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ROYAL SOUTH LONDON DISPENSARY.
4 cannot lie upon the right side, his dyspneea being thereby aggravated, and something seems to drag across his chest; nor on the left, as this causes pain there. He has slight pain
Hospital Reports. ROYAL SOUTH LONDON DISPENSARY. PLEURITIC EFFUSION AND MALIGNANT DISEASE.
Reported by WILLIAM TIFFIN ILIFF, JUN., Surgeon to
the
Dispensary.
IT is with no little interest that I have perused, in the last volume of the Guy’s Hospital Reports, Dr. Addison’s succinct and practical remarks on the fallacies attending physical diagnosis in diseases of the chest. Of the importance of the subject there can be no doubt; and the following case will afford an illustration of the seventeenth and twentyseventh propositions, which I here quote:—" Auscultation and percussion alone are insufficient to distinguish malignant disease, hydatids, or a tumour, from more ordinary diseases of the chest..... When serous effusion is very considerable, giving rise to unequivocal bronchophony, tubular respiration, and want of resonance and vocal vibration, physical examination has repeatedly led to a mistaken belief that these signs resulted from pneumonic or other consolidation of the lung." Joseph H-, aged forty-eight, was admitted as outpatient, Oct. 20th, 1846. He is a spare, but apparently healthy man; rather short stature; keeps a gingerbeer-stand in the streets; drinks freely of beer, not much spirits. Lost the sight of one eye many years ago by the explosion of a cracker; states that he has been ill two or three months with the following symptoms:-Pain at the pit of the stomach and left hypochondriac region, aggravated very much by eating, as the food seems to "scrape the bowels;" a sense of constriction and fulness, and frequent eructations,-these, however, causing relief. He is very irregular in his meals, owing to the pain occasioned, and has even gone two or three days almost without food, to avoid the suffering consequent on its being taken. He has not, however, been confined at home, but has continued his occupation. Tongue clean, somewhat red at the edges; no sickness; no pain on pressure; pulse regular and normal; rest bad at night. He attributes his suffering entirely to flatulence. His treatment consisted of opium, alkalies, bismuth, demulcents, &c., internally, with repeated applications of counter-irritants in the shape of mustard poultices, blisters, and turpentine stupes; but with only temporary relief. Towards the end of November, however, he began to complain of cough, which at first he had merely casually alluded to; and I examined his chest on the 24th, with this result :-The left side was very dull on percussion
throughout, anteriorly, laterally, and posteriorly; the right side resonant, except in the infra-mammary region, towards the sternum, where there was dulness. In inspiration, both
to the eyeand hand, no movement of the left chest was perceptible; and there is, I think, slight rounding of that side. The superficial veins of the thorax are large and easily traced, so also are one or two on the left side of the abdomen. Below, and to the right of the left nipple, there is a small dense body, the size of a pea, quite loose, and subjacent to the skin.Right side: Anteriorly, respiration puerile, harsh, very loud, and also posteriorly, with, in addition, some little large
crepitation.-Left side: Anteriorly and superiorly, respiration distant and blowing, giving the idea of its being laryngeal, or conducted from the opposite side; inferiorly, tubular breathing, as also posteriorly and laterally, though near the spine there was an approach to puerile respiration, with some slight mucous crepitation. Bronchophony audible superiorly and anteriorly, and especially posteriorly, even to the bottom of the chest, nowhere entirely absent, though most faint in the infra-mammary region. Heart’s sounds faint and confused, heard over increased space, and most mucous
clear beneath and to the right of the sternum. No bruit. By closely questioning the patient and his wife, I learned this additional history:-That he was a bell-ringer of some repute, and was last so occupied at St. Saviour’s, Southwark, on the 9th of November; and on finishing the peal, he had felt perfectly exhausted, and experienced great difficulty in breathing. About five months ago he was struck by the shaft of a cart on the left side, wherethe little tumour is now felt, (it did not, however, then exist,) and complained for a day or two of pain; but he was not laid’ up. Shortly after this he caught cold by sitting long in wet clothes, and this was succeeded by cough, dry and tickling, so violent at times as to cause epistaxis. Two or three months before I saw him, his stomach symptoms began to cause suffering, and he had been out-patient at one of the hospitals until the time he came under my care. Of late he has been only able with comfort to assume the semi-recumbent position in bed; he
shoulders; no marked tenderness on pressure; expectoration clear and scanty; spirits good; tongue as before; bowels rather irregular; urine free; appetite good; pain after eating rather less; sleep bad; pulse 80, regular, soft, and rather weak. For the last two days he has kept his bed. At between. the
