480 Clinical Record.

CASES OF EMPYEMA.

Case I. (Under the care of Dr. Thomas Watson. Reported by J. Brunton, M.A.)?J. M'A., aged 18, cotton-spinner, was admitted into medical ward No. 3 of Glasgow Royal Infirmary, on the 2nd of November, 1859. The history of his case is as follows:?For three years he has been troubled with a cough, which was dry and hard at first; but after a time he had haemop- tysis, and since then it is accompanied by a tough yellow spit. He has had recurrence of the haemoptysis for two years. He used to sweat at night, but for the last three months he has not done so. Four weeks ago he had rigors, immediately after which an abscess began to form on his left side, about three inches beneath the nipple. At the same time he had a very sharp stinging pain in the side. He has been losing flesh. On admission his only complaint is of the abscess. On exami-

nation there is an abscess at above spot at the base of the lung, and pointing outwards. The expansion of his chest in ordinary respiration is very

limited, and almost nil on left side. Breathing mostly abdominal; measurement of the left chest exceeds that of the right, at a point beneath the nipple, by three-quarters of an inch. Percussion of the chest gives clearness of the whole right lung, and entire dulness over the left, except a line along the spine in the inter- scapular region. Cracked pot sound can be heard at the apex anteriorly. Over the region of the stomach there is much tym- panitis. Respiratory sounds, as learned by the stethoscope, over the right lung are puerile, and free from crepitus. On the left side there is no vesicular murmur, and little air can be heard to enter the lung; what does enter gives a tubular sound. The voice sounds in interscapular region of left side and apex anteriorly are intensified and approach to pectoriloquy, and can be heard there only. Vocal fremitus on left side nil. Respira- tions twenty per rainnte?easy; decubitus on any side. On

searching for the heart, its apex beat is found to be between the cartilages of the fifth and sixth ribs, on the right side of the ster- num. H.S. normal though quick. Pulse 84. Tongue clean. Bowels regular. Urine loaded with urate of ammonia ? free from

albumen, and not very abundant. 5th. Pulse 84. Respiration 24. Tongue moist and clean.

Thirst considerable. Appetite fair. Spt. juniperi co. ?xii; acetat. potassse, ?ss; spt. etheris

nitros, ?ii. Sumat ?i. ter in die. Tegatur pectus inferius sinistrum vesicatorio per horas tres

modo. Habeat vini albi ?ii. 14^. Feels easier. Urine more abundant. Condition much

as when admitted. Abscess points, and is soft.

Cases of Empyema. 481

23rd. Abscess to-day was punctured, and an opening made over convexity of seventh rib. Exit was given to ?viii. of thin pus. Auscultatory sounds have undergone little or no change. Augeat. vinum ad ?vi. 1J., fSyrupi iodidi ferri, gii. Sumat 3i? mane et vespere.

24th. Very considerable discharge of thin pus continues. No

change, except that there is a little clearness at apex of left

lun&- . .

29th. Oozing of the pus continues. When he is placed in the erect posture, the fluid is discharged in a considerable and con- tinuous stream. Little change otherwise. Impulse of heart

strongest at mesial line. H.S. communicated with clearness to the apex and left margin of left lung.

Dec. 12t,h. His appetite lias improved* he takes food well; and his feelings of strength and comfort are decidedly amended. The discharge from the abscess has still continued?many ounces in the aggregate having had exit. The girth of the left side is lessened; the prominence of the intercostal spaces has gone; and some percussion resonance is noted in left axilla. The heart has receded towards its natural locality?the impulse being now noted at and under the right margin of sternum, Respirations 28. Expansion of chest on left side still very limited.?Continue treatment.

2<M. Goes on well. Apex of left lung clearing. Breathing easy. He is now pretty fat, and feels so strong that he has

expressed a desire to go home to work. 21s?. Goes on favourably. Case II.?(Under the care of Dr. Thos. Watson. Reported by

J. Brunton, M.A.)?J. M.C., aged 20, a carpenter by trade, was admitted into medical ward 3 of Glasgow Royal Infirmary on the 28th of November, 1859. The history of his case is as fol- lows :?Two years ago, he had an attack of inflammation of the

right lung. It was not very severe, so that he could attend to his work nearly all the time he was ill. However, he states that he never enjoyed good or perfect health since. Eight months ago he had, after rigors accompanied with sharp stinging pain in the left side, cough which was followed by expectoration, some- times white and frothy, at others thick and yellow. Under treatment the pain soon disappeared, but returned three months ago. He has had since, however, a great degree of dyspnoea, espe- cially on slight exercise, and a difficulty of lying on the right side; he says that if he does lie on that side, the pain, dyspnoea, and cough are very much aggravated. For some time he has had

night sweats. On admission he complains of dyspnoea and pain in the right

side, of weakness and inability to exert himself even to a small

degree. On examination the aspect of the patient is somewhat emaciated;

