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you lost

(That is, about eight months.) How were you taken?

“ With pain in the left side.” Did you have a chill ? “ No.” Any cough? “No." How long did the pain continue before you got relief?“ Two weeks.” Did you spit up any phlegm ? “ No.” Could you lie equally well on either side ? “I could sleep only on the left side." Have any flesh since ? “Yes, a good deal.” Have you had any sweating? “Not until the present time. During the last two nights I have noticed this."

Now, having heard the above histories, what would you say was the matter in these two cases, Mr. A ? “ Pneumonia in the first, and pleurisy in the second.” Well, let us see. The first patient now being stripped, we find that on the left side of the chest, about three inches below and a little to the left of the nipple, there is a fistulous orifice, from which there is constantly escaping a certain amount of discharge. On examining the rest of the thorax externally, we find that there is a very marked falling in under the left clavicle, and that there is an equally great, if not even more marked, retraction on the same side posteriorly in the upper portion of the chest. You will notice, furthermore, that during respiration, while the right scapula moves very freely, the left remains in a perfectly fixed position. In front, also, there is the same difference in movement between the two sides during respiration. Finally, we find that the apex-beat of the heart, instead of being in its normal situation, is almost directly under the right nipple.

What would you take to be the cause of this displacement of the heart, Mr. A? “ The abscess that is here present.” Where do you suppose that this abscess is situated ? " In the chest walls.” If you will reflect a little I think you will come to the conclusion that no abscess merely in the chest wall could possibly push the heart over to such an extent as is here the case. What do you think about it, Mr. B? "I should suppose that there had been a pleurisy complicated with pericarditis, that adhesions between the pleura and pericardium had resulted from this, and that consequently the heart had been drawn out of place.” The great objection to this view of the case is that it is evidently the left side of the chest that is affected here, while the pleurisy must necessarily have been on the right side, in order that the heart should be drawn towards the right by adhesions between the pericardium and pleura. What is your opinion, Mr. C ? “I believe that this is a case of empyema of the left side, and that the heart has been pushed over to the right by the presence of such a large quantity of fluid in the left pleura.” This looks as if we were getting at the true solution of the matter, and we will now, therefore, continue our exploration of the chest, and see if the physical signs confirm this view of the condition here present.

In the first place, we have complete flatness on percussion. When

we place the ear to the chest we find exaggerated respiration on the right side, and at the apex of the left lung feeble vesicular murmur; while below on this side, from about the level of the third rib, there is complete absence of all respiratory sounds. Vocal fremitus and vocal resonance are also entirely wanting below this level. The diagnosis is therefore very clear. The presence of empyema is of course confirmed by this external opening through the anterior chest wall, with constant discharge of pus. This is out of the usual position for such spontaneous openings, which is considerably higher up, although they ordinarily occur in front. The heart has been pushed over to the right by the amount of fluid that has been present, and has not yet returned to its normal position. It is altogether probable, however, that the displacement is even now considerably less than it was before the distended pleura was relieved by the drainage through the opening. Since this occurred the patient states that he has improved very much.

Now let us find out what the condition is in the second patient. In comparing the two cases we are at once struck with the difference in the appearances of the patients' chests. In the first we found the most marked retraction. In the second there is evidently a very considerable enlargement of the left side. In other respects, however, there are many points of resemblance ; for here on the left side, as in the other case, we get perfect flatness on percussion and entire absence of vocal fremitus, vocal resonance, and respiratory murmur.

The only difference is that in this case these signs extend all the way up to the apex. . As a result of the long continuance of this large accumulation of fluid in the pleura, the patient is now very weak and short of breath, and during the last two or three days has begun to suffer from severe sweating. As to the diagnosis in this case, there can be no doubt that there is subacute pleurisy; and you will seldom have a better opportunity of seeing the bulging of the intercostal spaces of which you read in the books, which is here so marked as to amount to a positive deformity. Whether empyema has as yet supervened is at present uncertain, though it seems highly probable that it has. The pulse I find is now 124, and the temperature 101° F., which I think is enough to indicate the presence of pus, although it would be more clearly demonstrated if the temperature were a couple of degrees higher. Still, this amount of increase in the pulse and temperature, taken in connection with the time that has elapsed since the pleural effusion first took place, and the fact that sweating has recently made its appearance, would seem to leave but little doubt that the fluid here present is no longer of a serous character. The apex of the heart in this case is found over by the right nipple, which is a greater amount of displacement than was met with in the other patient, although it is probable that before the opening occurred through the chest walls it was even more marked in that instance.

These are two very good cases to study together, because they show the same disease in different stages. In the first the spontaneous opening occurred very early. I do not understand exactly why this should have been the case, but I have found that such an early spontaneous evacuation is very apt to occur in the younger subjects of empyema. In this case the inflammatory process in the pleura was a rapid one; while in the second it has been much slower, and, indeed, probably subacute from the first. I do not suppose that it is the fluid itself that has changed here (in the second case), but rather the kind of inflammatory action in the pleura, which is now resulting in pus, instead of an effusion of serum, as at first. This second case shows the importance, therefore, of making a comparatively early opening where there is pleural effusion. The other warns us, however, that we should not interfere at too early a period, since a spontaneous opening of this kind is to be regarded as preferable to any artificial one that can be made. Here the point of opening is in a remarkably good position. The only unsatisfactory thing about it is that the aperture and passage are not quite free enough ; but as there is no objection whatever to putting in a drainage tube in a case of this kind, the difficulty can be readily obviated. On the whole, the prognosis is very favorable, — decidedly more so, indeed, than in the second case.

