CANADA MEDICAL & SURGICAL JOURNAL JANUARY, 1879. Original Communications. A CLINICAL LECTURE UPON A CASE OF CONTRACTION OF THE RIGHT SIDE OF THE CHEST, AND GREAT ENLARGEMENT OF THE SUPERIOR HALF By R. P. HOWARD, M.D., ETC., Professor of the Theory and Practice of Medicine, McGill University. REPORTED BY DR. VINEBERG.* GENTLEMEN,-Owing to the obliging disposition of the young man who accompanies me to-day, and who came from a distance for my opinion, I am enabled to show you a case of unusual interest. Its nature has been the subject of some diversity of opinion amongst the many physicians who have examined the patient; and though it is probably an example of a not uncommon pathological combination of lesions, it must be admitted that considerable obscurity and difficulty now surround it, as seen for the first time more than two years since its invasion. It will be necessary to give you as fully as possible the history of the case as related by the patient, who is a young man of much intelligence, and he will then be examined before you. A few additions have been made to this lecture since it was delivered. -R. P. H. NO. LXXVIII. 16 W. McD., 19 years of age, printer, gives the following history from memory: Had always enjoyed good health up to January, 1876. Hẹ then first experienced shortness of breath when walking, but had not any cough, and although looking ill, thought nothing of it. In the following May he had a slight cough, from taking cold, this continued about three weeks, but under the use of squills, prescribed by a physician, disappeared entirely. When he first consulted his medical adviser, great enlargement of the epigastric and hypochondriac regions was noticed, but its nature was not made out and seven weeks treatment did not remove it. During the succeeding thirteen weeks the swelling remained stationary. The patient, who was not under treatment, continued at his employment, and on November 1st, the cough having returned, he sought advice from the brother of his former attendant, who considered that he had tubercular disease of the right lung, but made light of the enlargement of the body above mentioned. He never had suffered pain in his side, nor, as far as he remembers, did he experience any until the winter set in ; but during that season he, on two or three occasions, experienced attacks of severe pain in left mammary and hypochondriac regions, which lasted eight or nine hours, and was deep seated and of a stitch-like character. The cough lasted all through the winter, and was of varying intensity; it frequently continued all night. He thinks the expectoration was chiefly of a frothy mucus, except during four weeks, when it was dark-green and purulent, and was always free from blood. The treatment during that period embraced, amongst other things, blue mass, iodide potassium, frequent blisters, and local applications of iodine, and mercurial ointment. In May, 1877, oedema appeared in the lower extremities, the eyelids were puffy in the morning, and his urine contained some albumen; but the dropsy disappeared in August. He visited Boston in July of that year, and saw some of the most eminent of the physicians there one of whom aspirated the right side of the chest posteriorly, but obtained no fluid. No opinion was given him respecting the nature of his case, but he was ordered to avoid medicine and work, and to live nutritiously. He made a second visit to that city in October, when, on comparing his person with a sketch taken at his previous visit, no change could be perceived. He then weighed 142 lbs. Since July, 1877, he has been free from cough, except for a couple of days together, and only after exposure; his breathing has improved, and œdema of feet and legs has continued stationary. Since the oedema first set in he has had to urinate eight to ten times during the day, and once during the night. His immediate family history is as follows: Both parents, four brothers, and four sisters, are alive, and with the exception of two of the latter, are all healthy. One sister has been the subject of some lung affection, and another is epileptic. June 11th, 1878.-Present Condition.-Stature, 5 feet 91 inches; weight, 150 lbs; fair complexion; pale; not badly nourished. Taking off his shirt, we note the following: Inspection and Measurement.-Notable deformity of thorax ; left half larger and fuller than right, which is flattened and retracted; the right shoulder and nipple on lower level than the left posterior border of right scapula projects, and dorsal spine presents a lateral curve, with the concavity to the right; semicircular measurement a few inches below nipple-right side, 153"; left, 173"; at nipples, right, 15 6-8′′; left, 17′′; axilla, right, 15 6-8'; left, 16 1-8". Expansion of the entire right half of chest very deficient; that of left very marked. Percussion elicits hyper-resonance over entire left chest— anteriorly, this note extends to right of mesian line as far as border of sternum; inferiorly, it coasts obliquely along close below left nipple, into lateral region, at level of 7th space; posteriorly, the left infra scap-region, over about 2 inches vertically, emits a flat note. In the right infra clavicular and axillary regions resonance is of dull, hollow, almost amphoric quality, but below the level of, and corresponding accurately with, a horizontal line drawn around the chest from the 3rd intercostal space, the stroke sound is flat, and the resistance great over the rest of the entire right chest. Auscultation.