No. 28.?Vol. VII. 3 p

482 Clinical Record.

his features being sharpened and bleached-like, and his fingers long and thin. His breathing is short and laboured. His left chest bulges very perceptibly, especially at intercostal spaces, where it is so protruded that the outline of the ribs is obliterated. Measurement at a point about an inch beneath the nipple gives for the left 1^ inches greater circumference than that of the right chest. Percussion of the whole left lung is very markedly dull, except a line along the interscapular region, and a little down-

wards, where slight clearness exists. Percussion of the right lung is clear, except at apex which is slightly dull, and where

" bruit de pot fel&" can be distinctly heard, and over the centre and lower portion anteriorly which are markedly dull. There is entire absence of vocal fremitus on the left side, that of the right, however, is pretty good; auscultatory sounds over left lung are nil except at the very apex, and over the slightly clear portion in the interscapular region, where tabular breathing and slight voice sounds are made out. Over the right lung at its apex, and espe- cially at tlie acromial end of the clavicle, there exist bronchophony, harsh and tubular breathing, with no or very little crepitus. Some sonorous rales can also be heard here. The cardiac dulness

is found to be transposed to the right side, and the sounds and impulse are best detected below the right nipple. Pulse 112, feeble. Respirations 48, chiefly abdominal. Expansion of the chest very limited over the whole left lung, and at the apex of right. Tongue furred, red at tip and edges. Appetite bad. Bowels regular. Urine scanty, and loaded with lithate of ammonia.

Specific gravity, 1030. Sputa scanty. Decubitus inclining to the left side. Countenance anxious.

29th.?Signs as noticed. He states that he has been under medical treatment for some time, and that his gums have been sore several times. IJ., Bitartratis potassao ?i.; acetatis potassse 3vi.; aquas bullientis lbii. ; solve et mis. et adde spiritus etheris nitrosi ?ii.; hujus misturse sumat ?ii. sexta quaque hor&. Appli- cetur sinapisma amplum tegens latus sinistrum thoracis, et repe- tatur quotidie.

December 5th.?He continues in statu quo. His appetite is somewhat improved. Action of the kidneys little increased. Bowels free. Continuatur solutio diuretica IJ., Massae liydrar- gyri gr. xii.; pulveris scillas, gr. xvi.; extracti taraxaci quantum sufficiat ut fiant pilulse xviii. ; sumat i. ter in die ; applicetur vesicatorium parvum (4x4) ad latus sinistrum per horas quatuor.

12th?No change in his condition. Heart's impulse still observed three inches to the right of the mesial line. The over-

expansion of the left side with abrogation of the intercostal spaces, continuing as marked as ever. General health also unchanged. Applicetur vesicatorium (3x2) infra mammillam sinistram et repe- tatur, loco mutato, post dies tres. 23rd.?A consultation having been called, it was agreed that

Cases of Empyema. 483

paracentesis be performed; the following measurements were taken the day previous to operation :?

Girth of left side at level of nipple, 18 J inches. Do. right do. do. 17J "

Do. left at lower extremity of xiphoid cartilage, 17f inches. Do. right do. do. 16? "

Expansion of chest in axillae, ? inch. Do. do. at the base of lungs, nil.

Apex beat of the heart on a level with the right nipple, and three inches to the right of the sternum. 24tli.?The operation of paracentesis was performed this morning

in the ward by Dr. Andrew Buchanan. An incision was made in sixth intercostal space to the outside of the nipple; the walls of chest were punctured, and about lbvii. of sero-purulent matter taken away ; microscopic and other examination of it gives pus, mucus blood, and exudation corpuscles floating in a highly albu- minous fluid.

Vespere.?He does well; has no pain. Pulse moderate, and skin cool. Heart has receded a little.

Case of Intestinal Obstruction.?(Under the care of Dr. Thos. Watson. Reported by J. Brunton, M.A.)?J. W. aged 24, servant, was admitted into medical ward 4 of Glasgow Royal Infirmary, on the 19th November, 1859. She had been in

perfect health until a month previous to admission, when, her catamenial discharge having ceased on the second day, she had rigors and pain in the lower part of the abdomen, without any other disturbance of her system, as far as she remembers. Her bowels were quite regular. Since that time she has been troubled occasionally with severe pains in the abdomen, and for a fortnight her bowels have been very irregular, constipated chiefly. She says she has not had a proper evacuation of her

bowels for some time. For the last four days she lias suttered somewhat from irritation of the stomach, has great thirst, and no appetite for food. She farther states that she has noticed a hard

lump in the lower part of the abdomen for a week or two. Her catamenial discharge took place quite regularly last week. On admission, she complains of the pain in her abdomen, of

obstinate constipation of the bowels, and anorexia. On exami- nation of the abdomen, percussion sounds are tympanitic over the whole, except over the lower part of descending colon and upper portion of rectum, where there is dulness on percussion and suc- cussive sound, with gurgling; pressure over this part gives pain. Per rectum no mass of impacted faeces can be detected, and the uterus is felt to be quite in its place. By the vagina nothing abnormal can be detected. Tongue furred, foul. Pulse regular, 80, and quite natural; stool natural.