In regard to the latter, the question now arises, Shall we make an opening in order to evacuate the contents of the pleural sac ? This should certainly be done by all means, and the sooner the better. One great danger of delay in such a case as this is that sudden syncope is liable to occur at any time. The course which I would advise here would be as follows: At first to draw off by means of the aspirator as much Auid as would be well borne at one time by the patient, — perhaps about forty ounces. If the fluid were found to be serous in character, I would then rest content; but if it were purulent I would at once make a free opening in the chest wall and introduce a drainage tube. In the case of young subjects and where the affection is comparatively recent the aspirator is usually all that is required; but these older cases are not found to do well unless some more active interference than this is made. Here, if the patient still continued to run down after the drainage tube had remained in position for some little time, I should raise the question of the advisability of removing one or two ribs. This would allow the chest wall to sink in to a greater extent, and thus, meeting the slowly expanding lung, diminish the large cavity which is now present, the lower portion of which would also probably become obliterated in consequence of the operation. If the discharge from the pleural sac were offensive, it would be necessary to keep it washed out with some appropriate disinfectant by means of the drainage tube.

In young subjects the chances are four out of five that the patient

will recover when a spontaneous opening takes place, and in cases of all kinds three out of five. In the first of the cases that have now been presented to you the lung is already expanding in the upper part of the chest in as favorable manner as we could expect, and the process will be accelerated when a drainage tube has been put in. There are doubtless adhesions here between the pleura of the affected side and the pericardium, and by means of these the displaced heart will be drawn over towards the left as the cavity diminishes in size. If, in addition, there were adhesions between the surfaces of the pericardium, we should expect that some displacement to the left would probably occur eventually.

But to return to the second case. Would it not be just as well to employ the trocar at once instead of the aspirator? Certainly not, in my opinion. All authorities to the contrary notwithstanding, I decidedly prefer that air should not enter the pleural cavity in cases where there is the faintest possibility of the fluid still remaining serous. Where the contents of the cavity have hitherto been serum, and air is introduced, it is pretty sure to change the character of the inflammatory process present, and instead of simply serum we have pus to deal with in the future. Where a free opening is immediately desirable on account of the urgency of the symptoms, and there is no longer any doubt about the presence


of course that is a different matter. Both these cases are especially interesting, because you will all meet with plenty of similar ones in your practice ; and I should be very much ashamed of any of you who should ever fail to detect the presence of Auid in the pleural cavity after being taught here how simple and unmistakable the signs are which indicate this condition. An abscess in the cellular tissue of the chest walls, for instance, such as an inexperienced observer might at first suppose to be the cause of all the trouble in the first case, could never possibly produce the displacement of the heart and other marks of pleuritic effusion which are here so pronounced.

The length of time that is required for recovery after a spontaneous opening has occurred is much greater than you would be likely to suppose unless you had had some experience in regard to the matter. If the young man now before you gets well within two years from the present time, it will be quite as much as we can expect. The only thing to do in the way of local treatment will be to maintain a free opening by means of drainage tubes, and if at the end of two years there is found to be no discharge at all he may be regarded as over his trouble. Should the opening be allowed to close up temporarily, however, the result would no doubt be a large accumulation of pus, and the prognosis would become much more grave. Such openings, if left to themselves, are very apt to close prematurely when the discharge gets to be much diminished in quantity, on account of the tortuous character of the


passage leading to the cavity. By the patient's constantly wearing a drainage tube, however, the possibility of the occurrence of such an accident is effectually guarded against, and when the discharge has become comparatively small a little rubber cup for receiving it may be attached to the end of the tube, which will give rise to little or no inconvenience. In addition, we should do all that is in our power to build up the general health of the patient, and a change of air is often of very great service. In most cases a locality where there is an elevation of from a thousand to fifteen hundred feet (not enough to put too much of a strain upon the unaffected lung) will be found to be very beneficial, as respiration can be more easily performed at such an altitude. The patient should remain in the open air as much as possible, but should avoid too violent exercise and all forcible expansion of the chest until he has almost completely recovered. Riding will be of service in exercising the muscles and distending the lungs, and the kind of exercise which is of the greatest amount of benefit in pleuritic troubles is riding a fast-walking horse. Of course, the most nutritious diet should be employed, and as far as direct medication is concerned cod-liver oil, iron, and similar agents will be found most useful.



Almost every surgeon who has had any experience with urethral diseases will call to mind how frequently he has been consulted by patients who come from under the care of their regular medical adviser with the statement that they are suffering with stricture, and that “the stricture is just at the neck of the bladder ;” still he knows how very seldom it is we find the contraction lower down the penile urethra than some four to four and a half inches, - indeed, rarely even so low as the bulbo-membranous junction. In fact, it may with safety be stated that the great majority of strictures are located in the anterior portion of the canal, that few are ever so far down as the bulbo-membranous junction, and fewer still in the membranous urethra. In a word, we may assert that the further we go from the external meatus the less frequently do we encounter true organic stricture of the urethra.

Although surgeons differ widely as to the precise location in which we oftenest find the contraction, still they are a unit as to its infrequency in the deep urethra, — and justly so, for being the result chiefly of urethral inflammation, we naturally expect to meet with it at that point in the canal where the inflammation first began, where it was most intense in its action, and where it lingered longest in its duration ; and as that portion of the canal is bounded by the external urethral

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