the close of my examination of his chest, he was seized with dyspnoaa and gasping, from which he was someminutes recovering. I may here remark, that in moving or shifting any article of dress, he cannot be induced to take time; his movements are rapid and. excitable. A little ginand-water was allowed. Broth and arrow-root. Castor-oil and tincture of opium every morning. A large blister to the left side. Hydrochlorate of morphia, half a grain, every night; an emulsive draught every six hours. Nov. 29th.-Has been much relieved by the regular action of the bowels, and has felt, on the whole, improved, until yesterday evening, when his breathing became worse, and his symptoms moreurgent. I found him to-day on his back, as usual, raised to about an angle of 350; clammy perspiration; anxious countenance; respirations 48 in a minute; more gasping; words uttered in jerks, he being unable to speak continuously; pulse 102, intermittent and irregular, soft, weak, and rather small. Great restlessness and inability to bear the least article of dress across his chest, at times even insisting on the door and windows being opened, (weather frosty, wind north-east;) cough in paroxysms; inability to expectorate ; tongue furred; urine high-coloured, loaded with lithates. Mustard poultices every eight hours to the chest. Vinegar of squills, half an ounce ; spirits of sulphuric 2ether, six drachms; spirits of nitric sether, half an ounce; syrup of white poppies, three drachms; camphor mixture to a sixounce mixture. Mix. One tablespoonful to be taken frequently. Compound squill pill, four grains; powdered ipecacuanha, one grain, every six hours. 30th.-One P.M.: Very little alteration; has had a bad night; sounds of chest much the same; rather more bronchial obstruction; heart’s sounds confused; expectoration purely bronchitic, rather viscid, speckled with carbonaceous particles ; position the same; face pallid; feet warm; pulse much the same, rather weaker. To continue the treatment.Half-past seven P.M.: Much lower; pulse 100, very weak, irregular, and intermittent; respirations 50; not much pain, but extreme sense of constriction ; left side inferiorly, tympanitic from distended stomach; respiration more obstructed ; heart’s sounds more clear, and audible to the left of the sternum. He was able to sit up in bed for a minute or two, when the sounds of the left chest were remarked to appear close under the ear; but careful examination was out of the question. Urine loaded with lithates, moderately coagulable, sub-acid. Dec. Ist.-After much suffering and great distress, especially at the last, he died at nine o’clock A.M., retaining consciousness to the last. Necropsy, twenty four laarcrs alta death. - Pres en t, Dr. Birkett, Mr. Callaway, jun., and myself : weather frosty. Body slightly emaciated, destitute of fat; muscles of a dark red colour, and well developed; axillary glands on both sides strumously enlarged ; a scirrhous tubercle below the left nipple. On opening the thorax, the pleura on the left side was firmly adherent to the ribs, and the heart was centrally situated. In the right pleura was found rather more than a pint of clear serous fluid, and the pleura pulmonalis was sprinkled here and there with flattened patches of white matter (very much like drops of tallow) of malignant character ; there were also rounded elevations of emphysema; the apex of the lung was hard, and a little puckered, and the whole lung of a darker colour, and rather more solid than natural, and in the apex were observed some spots of malignant matter. In the left pleura there were four pints and a half of sanguineous and glutinous serum; the lung was small, compressed, dark coloured, fleshy, and contained but little air; the tubes were large, hard, gaping, and in some parts surrounded by hard white deposit, especially at the point of entrance of the great vessels, (indeed, the whole posterior mediastinum was filled with the same matter;) the apex of the left lung was attached by firm adhesions to the posterior wall of the upper part of the cavity, and a little below, on the same wall, was attached the mass of the lung, occupying a space of about six inches in length and three in breadth, and reaching to a point between the sixth and seventh ribs. A little below this, and rather anterior, was. attached one end of a strong bridle of adhesion, about two inches in length, the other extremity being attached to the. severe
5
pleura over the pericardium. The whole internal surface ofdeath) saw him with me, and examined his chest as far as could the left pleura was drawn and puckered like old strumousI be without distressing the patient-indeed, only anteriorly,scars, and deeply and profusely inlaid, and elevated with and was rather inclmed to the belief that there was fluid flattened white malignant tubercles. The floor of the cavity present. In the evening of that day, I again visited the The pericardium contained patient, in company with my father and Dr. Birkett, and took was contracted and drawn up. about two ounces of clear serum; its reflected surface was! with me the tapping instruments, intending, should our exa.
