Clinical Lectures Delivered in the Out-Patient Department of the Hospital for Sick Children, Great Ormond Street

W. B. Cheadle
1872 BMJ (Clinical Research Edition)  
Assistant-Physician to the Hospital; Senior Assistant-Physician to St. blary's Hospital; etc. II.-HYDROTHORAX AFTER SCARLATINA. CASE. -Dropsy after Sczrlatina. -Hydirolthorax.-Treat,nentf by Digi. Ia?is.-Copious Diuresis.-Coliapse of thte Chest-Wall.-Com.piee Re. .oz'ewy.-Remarks.-Frederick C., a large healthy looking child, two years old, first came here three months ago. His appearance at that time presented a great contrast to his present condition, for his lips were bloodless, his face pale
more » ... and bloated, and his whole body swollen: he was suffering, in fact, from general anasarca. The history given by tlle mother was, that the child had had scarlatina three months previously, and when recovering from this was again laid up with what the doctor in attendance called congestion of the lungs. The boy had never been well since, and had lately become more pale and puffy in the face. The urine was examined and found to be albuminous. There was stated to be some dyspnoea, but not of any distressing kind, and the chest was not examined. The patient was ordered to take five minims of the tincture of perchloride of iron, with a drachm and a half of infusion of digitalis in caraway water three times a day. This was continued without intermission for fourteen days, at the end of which time the mother brought the child again, and related the following curious story. She did so spontaneously, and without any leading ques. tions being put by me. She stated that the child was in the habit of passing urine in the bed, and that tlhree nights previously the quantity had been so great that it soaked through the blankets and mattress and dripped on to the floor. Such an occurrence had never happened before, and she thought the quantity so extraordiniary that I ought to be informed of it. There was another strange thing she had observed with regard to the child to which she wished to call my attention: when she stripped the child for the purpose of washing it on the morning following the night alluded to, she was struck by a curious alteration in the shape of the chest. The left side seemed to have bulged out and become unnaturally prominent in front. The change must have taken place since the previous day, since she was in the habit of giving the child a bath every morning, and also of rubbing oil into its chest, with the object of relieving the difficulty of breathing. The alteration could not, therefore, possibly have escaped her notice. She was much disturbed at the discovery of this deformity, and showed it to her husband on his return home. No other change was observed in the child's condition, except that it seemed more comfortable and slept better. The boy's chest is now perfectly symmetrical, as far as the eye can judge, although careful measurement still shows a slight inequality between the two sides; but when he was stripped before me then, there was a remarkable difference between the two halves of the thorax in front; the left was rounded and prominent, the right flattened and retreating, especially from the second rib downwards. Very little furtlher examination was required to show that the left side of the thorax was in its natural condition, and not "grown out", as the mother supposed. The chest was deep, and this appearance was the result of the contrast produced by the falling in of the right side. That the deformity was produced by conitraction of the right side, and not by distension of the left, was further proved by the fact that all over the left side the respiratory sounds were clear and good, expansion free, and resonance perfect; while, on the right side, breathing was very deficient at the lower part of the lung, both in front and posteriorly: under the clavicle, and near the spine of the scapula, it was bronchial. At the base behind there was duliiess on percussion over the lower third; and vocal vibra tion, which was perceptible enough on the left side, could not be felt there. The heart's apex was beating half an inch to the right of the left nipple, harving been drawn over to this extent, with the medias-57' tinum to help to fill the space previously occupied by fiuid, and not yet reoccupied by the imperfectly expanded right lung. On carfl measurement, the left half of the thorax was found to be ten and three. quarter inches round, the right ten inches only. This, you will remember, is the reverse of what obtains in the normal condition, the t half of the chest being usually a little larger than the left The face was much less puffy, and the urine showed only a trace of albmen When examned again on August 15th, the child wa suffering from catarrh; coarse rhonchi were heard all over the chest. There was still deficiency of breathing and resonance at the base of the right lung, but it was less marked than before. The deformity remained without obvious change; the right side of the thorx was still flattened. On measuring the chest, however, there was now found to be a difference of half an inch only between the two sides. The urine contained no albumen; there was no sign of cedema, and the anaemia had almost disappeared. A mixture containing ammonia and senega was ordered, in place of the iron and digitali& As the catarrh abated, cod-liver oil and steel wine were given. On again examining the chest, on September 29th, a decided change was at once perceptible. The rit side had expanded, so that the difference between it and the left Wa not very striking at first sight, although seen distinctly enough on looking for it. Good breathing could be heard quite to the base of the lung, although this and the resonance on percussion were not so full as on the left side. The measurements gave the latter lob inches, the right io} inches; the difference was reduced to three-eighths of an inch. The patient went into the country at this time and regularly improved, so that, when he presented himselfagain at the end of October, as far as the eye could judge the symmetry of the chest was completely restored. No visible deformity whatever remained ; accurate measurement showed a difference of about one-eighth of an inch in favour of the left side. The respiratory sounds and resonance on percussion were good everywhere, and no difference in these respects could be detected between the two sides. The account so circumstantially given by the mother, and the physical signs actually observed, reveal very distinctly the series of events which occurred in this case. The child had scarlatina, followed by dropsy, with serous effusion into the right pleural cavity. The effused fluid was reabsorbed, and collapse of the chest-wall followed. The compressed lung gralually recovered its elasticity and permeability, swelled out again to its former bulk, the bulged-in chest-wall expanded, and the right side of the thorax became symmetrical with the left. About these facts there can be no doubt whatever. The child had anasarca and albuminous urine when first seen; and although, when the chest was first examined a fortnight later, and subsequently to the diuresis, there was no large amount of fluid in the right pleural cavity, the presence of a certain quantity there, the collapse of the lung and the chest-wall, and the subsequent complete expansion, prove that the effusion had at one time been considerable. Nor can there, I think, be much question that the principal portion of the fluid was absorbed in a very short space of time. It is possible that a certain quantity might have been taken up gradually, and the resulting space filled by partial re-expansion of the collapsed lung, and some increased expansion of the opposite lung, without falling in of the chest-wall, or with collapse so slight as to escape observation. That the chest-wall should resist the external atmospheric pressure, and retain its form for any length of time after the fluid disappeared, and then suddenly give way, seems impossible, when the flexible character of the ribs in so young a child is considered. If the fluid had disappeared gradually, the ribs would have given way gradually also. That no such gradual sinking in of the right side took place, is satisfactorily established by the mother's evidence. The change must have attracted her notice, in her daily inspectioni of the child, long before it had reached the extent at which it had arrived when the discovery was made. There can be little doubt, I think, therefore, that the falling in of the chest-wall occurred between one morning and the succeeding one-i.e., within twenty-four hours-and that this was a consequence of the fluid being rapidly absorbed at the same time. So much seems certain; and there is ino reason to doubt the mother's statement, that these events were accompanied by an extraordinary diuresis. Iler spontaneous report of it, ignorant as she of course was of any possible connection between the chest-deformity and the flow of urine, is an undesigned coincidence of the highest value as a point of evidence. Now, the coiincidenice of these two events-the disappearance of fluid from the pleural cavity, and the elimination of an unusual quantity of fluid by the kidneys-might be an accidental coincidence, and nothing more. Yet the two processes couldlhardly go on together without having an influence one upon the other. If fluid were absorbed as the primary action, its presence in the blood-current in excess would probably excite diuresis, just as we know the entry of fluid into the a NOV. 23, 1872.] -I t 11
doi:10.1136/bmj.2.621.571 fatcat:gpifz2tcxfetjavqzajghp6344