-Exaggerated respiration over left chest, with comparatively feeble vocal resonance and fremitus. Blowing respiration, increased vocal resonance (pectoriloquy) and fremitus exist over whole right half of thorax, are most marked above the level of third interspace; all respiration ceases to be audible below 9th rib posteriorly; a fine, sharp bubbling is heard at end of inspiration in 4th right interspace from sternum into axilla and shade off superiorly. Heart's impulse and sounds more perceptible in lower sternal region, and at right border of that region, than at usual site inside of left nipple. Extending the examination to the abdomen, we are struck with the great enlargement of the upper zone, the epigastrium and both hypochondria being occupied by a firm, smooth, resisting body, which gives a dull note on percussion, as though the entire liver were very much enlarged. The fullness is most prominent in the epigastrium, especially over its left half. The dull percussion note over this enlargement extends not only over the whole upper abdominal zone, but blends superiorly with that present in the right mammary, in the cardiac and lower part of the left mammary regions, and encroaches inferiorly upon the middle abdominal zone. The hollow percussion resonance of the stomach is masked by the flat note of the resisting mass which seems to be in front of it. A horizontal depression exists around the abdomen, corresponding to the lower margin of the dull and prominent region, and divides the belly into two portions. The lower portion is smooth, its walls tense, and in the erect posture fluctuation is perceptible as high nearly as the umbilicus. In the recumbent posture on the left side, sudden palpation appears to displace fluid and permit the enlarged liver to be felt by the fingers. Owing to the tenseness of the parietes, the lower edge of the liver cannot be distinguished. Superficial epigastric and mammary veins very numerous and tolerably enlarged; lower extremities, up to buttocks, pit upon pressure; no oedema of scrotum; slight puffiness of eyelids. To the above physical examination, which yon have just witnessed, may be added the following facts:-Patient micturates eight or nine times in the day, and, if awake, once or twice during the night. The urine is normal in colour, free from albumen, tube casts and renal cells. About four pints passed daily. His breathing is short, especially when exerting himself, but he is free from cough and expectoration. His blood of rich red color; red corpuscles collect into rolls, are abundant, of uniform and fully average size; while they are tolerably numerous, but not excessively so; small granules present in moderate amount. In forming an opinion as to the nature of this case, we will begin with the chest, the right side of which is so much retracted and smaller than the left.-What are the conditions known to produce marked retraction of one side of the thorax with dull percussion resonance? 1. Infiltrating carcinoma of the lung; 2. General collapse of one lung, both rare affections; 3. Chronic pleurisy, with retraction; 4. Chronic phthisis, both common affections, and 5. Cirrhosis of one lung, a comparatively rare affection. Let us endeavor to determine which of these conditions obtains in this young man. 1. Carcinoma of a lung, especially when diffused, may produce retraction of the side of the chest. But the circumstance that the patient has suffered from his disease for over two years, and that, instead of losing flesh and becoming weak and cachectic, he is gaining weight and strength, is quite incompatible with the existence of infiltrating carcinoma of nearly an entire lung; a disease which is uniformly progressive and usually fatal in from two to two and a-half years. And there are several other facts opposed to such a view. No mediastinal tumour, so frequently present in pulmonary carcinoma, exists, for the dull percussion note does not extend beyond the middle line-rather it falls short of it-—nor are the veins on the front of the chest and shoulder, and at the root of the neck, enlarged and varicose; there is no contraction of one pupil, no alteration of the voice, no oedema of the neck and of the affected side of the chest; in short, the pressure signs of intra-thoracic tumour are wanting. Hæmoptysis and red or black currant jelly-like expectoration have not occurred. There is no enlargement of any of the |