.
mination of his chest seem to justify it, to explore at least, and if fluid were present, to remove it, as affording the only hope of relieving the extreme oppression. The reasons which deterred me from this were-1st. The inability to find by auscultation any one spot wherethe sounds conveyed to the ear might seem, as far as could be, to ensure the safety of exploring. 2nd. The heart was more audible in the left infra-mammary region, and its sounds clearer than heretofore. (Could this have been at all occasioned or influenced by the accession of a tympanitic condition of the stomach?) And 3rd. On applying the ear briefly to the posterior parietes of the left chest, the sounds were too close to the ear. Careful examination was out of the question, as in the semi-recumbent position alone did he seem able to breathe, I may almost say, at all. The exploration was reluctantly abandoned, and death soon terminated the patient’s sufferings. In concluding, it may be well briefly to consider the connexion between the symptoms during life and the morbid condition displayed by the post-mortem examination. 1st. The presence of the extensive collection of fluid, the - Re)M
subjacent
,
posi-
Original Papers.
Hospital Reports. ROYAL SOUTH LONDON DISPENSARY. PLEURITIC EFFUSION AND MALIGNANT DISEASE.
Reported by WILLIAM TIFFIN ILIFF, JUN., Surgeon to
the
Dispensary.
IT is with no little interest that I have perused, in the last volume of the Guy’s Hospital Reports, Dr. Addison’s succinct and practical remarks on the fallacies attending physical diagnosis in diseases of the chest. Of the importance of the subject there can be no doubt; and the following case will afford an illustration of the seventeenth and twentyseventh propositions, which I here quote:—" Auscultation and percussion alone are insufficient to distinguish malignant disease, hydatids, or a tumour, from more ordinary diseases of the chest..... When serous effusion is very considerable, giving rise to unequivocal bronchophony, tubular respiration, and want of resonance and vocal vibration, physical examination has repeatedly led to a mistaken belief that these signs resulted from pneumonic or other consolidation of the lung." Joseph H-, aged forty-eight, was admitted as outpatient, Oct. 20th, 1846. He is a spare, but apparently healthy man; rather short stature; keeps a gingerbeer-stand in the streets; drinks freely of beer, not much spirits. Lost the sight of one eye many years ago by the explosion of a cracker; states that he has been ill two or three months with the following symptoms:-Pain at the pit of the stomach and left hypochondriac region, aggravated very much by eating, as the food seems to "scrape the bowels;" a sense of constriction and fulness, and frequent eructations,-these, however, causing relief. He is very irregular in his meals, owing to the pain occasioned, and has even gone two or three days almost without food, to avoid the suffering consequent on its being taken. He has not, however, been confined at home, but has continued his occupation. Tongue clean, somewhat red at the edges; no sickness; no pain on pressure; pulse regular and normal; rest bad at night. He attributes his suffering entirely to flatulence. His treatment consisted of opium, alkalies, bismuth, demulcents, &c., internally, with repeated applications of counter-irritants in the shape of mustard poultices, blisters, and turpentine stupes; but with only temporary relief. Towards the end of November, however, he began to complain of cough, which at first he had merely casually alluded to; and I examined his chest on the 24th, with this result :-The left side was very dull on percussion
throughout, anteriorly, laterally, and posteriorly; the right side resonant, except in the infra-mammary region, towards the sternum, where there was dulness. In inspiration, both
to the eyeand hand, no movement of the left chest was perceptible; and there is, I think, slight rounding of that side. The superficial veins of the thorax are large and easily traced, so also are one or two on the left side of the abdomen. Below, and to the right of the left nipple, there is a small dense body, the size of a pea, quite loose, and subjacent to the skin.Right side: Anteriorly, respiration puerile, harsh, very loud, and also posteriorly, with, in addition, some little large
