1905 The Lancet  
GENTLEMEN,-In my wards at St. Bartholomew's Hospital I have had during the present month eight cases of pleurisy. CASE 1.-The patient, a strong-looking man, aged 23 years, was admitted on April 25th, with pain on the left side, a short cough causing pain on that side, and shortness of breath on moving his body. Fourteen days before admission he had been seized with pain in the side and cough, and four days before admission he became very short of breath. His left chest when I first saw him was
more » ... ull except a small apical region. There were no vocal vibrations, no breathing sounds, and no movement on the left side : 90 ounces of clear fluid were withdrawn from his left pleura. His temperature had been raised but remained normal after the paracentesis. The next day a friction sound was audible and some vocal vibrations were present. On May 15th breathing sounds were faintly audible at the left base and no friction sound could be heard. CASE 2.-This patient was received into the same ward as the previous patient. He was a muscular seaman, aged 25 vears, and had signs of pleurisy on his left side. He had had pneumonia three months before. On April 25th he suddenly fell ill and went to bed with a cough causing pain in his left side. The pleural physical signs did not increase and on the next day he had bronchial breathing over the lower lobe of the lung, with increased vocal vibrations. The aspect of the case was that of pneumonia and not of pleurisy. On the sixth day his temperature fell to below normal and the physical signs gradually disappeared afterwards. His arms were tattooed in red and blue-a butterfly, the Royal standard, and a girl's head in a circle of leaves. The work was artistic and had been done in Hong-Kong, where he had been for three years and eight months, returning in November, 1903. The finest tattooing we see in St. Bartholomew's Hospital is that of Japan-delicately drawn butterflies and storks on the wing as good as those of porcelain. That of China comes next and then the Burmese work, often lizards and figures of Buddha and elephants, as well as regimental badges. That done in Hindostan is generally, like native art, slightly altered for the worse by a tendency to imitate European work and resembles in its want of grace the portraits of British officers by native artists which used to be sent home in the days of the East India Company. The tattooing of Malta has less merit still and that of our own ports and camps is the rudest of all. CASE 3.-The third patient was a carpenter, aged 32 years, from whose chest on the day of his admission 30 ounces of clear fluid were withdrawn by paracentesis. He was admitted with pain in the left side and shortness of breath. The pain had come on suddenly on April 5th and his breath had since grown more and more short while the pain continued. Ten years before he had had pleurisy. His temperature was 100° F. The impulse of the heart was chiefly to be felt to the right of the sternum. There was dulness to the level of the third rib before and behind on the left side, with impaired movement and absence of vocal vibrations. Three days after tapping bronchial breathing was heard over part of the dull area, which had nearly, but not quite, disappeared a fortnight later and had quite disappeared in a further week. A month after admission breathing was still feebler on the left side than on the right and there was very slight general impairment of resonance on the left side. The temperature after an evening rise to from 99° to 995° became normal three weeks after admission and throughout had no sudden fall. The improvement after the paracentesis was marked. CASE 4.-The patient, a man, aged 50 years, had a not very distinct pleural creak at his right apex behind and in front well-marked signs of a cavity. He had double aortic disease. He was admitted with a copious haemoptysis, had several attacks in the ward, ceased to spit blood after a time, and then again had a recurring haemoptysis in a copious access of which he died. Post mortem old pleural adhesions over a tuberculous lung with a large apical cavity were found. CASE 5.-The patient, a stonemason, aged 23 years, was admitted with severe pain in the right side. Two days before he had had a severe rigor, felt very ill, and had pain in the side. His temperature was 103' 80 F. and his pulse was full and bounding. He had some cough and scanty watery sputa. In the right axilla and at the base a loud friction sound was to be heard. No bronchial breathing was heard and no rusty sputa appeared. The temperature fell gradually through five days ; in the first 24 hours of descent from 104° to 101°. The patient had obvious general emphysema and said that he had had a cough on and off for years. CASE 6.-In my female ward a patient, aged 38 years, obviously the subject of advanced pulmonary tuberculosis, has a cavity at the left apex with a friction sound over the lower lobe behind, and is another example of pleurisy associated with tuberculosis. CASE 7.-The seventh patient was an infant, aged 15 months, from the left side of whose chest ten ounces of pus were withdrawn. The prominent symptom was shortness of breath. The lower three-fourths of the child's left back were absolutely dull but a puncture made before admission had failed to demonstrate the presence of pus. The evening temperature was 101° F. Above the angle of the scapula loud bronchial breathing was to be heard behind and over the whole apex in front. The child was so much exhausted that I thought it well merely to feed it from April 7th to 17th and then drew off two ounces of thick pus. The child slept better but the physical signs were scarcely altered. The temperature fell to 99 5° each evening. The sense of resistance on percussion seemed to me increased by the 20th, and on the 22nd as it did not alter I had a rib resected when eight ounces of pus were withdrawn. The breathing sounds became audible, the child regained strength and colour, and the temperature gradually became normal. CASE 8.-A boy, aged five years, was the eighth patient. He was admitted on March 28th with whooping-cough which he had had since the end of January. The cough was severe, there were many attacks every day, and each was prolonged. After these had moderated, but while they were still numerous (18 a day) a patch of absolute dulness was found at the right base on April 10th. This persisted and I arrived at the conclusion that it was an empyema but postponed an operation till the cough should be less frequent. The patient coughed up a quantity of pure airless pus and the physical signs in two hours were almost normal. For four days a little more pus came up and then no more. Great improvement took place and he is now convalescent. An empyema had pointed into the lung and had been coughed up. These eight cases present considerable variety and suggest several points for consideration. Why, in the first, a week after the paracentesis, though no fresh fluid was exuded, were the breath sounds still faint over the lower half of the left lung ? 7 In the second case, had the attack of pneumonia three months before any relation to pleurisy and pneumonia which came under my care 7 In the third case, had the pleurisy of ten years before any relation to the attack I have described ? 7 How much of the results of the physical examination ought to be set down to the new and how much to the remote attack of pleurisy ? 7 In the fourth case, the firmness of the apical adhesions indicated the long duration of tubercle there. In the fifth, why was the temperature so high while the gradual and not sudden fall, the absence of rusty sputum and of bronchial breathing seemed to prove that a true pneumonia was not present ? 7 In the sixth, as in the fourth case, the connexion between the tubercle in the lung and the pleural adhesion outside it was plain. What was the explanation of the pus in the seventh case ? 7 Did the bronchial breathing indicate that a pneumonia had preceded the empyema ? 7 What in the case of whooping-cough was the origin of the pus ? 7 Many other clinical varieties of pleurisy may be observed. A patient of mine with locomotor ataxy became much worse in appearance and very short of breath but without
doi:10.1016/s0140-6736(00)68582-3 fatcat:wxdwsjbdnbfq3obqqyqgcbd4ia