A CASE OF EMPYEMA FOLLOWING ON

REMITTENT FEVER.

By Surgeon P. 0. "W. HAILEY, Indian Medical Service.

Naick Gaya Bux Singh, at. 32, was admit- ted into the 12th Kelat-i-Ghilzi Hospital at Luck- now, on February 24th, 1888. He was then just convalescing from an attack of remittent fever for which he had been treated in the hospital of the Burmah Military Police, to which corps lie belonged. As the battalion of Burmah Police was leaving Lueknow for Burmah, he was left behind at the depot of the 12th Kelat-i-Ghilzi. On admission he was weak and generally pulled down from the effects of the remittent fever, which had lasted lor nearly four weeks. At the time of admission he had a slight cough, but otherwise was on the road to convalescence. Some expectorant and tonic mixtures were

ordered. He then progressed fairly favourably until March 6th, when the cough became more troublesome, expectoration profuse and muco- purulent. The left base was found to be dull on percussion, the breath sounds were deficient, as also was the vocal resonance. Tactile vocal fremitus was increased. No friction souud audible. Effusion at the left base was diagnos- ed, and as there was evidently 110 great quantity of fluid, the ordinary expectant treatment was adopted. At this date the heart sounds were normal, and the cardiac dulness remained un- altered.

272 THE INDIAN MEDICAL GAZETTE. [Sept., 1888.

March 12tli. ? Dulness at the left base lias

increased considerably. Some oedema of legs and slightly of the face. Urine normal, specific gravity 1020; no albumen. Evening temper- ature only slightly above normal.

March 16th.?Physical signs increasing ; tac-

tile vocal fremitus markedly increased all over left side of chest. Complete dulness behind

augle of scapula and in front up to 4th rib. March 23rd. ? Breathing vesiculo - tubular

above, evidently due to pressure of the effusion. Breath sounds weaker on left side. Skodiiic re- sonance beneath the clavicle as far as third rib. Pulse 110. Respiration 22. Evening temperature 100? Ft. Some oedema of face, legs, and slight cedematous marking produced by the pressure of the stethoscope on the chest wall?. Heart

considerably displaced, cardiac sounds only audible to right of the sternum. Face and

lips are becoming slightly livid. Eye-lids and face puffy. A hypodermic syringe was intro- duced in the 6th space in mid-axillary line. No fluid was drawn off, however, although the

syringe was introduced in two places. March 25th. ? Hypodermic syringe again

introduced: mingled serum and pus with-

drawn. The patient was at once put under chloroform, and an incision was made in the 6th

space in the mid-axillary line. The intercostal

fascia and muscles were divided on a direc- tor and the pleura exposed. A few muscular

arterial twigs were divided and ligatured. The pleura was bulging slightly, and an attempt was made to thrust a director through it. This, however, could not be done, and a soalpel was used to divide it. Upwards of four pints of pus were evacuated from the pleural cavitv. The cavity was washed out thoroughly with Tine. Iodi 5'ii to the pint, and a large drainage tube, 2| inches long, was introduced. As the

pulse was becoming weak, it was not considered safe to administer any more chloroform, and

therefore no counter-opening was made, and it was decided to make the counter-opening, should it be necessary subsequently. The wound was dressed with lint, soaked in carbolic lotion, 1 in

40, followed by a thick layer of tow also soaked in carbolic and afterwards wrung out. The whole was secured with a chest bandage in the

ordinary way. March 26th.?Morning temperature normal.

Considerable discharge which has soaked ? ?

through the dressings. Discharge quite sweet. The wound was dressed in the same way. De- cided not to wash out chest while the discharge was sweet and the temperature normal. Heart sounds audible in normal position.

April 4th.?For the last week temperature has been normal and patient improving. To-

day, however, an evening temperature of 99-8? was recorded, and the pus is becoming slightly foul.

April 6th.?Pus very foul. Evening temper- ature 100?. Decided to make a counter-opening.

April 7tli.?Counter-opening made in 10th

space behind posterior axillary line. An attempt was made to pass a long probe from the upper to the lower openings, but unsuccessfully as

there were numerous adhesions which barred the way. The lower opening was found to lead into an encysted cavity, bounded by firm adhe- sions, and occupying the lower part of pleural cavity. The cavity was washed out Avith car-

bolic lotion 1 in 40, and a small drainage tube put in. The whole pleura was then washed out with carbolic through the opening in the 6th

space.

April 7th.?Evening temperature 99-8?. Res- pirations 36 and pulse 112 per minute. Dis-

charge still rather foul.

April 12tli.?Evening temperature 99?. Pus

quite sweet. Discharge less.

April 15th.?Discharge much less,quite sweet. Lower wound has nearly healed, there being no discharge from it. The drainage tube taken out from upper wound, shortened f inch, and replaced. Pleura syringed out as usual.

April 29tli.?Drainage tube taken out and replaced by one of smaller calibre. Hardly any pus. He is getting stronger rapidly.

JMay 4th.?Drainage tube removed, wound practically healed except a very email sin us. Air enters over the whole of the left side of

chest. Very slight retraction of chest walls at apex, producing slight flattening of the chest. Otherwise recovery complete. Deficient reso- nance over base and lower part of axilla, pre- sumably due to thickened pleura. Remarks.?In another case I would certainly

prefer to make a single opening in the line of

the scapular angle as affording much better drainage and doing away with the necessity of a counter-opening. A point of minor interest iu this case was the fact that the hypodermie syringe twice failed to draw off any fluid, al-

though the chest was obviously full. While

incising the pleura, I had an opportunity of appreciating the reason of this. The delicate needle of the hypodermic syringe has probably failed to penetrate the thickened pleura, or

possibly such was the toughness of the mem- brane that it was pushed along by the point of the needle instead of being penetrated by it. It

was only by substituting a larger needle for the one used before, and by introducing it with a rapid thrust that this little difficulty waa

overcome. Another time I should prefer to

make a little nick in the skin first with a scalpel, and then to push the hypodermic needle sharply in with a slight rotatory motion.