmore, set. 28, had had pneumonia and typhoidfever a year ago, in Columbia, under Dr. Pope. There wascomplete dullness over left chest, without cough or respira-tory sounds, and no expansion upon breathing, but comple-mentary active expansion of the right.
Diagnosis :—Absence of fluid. Cause of dullness; tuber-culosis, or fibroid phthisis, with contraction of chest walls,which were flattened. Patient does not complain of chestor heart, but came in with an injured foot; and the condi-tion of the lungs was discovered by us only upon carefulexamination; found also a prolonged, aortic obtructive firstsound at base of heart, swallowing up the second sound ;
can hear both first and second sounds at the apex, to theright of the nipple and below it. He did not complain ofhis chest.
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