ACUTE PLEURISY WITH EFFUSION; INTERSTI TIAL PNEUMONIA (CHALICOSIS), WITH EN- CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. BY J. M. ANDERS, M.D., Ph.D., Professor of Practice in the Medico-Chirurgical College; Visiting Physician to the Philadelphia Hospital, etc. GENTLEMEN,-Those of you who were here at my last clinic will recall the case I then showed you, one of acute pleurisy with effusion. We will call attention once more to the chief points in the clinical history of the case. Man, aged thirty-seven years; laborer by occupation; nativity, Italian. He had some of the diseases of childhood, followed by an attack of malaria, but since then has been in good health until the present attack, which began December 23, 1893. The onset was marked by a severe chill, followed by high fever, intense headache, and general muscular and bone pains. A few days before admission he was seized with a stitch-like pain in the region of the right nipple, extending to the back, and accompanied by dyspnoea and cough, with the expectoration of a scanty amount of mucus. On being admitted to the institution (January 4, 1894) the countenance was flushed, respirations were shallow and rapid, showing marked dyspnoea, and a hacking cough with little expectoration was present. Further examination at the time of admission revealed a right-sided pleural effusion, the liquid rising to a level anteriorly with the nipple and posteriorly with the inferior angle of the scapula. Last week, on making an examination, the fluid still arose to the nipple-line with the patient in a sitting posture, and changed on changing his position. At that time the differential diagnosis, prognosis, and treatment were spoken of. I wish to-day, however, to add a few words as to the treatment in cases of sero-fibrinous pleurisy. As the effusion is due to an inflammation and not to a simple transudation, reduce the inflammation of the pleura by means of mild diaphoretics and diuretics, together with repeated small doses of salines, sufficient to cause moderate purgation. Opium and quinine are two remedies which control inflammations of serous membranes, the former being given in the form of suppositories or hypodermically, and the latter in divided doses, sixteen to twenty grains in twenty-four hours. In this patient, the temperature dropped to normal last week for the first time. In many cases, after the fever has entirely disappeared, the amount of fluid in the chest remains the same, and then the indications for paracentesis are to be considered. These may be properly subdivided into two classes or considerations. First, during the acute stage: (a) To save life, and not to get rid of the fluid. (b) When one pleural sac is completely filled, as shown by dulness on percussion reaching upward to the clavicle, or when Skoda's resonance extends downward only as far as the second rib or interspace, in which case there is considerable intra-thoracic pressure, this being always an indication for aspirating. If hyper-resonance extends lower, reaching the third rib or interspace, it is well to hesitate, as the danger from intra-thoracic pressure is not so great, and the fluid may be finally absorbed. (c) Marked displacement of the heart, with the development of one or more murmurs, may occur, and denotes the indication for immediate aspiration. Distortion and compression of the great vessels from pressure of the fluid take place, which disappear as the pressure is removed by withdrawal of the fluid. (d) In double pleurisies, if both sides are filled one-half with liquid, aspirate, as sudden death may occur from the rapid filling of one side. (e) Always watch the unaffected side, and detect the first signs of involvement. If moist râles, ægophony, broncho-vesicular breathing, and impaired resonance appear, aspirate immediately, stimulate the heart, and apply dry cups over the affected area. The risk in allowing the fluid to remain is too great. Should serious symptoms arise during the acute stage, such as orthopnoea or a tendency to syncope, aspirate and withdraw a portion of the fluid. Second, in afebrile or subacute cases, when should aspiration be performed? When nature makes no attempt at absorption. At the time the temperature becomes normal a thorough examination should be made, and the exact amount of fluid in the chest ascertained. If the quantity be not diminished in one week after the drop to normal, aspirate, withdrawing a limited amount. In cases where there is absence of temperature from the beginning, withhold operating for about three weeks, but do not wait longer; the elasticity of the lung, if compressed too long, will be destroyed; the latter will not regain its function, and dangerous sequelae may result. The medical treatment in this case consisted of five grains of potassium iodide, with ten minims of the syrup of ferrous iodide, given four times daily, to promote absorption. This combination has been much used, and rarely fails to produce some effect in lessening the amount of fluid. On making an examination at this time, I find the patient's general condition comfortable, the