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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 The following day he was aspirated and 2J litres of fluid withdrawn ; the accumulation was rapid, and on the 17th the condition was very much as before.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 both apices. 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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