Report of Nine Cases (Second Series) of Pleuritic Effusion; with Removal of Nine Hundred and Six Ounces of Fluid. Also One of Paracentesis in Abscess of the Liver;—a Pint and a half of Pus evacuated, with Recovery. By E. Peyre M. I)., Professor in the Medical College of the State of South Carolina, and one of the Physicians to the City Hospital, Charleston. Our principal object in recording this new series of cases of paracentesis for pleuritic effusion (the others having been re- ported in the The Virginia Medical Monthly, Sept. 1882, and The Medical News for Dec. 22, 1883,) is, that they will force upon us the conviction that this diseased condition is extremely frequent, and that often it is not recognized and rerqedicd. Upon taking charge of the wards under our care in the hospital, which con- tain not more than sixty to eighty beds, we encounter during our last term of service of less than four months seven cases of pleuritic effusion; and detect the presence of hydrothorax by the autopsy in seven others not operated upon, besides leaving four additional cases under treatment. Most strange and sin- gular fortune that it should happen to us in the ensuing four months to discover four more also, in private practice, and re- move fromtwoof these an additional two hundred and sixty-nine ounces. In the third case there was an offensive purulent accum- ulation in the pleural sac, which finally broke into the right lung causing gangrene of that organ; but surgical interference offered in time for its relief, was refused. Such an irruption of eases (twenty-two,) occurring in the practice of a single individual (and, with three exceptions, we have heard of no others at the meetings of the Medical Society and Medical Association of South Carolina), can hardly be as- cribed to fortuitousness, a fatality, or a mere coincidence! Many of these people were walking about seemingly in comparative comfort, and, with the exception of dyspnoea, or some unimpor- tant sign of disease, giving scarcely any outward or superficial manifestation of the presence of intra-thoracic accumulations, which might—besides materially increasing their sufferings—go on to imperil or destroy their lives. The present exhibit added to our first series (eight cases, with four unpublished—total thirty-four), fully warrants us, there- fore, in urging unusual care and watchfulness in searching for 2 the presence of pleuritic or pericardial effusion, whenever dj-sp- ncea and oppression exist; and even when absent, for are not essential symptoms. To discover the existence of fluid in the thoracic cavity is a comparatively coarse procedure ; and though it may presuppose some experience and practice, does not call for the exercise of any special refinement in ausculta- tion and percussion; whereas to detect pericardial effusion is far more difficult, and requires exceeding nicety and skill in diagnosis. It is not our province to enter here a special plea for such operations. It requires no great draught upon the imaginative faculties to conceive the relief afforded in such cases by early, judicious, and when necessary, repeated tappings. IIow salu- tary must be the removal of pints or quarts of serous or sero- fibrinous effusions by the formation of which the blood had been robbed of its most important elements, which had been com- pressing the lungs; displacing and disturbing the heart, impair- ing the power of absorption and the normal functions of the organs in every region of the body ; or which, passing by diape- desis into neighboring structures, as the pericardial sac or even into the abdominal cavity, were mining the foundations, as it were, of the very citadels of life. The following cases of paracentesis thoracis occurred in the medical wards of the City Hospital, from July 1 to October 1, 1884, and to Dr. W. B. Bratton, House-Physician, we are in- debted for the notes: Case I—Wm, McP., aet. 70, admitted July 3d. History and symptoms of chronic pleurisy. Hypodermic needle showed presence of fluid in right pleura, confirming other diagnostic signs. July 5. One quart was evacuated with aspirator. 15th. Two quarts more were drawn from same pleura. Diu- retic of tinct. squill, etc., iodine externally, tonic treatment, etc., completed the cure. Discharged August 6. Case II—Jane H., rot. 30 years, admitted July 10. Cardiac hypertrophy, degeneration and failure, with consequent hydro- tliorax and hydo-pericardium. Effusion greatest in right pleura, and thoracentesis called for by urgent dyspnoea. July 17. Aspirated right pleura, drawing forty-eight ounces, without entirely exhausting the sac of fluid. Re-accumulation promptly took place; but general anasarca, and her condition otherwise, made a repetition of the operation inadvisable, as useless. Died on 20th. Case III—Calvin, J., set. 40, admitted July 15. A case of atrophic kidney probably, followed by hypertrophied left ven- tricle and mitral failure. In spite of treatment, the serous effu- sion in both pleurae which resulted called for operation on August 15, and about two quarts were drawn from right pleura, 3 which seemed rather the fuller of the two. Deemed inadvis- able to interfere with the other just then. At date (Sept. 30,) doing very well under general treatment. Case IV—Jeffrey, G., set 40,admitted July 17. This is prob- ably a case of mitral regurgitation following great hypertrophy consequent upon chronic Bright’s Disease. Indeed the mitral failure has become apparent only since admission. The patient was of scrofulous, perhaps syphilitic taint, and there had prob- ably been an old pleurisy on right side. At least, I can only