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Related post: sputum; development of pulmonary tuberculosis.
Henry H., stevedore, aged 36, admitted June 13th, 1889,
TUBERCULOUS PLEURISY. 83
complaining of severe cough. A sister and one brother
died of consumption ; father of asthma. The patient has
been an extremely healthy man, and looks vigorous and
well nourished. He states, however, that he has had a
cough for many years, certainly for as long as three years.
He has been getting short of breath lately. Patient is not
at all anaemic ; chest is well formed ; the right side looks
full, and is almost motionless on deep inspiration ; the apex
beat is in the fifth interspace, two inches outside the nipple
line. The left side measures 19 inches, the right 20 inches ;
expansion on the right side is scarcely a quarter of an inch ;
on the left over an inch. Percussion gives on the right side
a dull note to the clavicle in front, behind to the top of the
lung, and to the left a little beyond the mid-sternal line.
The left side is resonant. Tactile fremitus is very much
lessened, but on saying 99 it is not entirely absent on the right
side. Breath sounds are distant, feeble, scarcely audible.
Whispered voice over the dull region behind is not heard.
Exploratory puncture shows a thin, greenish yellow, sero-
purulent fluid. The following day he was aspirated and 2J
litres of fluid withdrawn ; the accumulation was rapid, and
on the 17th the condition was very much as before. He was
aspirated again, and 32 ounces of fluid removed. This fluid
was greenish yellow, with many fat molecules. The fluid
re-accumulated rapidly, and he Buy Aerovent was aspirated again on the
19th with a withdrawal of 32 ounces, and on the 22d with
a withdrawal of 29 ounces, and on the 26th with a with-
drawal of 27 ounces. On the 29th it was noted that in
front percussion is now clear to the level of the nipple ;
dulness from this point down. Posteriorly it is clear to the
middle of the scapula. There are fine crackling rales in
the axilla, distant breath sounds over the dull area. By
the 8th of July he had improved so much that he was dis-
charged. The heart impulse was in the fifth interspace,
just below the nipple, and there were marked friction sounds
84 THE SHATTTJCK LECTURE.
in the left mammary region and in the scapular region
behind. The cover slips and cultures made by Dr. Abbott
from the fluid were negative. When he entered the hos-
pital the sputum was abundant, sero-purulent, and was
examined repeatedly with negative results. Subsequently
his cough lessened and expectoration was .more scanty,
thicker, and greyish yellow in color. At no time did the
temperature rise above 100�, and it was usually between
98� and 99�.
He left the hospital with a diagnosis of pleurisy with
effusion, and though there was a suspicion, based chiefly
upon the fact that he had had a cough for so long, the
diagnosis of tuberculosis could not be positively made, and
he looked such a vigorous, healthy man that it did not seem
likely. He attended in the dispensary, where I saw him
repeatedly. On the 20th of July it was noted that though
the apex beat was just below the nipple in normal position,
there was everywhere defective resonance over the right
side, not absolute flatness, and everywhere from the second
rib down there could be heard a loud, leathery, creaking
friction. He remained in very good condition, though the
cough still persisted. He had no fever. On September
10th tubercle bacilli were found in his expectoration. The
leathery, creaking friction persisted, and the defective reso-
nance on the left side. He had lost somewhat in weight,
and the cough had become aggravated. On September
4th, 1890, I made the following note : There is marked
depression of the right shoulder ; shrinkage of the right
chest. Heart is a little drawn over ; impulse in left para-
sternal line. The resonance is defective above, and shades
to dulness below the level of the fourth rib. The tactile
fremitus is felt to the base. At the right apex the breath
sounds are somewhat feeble ; there are numerous rales on
coughing, and on drawing a deep breath the sounds are
amphoric. Marked cavernous breathing at the apex behind.
TUBERCULOUS PLEURISY. 85
The breath sounds are feeble over the whole of the right
base. Patient was under observation throughout 1891.
He constantly had cough, and lost a good deal in weight.
On the 22d of June the note was : He still looks well ; the
feet swell at intervals ; temperature normal ; the right chest
more contracted and the spine is curved. Even on deep
inspiration there is very little mobility. Marked cavernous
signs at the right apex. There is no note of the patient
after this date.
Case XI. Pleurisy five months before; acute onset of
second attack; effusion on left side; gradual re-
covery; detection of tubercle bacilli in sputum,
three and a half years after signs of disease at
The following case illustrates the importance in diagonsis
of a systematic examination of the sputum :
Jos. A., aged 29, German, admitted July 1st, 1889,
complaining of pain in the chest, cough and shortness of
breath. A brother died of consumption in 1885. Parents
dead, not of tuberculosis. The patient was well as a boy
and enjoyed excellent health. Five months ago he had an
attack similar to the present one ; was ill in bed for two
weeks. He got quite well, but it left him with a 'little
cough. Present illness began six days ago, June 24th,
with fever, chilly feelings, and slight cough. He worked
until the 29th, and only went to bed yesterday ; temperature
on admission 102� ; respiration 40 ; pulse 96. Well built,
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