crepitation.-Left side: Anteriorly and superiorly, respiration distant and blowing, giving the idea of its being laryngeal, or conducted from the opposite side; inferiorly, tubular breathing, as also posteriorly and laterally, though near the spine there was an approach to puerile respiration, with some slight mucous crepitation. Bronchophony audible superiorly and anteriorly, and especially posteriorly, even to the bottom of the chest, nowhere entirely absent, though most faint in the infra-mammary region. Heart’s sounds faint and confused, heard over increased space, and most mucous
clear beneath and to the right of the sternum. No bruit. By closely questioning the patient and his wife, I learned this additional history:-That he was a bell-ringer of some repute, and was last so occupied at St. Saviour’s, Southwark, on the 9th of November; and on finishing the peal, he had felt perfectly exhausted, and experienced great difficulty in breathing. About five months ago he was struck by the shaft of a cart on the left side, wherethe little tumour is now felt, (it did not, however, then exist,) and complained for a day or two of pain; but he was not laid’ up. Shortly after this he caught cold by sitting long in wet clothes, and this was succeeded by cough, dry and tickling, so violent at times as to cause epistaxis. Two or three months before I saw him, his stomach symptoms began to cause suffering, and he had been out-patient at one of the hospitals until the time he came under my care. Of late he has been only able with comfort to assume the semi-recumbent position in bed; he
shoulders; no marked tenderness on pressure; expectoration clear and scanty; spirits good; tongue as before; bowels rather irregular; urine free; appetite good; pain after eating rather less; sleep bad; pulse 80, regular, soft, and rather weak. For the last two days he has kept his bed. At between. the
the close of my examination of his chest, he was seized with dyspnoaa and gasping, from which he was someminutes recovering. I may here remark, that in moving or shifting any article of dress, he cannot be induced to take time; his movements are rapid and. excitable. A little ginand-water was allowed. Broth and arrow-root. Castor-oil and tincture of opium every morning. A large blister to the left side. Hydrochlorate of morphia, half a grain, every night; an emulsive draught every six hours. Nov. 29th.-Has been much relieved by the regular action of the bowels, and has felt, on the whole, improved, until yesterday evening, when his breathing became worse, and his symptoms moreurgent. I found him to-day on his back, as usual, raised to about an angle of 350; clammy perspiration; anxious countenance; respirations 48 in a minute; more gasping; words uttered in jerks, he being unable to speak continuously; pulse 102, intermittent and irregular, soft, weak, and rather small. Great restlessness and inability to bear the least article of dress across his chest, at times even insisting on the door and windows being opened, (weather frosty, wind north-east;) cough in paroxysms; inability to expectorate ; tongue furred; urine high-coloured, loaded with lithates. Mustard poultices every eight hours to the chest. Vinegar of squills, half an ounce ; spirits of sulphuric 2ether, six drachms; spirits of nitric sether, half an ounce; syrup of white poppies, three drachms; camphor mixture to a sixounce mixture. Mix. One tablespoonful to be taken frequently. Compound squill pill, four grains; powdered ipecacuanha, one grain, every six hours. 30th.-One P.M.: Very little alteration; has had a bad night; sounds of chest much the same; rather more bronchial obstruction; heart’s sounds confused; expectoration purely bronchitic, rather viscid, speckled with carbonaceous particles ; position the same; face pallid; feet warm; pulse much the same, rather weaker. To continue the treatment.Half-past seven P.M.: Much lower; pulse 100, very weak, irregular, and intermittent; respirations 50; not much pain, but extreme sense of constriction ; left side inferiorly, tympanitic from distended stomach; respiration more obstructed ; heart’s sounds more clear, and audible to the left of the sternum. He was able to sit up in bed for a minute or two, when the sounds of the left chest were remarked to appear close under the ear; but careful examination was out of the question. Urine loaded with lithates, moderately coagulable, sub-acid. Dec. Ist.