attribute the much greater serous effusion which occurred, with- out rise of temperature, etc., on right side than on left, to some such change in the right pleural sac. D3Tspnoea, etc., demanded operation. July 23—Sixty-seven ounces were drawn from right pleura, and patient put on appropriate treatment. Nevertheless, the same symptoms called for a repetition of the tapping on Aug. 10, when sixty-one ounces were drawn, and on Sept. 17, Avhen seventy ounces were aspirated. Sept. 29. Dyspnoea, cough, failure of heart, etc., called for aspiration again—right pleura having once more swelled. Drew eighty four ounces, and strapped that side. As to quantity of fluid, and frequency of operation, the fol- lowing will give a compact view :— Case 1. Right pleural cavity, 32 ounces; right pleural cavity, 64 ounces. Case 2. Right pleural cavity, 48 ounces. Case 3. Right pleural cavity, 64 ounces. Case 4. Right pleural cavity, 67 ounces; right pleural cavity, 61 ounces; right pleural cavity, 70 ounces; right pleural cavity, 84 ounces. Punctured almost invariably between sixth and seventh ribs —mid-axillary line. It is somewhat surprising, that in every case, without excep- tion, the right pleura should have been found involved either alone, or chiefly. While these were all the cases operated on for removal of pleural fluid, there were two eases, those of Isaac II., and Robert G., in which an attempt was made, ineffectually, owing to state of instruments used, to evacuate pleural effusion. Both died, and effusion of considerable extent was found in the right sac in the case of It.; and excessive accumulation in both sacs, in the case of G. Ilydro-pericardium was foipid in both—not enough to cause death independently of hydi’othorax. Besides, there were the cases of Marcus N., Amy S., Eve W., and A. B. All these suffered from ascites, and were tapped for its relief—A my S., several times: in all hydrothorax was either made out, or confidently predicted, oedema of chest walls, in all but B. preventing absolute demonstration. Operation was use-: 4 less, and all died. In each and every one both pleural sacs were distended with effusion. Then, in case of Dober McN., who died before relief could be afforded, fluid was diagnosed in right pleura, and ono and one- half pints found there after death. As no record was kept of every case, some have no doubt escaped me; at present there are in the ward at least four cases of abnormal collection of fluid in pleura. Case V—Louis Y. H., a;t. 55, white male; admitted June 13, with great distension of abdomen and chest, with swelling of legs and arms. After careful examination no organic disease could be found. Heart sounds not.clear, but no lesion could ho positively made out; urine normal; liver somewhat enlarged. Diagnosis: chronic malarial poison reducing tone of vessels. At 10 P. M., dyspnoea so great patient was tapped by house physician, and about two gallons of fluid drawn from abdomen. Fluid being found in pleural cavity of right side on July 4, patient was aspirated between seventh and eighth ribs near angle, and f. oz. xxxvi drawn off; great relief experienced. Patient put on a tonic, diuretic mixture, and improved steadily. Dis- charged August 1st, well. Ho return of fluid up to this date. Case VI—M. F. McB., set. 36, white male; hard drinker, digestion poor, stomach irritable, general condition poor, much emaciation. Patient had been exposed to a damp, cold, and sunless jail. Idas cough and pain in side, with considerable dyspnoea. Diagnosis: general debility with chronic pleurisy; there being considerable effusion detected on right side, patient was aspirated on July 24th between sixth and seventh ribs, below the angle of the scapula, and f. oz. xxxvi removed. Great relief experienced. At date, Oct. 10, fluid seems to have re-ac- cumulated to some extent. Case YII—Mrs. K., set. 70, white female ; admitted July 21, 1884. Petient’s legs oedematous, little or no fluid in abdomen; urine about normal; heart weak, intermittent and irregular. Patient “ took cold ” several years ago going into a damp cellar: she has great dyspnoea, and is pretty weak; dullness over greater part of right side. Fluid being found by hypodermic needle, patient was aspirated on August 5th between sixth and seventh ribs, three inches below the angle of the scapula, and f. oz. xxvii removed; great relief experienced. Patient put on tonic diu- retic ; swelling of legs much reduced. At date, fluid has re-ac- oumulated to some extent. [Above three cases, July 1 to October 10, 1884, reported by Dr. Mazyck P. Pavenel, House Physician.] Case VIII—Was consulted by letter, by a lady, Mrs. P., set. 55, residing at a distance from this city, who complained greatly of dyspnoea, fainting attacks, and great oppression with inability to sleep. Suspecting pleuritic effusion as a probable 5 cause, we visited her taking the precaution to provide an aspi- rator, to which Fitch’s Dome trocars were attached. Upon examination, it was found that grave disease of the heart co-existed with effusion ; and a few minutes after arrival forty-eight ounces of sero-sanguinolent fluid were removed from the right cavity of the thorax. The suffering and oppression had been extreme, at intervals, for many weeks before our visit (which prevented her from coming to the city), and though partially relieved, she survived but a few days. Case IX—In attendance upon Mr. G., ret 40, who was suffer- ing from difficulty of breathing and great oppression, especially at night. He declared that he was perfectly well three months previously, i. e., in February last; but had been exposed to draughts of air