dyspnoea much less marked, and the cough much improved. The flatness does not extend as far upward as the nipple, both anteriorly and laterally, showing beginning absorption. The indications for aspiration are, therefore, not present, and we will continue the internal treatment, and notice the patient's condition one week hence. The next case I have to show you is most interesting: it is similar in some respects to the one you have just seen, although not nearly so typical in character. Male, aged fifty; occupation, brickmaker since eleven years of age. One parent and one sister are dead; causes of death not known. His remaining parent and another sister are living and well. When a child he had measles and whooping-cough, and in 1876 a severe attack of small-pox, from which, however, he fully recovered. Two years ago he noticed for the first time slight dyspnoea on exertion, accompanied by some cough with little expectoration. His general health, he states, was good at this time, and he did not lose flesh. The cough, however, continued, and one year ago last December he had a severe attack of influenza, followed by right-sided pleurisy with effusion, and was quite ill for some time, but finally recovered, and remained in good health until September, 1893, when he caught cold and the dyspnoea returned, accompanied by persistent cough with muco-purulent expectoration. He continued to work, and one month ago the symptoms became much intensified. Despite this he would not give up work until two days before admission. When I first saw him his face was flushed, dyspnoea was marked, and persistent cough was present, with scanty expectoration. The temperature was irregular and subremittent in character, reaching 101° in the morning and rising to 102° or higher in the evening. Physical examination of the chest in front showed diminished expansion on the right side, the supra- and infraclavicular fossæ being well marked, and the respiratory movement on that side in an upward and downward direction. Anteriorly on the left side expansion was good, the movement being upward and outward. The apex-beat could be seen in the fifth interspace, but was displaced nearly one inch to the right. The impulse was feeble. Posteriorly on the right side there was retraction, beginning at the angle of the scapula and extending laterally, together with diminished expansion on that side, some movement being noticed over the base. Palpation. On the left side, anteriorly and posteriorly, tactile fremitus was good throughout. Over the upper half of the right lung anteriorly fremitus was much diminished or entirely absent, being relatively more marked over the right base. Percussion over the upper third of the right side anteriorly showed flatness with impaired resonance over the lower two-thirds. Posteriorly flatness extended down to the spine of the scapula, and from that point to the base of the right lung there was dulness; over the extreme base, impaired resonance. Percussion over the left side anteriorly and posteriorly showed extra resonance throughout. On auscultating over the right lung anteriorly, the breath-sounds were impaired down to the nipple; below that friction râles could be plainly heard, accompanied by a feeble respiratory murmur. On the same side posteriorly, above the angle of the scapula, breath-sounds were entirely absent; below that the sounds were heard feebly, together with a few friction râles. Four days later the physical signs were recorded as follows. Posteriorly over the lower half of the right lung increased tactile fremitus, with impaired percussion resonance, extending to the middle third. Above the angle of the scapula, where the breath-sounds were formerly absent, broncho-vesicular breathing could be heard. The diagnosis of plastic pleurisy with effusion, which had largely disappeared, was then made. One week later, practically the same signs were discovered posteriorly. Anteriorly on the right side percussion showed flatness extending to the base of the lung in front; over the upper third of the lung vocal fremitus was entirely absent. The breath-sounds about the region of the nipple were also absent, no friction râles being heard. From the limited area of dulness not changing with the position of the patient, in conjunction with the other physical signs, the effusion was thought to be an encysted or sacculated one; hence the exploring needle was used, which confirmed the diagnosis. In cases of this character, where some doubt exists as to the condition present, the exploring needle affords the only sure means of establishing a positive diagnosis. In this case the needle was passed between the third and fourth ribs, in a line drawn obliquely outward and upward from the nipple to the apex of the axilla. When first examined, if you will remember, the area of flatness was circumscribed to the right apex, but to-day, on percussing, we have flatness extending to the base of the lung. The question now arises, Is this a monolocular or a multilocular cyst? which can be decided only by aspirating. In order to find whether the cysts, when |