-After much suffering and great distress, especially at the last, he died at nine o’clock A.M., retaining consciousness to the last. Necropsy, twenty four laarcrs alta death. - Pres en t, Dr. Birkett, Mr. Callaway, jun., and myself : weather frosty. Body slightly emaciated, destitute of fat; muscles of a dark red colour, and well developed; axillary glands on both sides strumously enlarged ; a scirrhous tubercle below the left nipple. On opening the thorax, the pleura on the left side was firmly adherent to the ribs, and the heart was centrally situated. In the right pleura was found rather more than a pint of clear serous fluid, and the pleura pulmonalis was sprinkled here and there with flattened patches of white matter (very much like drops of tallow) of malignant character ; there were also rounded elevations of emphysema; the apex of the lung was hard, and a little puckered, and the whole lung of a darker colour, and rather more solid than natural, and in the apex were observed some spots of malignant matter. In the left pleura there were four pints and a half of sanguineous and glutinous serum; the lung was small, compressed, dark coloured, fleshy, and contained but little air; the tubes were large, hard, gaping, and in some parts surrounded by hard white deposit, especially at the point of entrance of the great vessels, (indeed, the whole posterior mediastinum was filled with the same matter;) the apex of the left lung was attached by firm adhesions to the posterior wall of the upper part of the cavity, and a little below, on the same wall, was attached the mass of the lung, occupying a space of about six inches in length and three in breadth, and reaching to a point between the sixth and seventh ribs. A little below this, and rather anterior, was. attached one end of a strong bridle of adhesion, about two inches in length, the other extremity being attached to the. severe
5
pleura over the pericardium. The whole internal surface ofdeath) saw him with me, and examined his chest as far as could the left pleura was drawn and puckered like old strumousI be without distressing the patient-indeed, only anteriorly,scars, and deeply and profusely inlaid, and elevated with and was rather inclmed to the belief that there was fluid flattened white malignant tubercles. The floor of the cavity present. In the evening of that day, I again visited the The pericardium contained patient, in company with my father and Dr. Birkett, and took was contracted and drawn up. about two ounces of clear serum; its reflected surface was! with me the tapping instruments, intending, should our exa.
.
mination of his chest seem to justify it, to explore at least, and if fluid were present, to remove it, as affording the only hope of relieving the extreme oppression. The reasons which deterred me from this were-1st. The inability to find by auscultation any one spot wherethe sounds conveyed to the ear might seem, as far as could be, to ensure the safety of exploring. 2nd. The heart was more audible in the left infra-mammary region, and its sounds clearer than heretofore. (Could this have been at all occasioned or influenced by the accession of a tympanitic condition of the stomach?) And 3rd. On applying the ear briefly to the posterior parietes of the left chest, the sounds were too close to the ear. Careful examination was out of the question, as in the semi-recumbent position alone did he seem able to breathe, I may almost say, at all. The exploration was reluctantly abandoned, and death soon terminated the patient’s sufferings. In concluding, it may be well briefly to consider the connexion between the symptoms during life and the morbid condition displayed by the post-mortem examination. 1st. The presence of the extensive collection of fluid, the - Re)M
subjacent
,
posi-
Original Papers.