while at work in a large store, and undoubtedly he had had a latent and undetected pleurisy. lie had no fever at any time after we saw him ; his urine was highly albumi- nous (three-fourths of test-tube); insufficiency of the aortic and stenosis of the mitral valves existed, with some dropsy of the lower extremities; mind, as usual in all such cases, per- fectly clear. After careful examination and the preliminary insertion of the liyopdermic needle, ninety-two ounces of serum, slightly stained with blood, were removed (April 25, 1885), with the aspirator from the right cavity of the chest. Dr. J. M. Cald- well and my son, Dr. W P. Porcher, were present. The needle was entered three inches below the lower border of the scapula. We find it to be an indifferent matter whether the puncture be made here, or at the middle axillary space, at a point intermediate between these two, or even in front below, and to the outside of the nipple; the main indication is to select the centre of the area of dullness; and, for obvious reasons, avoid penetrating too high or too low. An attack of cough warned us to desist. Great relief from the desperate attacks of dyspnoea followed. In ten days, how- ever (May 5th), we discovered that the fluid had re-accumu- lated, notwithstanding that blisters and iodide of potash, with diuretics, had all along been employed, and ninety-five ounces of a similar fluid were evacuated. Again his life is measurably prolonged; the fluid is re-accum- ulating for the third time; We fear that two more quarts can be aspirated, but the patient is anxious for a repetition of the ope- ration, on account of the great relief it necessarily affords. [May 17, removed eighty-two ounces.] But where disease of the heart co-exists, far greater gravity is imparted, and this patient has three organic diseases to con- tend with, namely, of the pleura, the heart, and the kidneys. Oases such as this—equally with anasarca, where the entire 6 body, “pallid and languid,” saturated and sodden by serum— recall to us the pathology of Horace (Carm. Lib. ii. 2) :— Orescit'indulgens sibi dirus bydrops Nec sitim pellit, nisi causa morbi, Fugerit venis, et aquosus albo Corpore languor. With the direfully irremediable nature of which the ancients, who probably had no aspirators—were as much impressed as we are. (See also Ovid, Fast. I. 211.*) Abscess of Liver.— One pint and a: half (24 ounces') of pus re- moved; with recovery. (Reported by I)r. 1ST. Y. Alford, House Phy- sician). Patrick J., age 37. Patient presented himself for treat- ment in the medical ward of the hospital, September 11, 1884; is a native of Camden, South Carolina, from whence he removed to Charleston ten years ago, where he has resided ever since, except the past three years spent in Savannah, Georgia, in a malarial portion of the city, and he became subject to “ chills and fever.” A pain over the region of the liver began about the first of July last, and has been continuous, but not severe, and with no history of injury connected with it. Two weeks previous to his admission, it became more acute, and within the past week lie has had several chills and vomited once or twice. Present Condition.—Somewhat reduced in flesh ; loss of appe- tite; having a disgust for all kinds of food ; motions from the bowels are regular once a day, sometimes twice ; stools are straw colored and pasty; breathing hurried and shallow; deep inspirations or sudden movements of the body elicits pain; ten- derness is experienced on pressure in the region of the umbili- cus and hypochondrium; the area of hepatic dulness is increased in all directions—notably below the false ribs, where there is also considerable tension and swelling; the point most notice- able is on a level with umbilicus about four inches to right and in a line with nipple; fluctuation is distinct and a hypodermic needle was introduced and pus withdrawn. The attending phy- sician (Dr. Pore her) was sent for, and abscess of liver diagnosed. He decided to puncture it immediately with a large size trocar at the location mentioned above, where swelling was most marked, and a pint and a half of pus of a yellowish color, be- coming bloody towards the last, escaped. A drainage tube was passed through the canula, and the latter removed, leaving the former in place; pus continued to discharge. (Operation after the method of Dr. Patrick Manson, of the Chinese Maritime Service). Had a chill the next day, and bis temperature rose *W"e are inclined, however, to think that both of the classic authors referred tp, had In mind the inappeasable thirst and the polyuria of diabetic dropsy. 7 to 105.2°; nauseated and vomited two or three times. R. Qui- nine and iron given three times a day. Sept. 15. Temperature has reached 105°, every evening since the operation; drainage tube removed; opening discharging continuously. Sept. 16. Temperature did not rise higher than 102° to-day ; is more comfortable, and has more relish for food, but has diarrhoea. Dec. 16. Temperature normal; appetite is better; regained some flesh and the area of liver dulness markedly diminished, though pus continues to drain away. Has been taking quinine, sulphide calcium, Fellow’s syrup of the hypophosphites, and sherry wine. March 1, 1885. Ilis general condition is much improved; the discharge from fistulous opening is small in amount and thin and serous in looks; appetite very good; bowels-jugular and stools more of a natural color. Pat rentes still-under treat- ment in the hospital. April 20. Has been discharged from hospital, and can walk two miles without inconvenience. .May 12. Ho signs of his former disease.