Injections were immediately ordered and given, without relief,

484 Clinical Record.

farther than that a very small quantity of feculent matter was evacuated.

20th?Injections to be repeated; a long tube to be used, and passed well up the rectum. Hab. magnes. citratis donee alvus soluta fuerit.

21 st?The action of the citrate of magnesia was quite unavail- ing. She had no alvine evacuation. Stercoraceous vomiting in large quantity having set in during the night, and being in the morning almost constant, it was thought advisable to hold a consul- tation, which was done. Enemata of warm water were advised, to be followed by small doses of sulphate of magnesia by the mouth.

!?., Sulph. magnesiae ?ii. j aquae lb. ii.; solve; hab. giss. quaque hor& ad cathar&iin, ex aquae subtepidae Oi. Her urine was passed easily. Pulse still regular and natural,

though her countenance is anxious and somewhat sunken, and her skin dusky.

p.m.?The enema of warm water was returned without any trace of feces. She had, some time after, a degree of freedom from pain, which now threatens to return with severity. Sterco- raceous vomiting has continued. She has a fatigued, anxious, and exhausted look, and dingy-yellow tinge can be observed on the skin. Percussion still tympanitic over whole abdomen, except over ileo-coecal valve, where gurgling exists. Her pulse, which, both yesterday and this morning, did not exceed 72, is still only 80, soft, without any character of wiriness. There is no acute

pain produced by pressure over the abdomen, but a general sense of soreness.

Calomelanos Qi., pulv. opii gr. iv. Div. in partes xii.; sumat i. quarta qq. hora. Omitt. sulph. magnes. 22nd?Last night the injections were repeated fully, but with

very little, if any, good effect. After the injection, the pain in the abdomen became less. Evacuation of the fluid brought away no fcecal matter. The aspect of patient is anxious and sunken; skin yellower and more dingy than yesterday. Pain in abdomen not so great. Vomiting less. Pulse 84, pretty good. Tongue furred. Applicentur fotus abdomini.

Vespere?Her abdomen has swelled considerably, and is very painful. No passage through the bowels obtained. Pulse full and

hard, 90. Tongue foul; breath fetid. Contin. pulv. cal. et opii. 23rd?Pulse 96; no other change. Tongue slightly furred;

face flushed; no rigor. Still vomits. No dejection. Gums not affected by the calomel.

Continuantur pulveres donee vesper advenerit, dein omittan- tur. Hora somni habeat haustus c. liq. opii sedativ. gtt. xlv. Applicentur regioni umbilicali hirudines x. 24th?The vomiting has ceased since last night, and the pain

considerably diminished. There is no evacuation, however. General abdominal fulness, with moderate tympanitis, present.

Reviews and Bibliographical Notices. 485

Pulse 96 ; expression better. Tongue clean and moist. Takes a little food. Repetatur hodie enema aquae tepidse.

!?., Pulv. opii gr. iss., ipecac, gr. lss. misce; fiat pilula, hor& somni sumenda. Continuantur fomenta.

25th.?Pulse 84, soft, pretty full. She suffers little or no pain at this moment; pressure producing only uneasiness. The dis-

tended condition of abdomen continues, but is not increased. No

vomiting since yesterday. Tongue moist and clean. Yesterday she had an evacuation small in quantity, consisting of a few small scybala. I?. 01. ricini ?i., sumat statim, et repetatur nisi dejecerit alvus, aut dolor aut nausea supervenerit, vespere hora septim&. Contin. fomenta.

26<//?She had two doses of oil yesterday. At the time of

physician's visit she has had an abundant feculent motion, semi- fluid and mixed, with masses firm enough to remain consistent. She expresses herself much relieved. Pulse 90, soft. Pain as

yesterday. Abdominal distension less. Percussion sound clear, except ileo-coecal region, which is still dull. 28#A?Hab. ol. ricini gi. 29tli?The oil ordered yesterday produced copious feculent

evacuations. Abdomen is now soft, free from pain. Pulse 84, soft. Tongue clean and moist; appetite returns. She may be

considered well. Dismissed cured.