A Remarkable Case of an Empyema. By Mr. Joseph Warner, F. R. S. and Surgeon to Guy's Hospital

Hubner's kind, here mentioned, is only a variety of that I call creta, tripela alba dicta, p. 76. No 1. Your Lordship will please to observe, that of all the said kinds none are produced in general by any such operations of nature, as Mr. Hubner intimates; therefore, my Lord, reason will convince, that this is only a partial and local origin of his Tripoli, by concurring circumstances of wood and Tripoli buried together in the bowels of a volcano; for as we find this very species elsewhere produced without such circumstances, it is certain they are not the sole efficient causes of its production. I am, with great submission and respect, My Lord, Your Lordship's most devoted, most obliged, and most obedient humble servant, Bearbinder Lane, 19 June, 1759. Emanuel Mendes da Costa. XXII. A remarkable Case of an Empyema. By Mr. Joseph Warner, F. R. S. and Surgeon to Guy's Hospital. Read June 28, 1759. MORRIS EVANS, aged 30 years, on the 13th of March, 1759, was admitted into Guy's hospital, with a remarkable complaint in his chest, which attacked him in the month of August 1758, with the symptoms of a pleurisy. Upon inspection it appeared, that the left side of the thorax was greatly enlarged, and prodigiously distended: the pectoral muscle was somewhat raised up; on pressure it felt soft, and readily gave way: upon a removal of the pressure, the integuments resumed their former appearance, no marks of impression remaining on this, or any other part of the thorax, so as to constitute the characteristic of an oedematous swelling. The spaces betwixt the 9th and 10th, and betwixt the 10th and 11th ribs, counting from above, were visibly enlarged, and somewhat elevated: they felt soft, and yielded to the fingers; but were not at all inflamed, or otherwise discoloured. Upon examination, I discovered a fluctuation in both these parts. The general symptoms that attended this case were similar to those arising from all considerable collections of fluids deposited in either cavities of the thorax: for instance, the patient had a continual flow fever; a short cough, but without the least expectoration of matter; a great difficulty in respiration, particularly in the acts of expiration. He was incapable of lying down on the right side, without very great uneasiness; he was much emaciated; and his countenance was uniformly fallow: he did not complain of so much pain, or so great a difficulty in breathing, when in an erect posture, as I have sometimes observed in diseases of this kind even where the quantity of extravasated fluid has been much less; but at the same time I must acknowledge, that no fair inference could be deduced from hence, because of the peculiar position the diseased side was put in when the poor man sat down, or stood up; either of which he was incapable of doing without being supported. The left side of the thorax inclined forwards, and protuberated in a peculiar manner, so as to give the head and trunk an horizontal posture; in which position of the body, the weight of the contained fluid most certainly was, in part, prevented from pressing so forcibly upon the left portion of the diaphragm, the mediastinum, and the right portion of the lungs, as it must necessarily have done in a more erect position of the body. He had one symptom, which I had never before observed in patients labouring under this complaint; that is, he was incapable of lying on his back, without bringing on very alarming threats of suffocation; but he did not remember ever to have heard any noise or rattling of the pus upon motion. He could lie most conveniently on his left side; but even that posture was of late become very painful to him. In short, he could find no tolerable posture to put his body into, but that of inclining it considerably forwards, which (I have already observed) he was under a necessity of doing, to enable him to draw his breath; and I dare venture to say, that, upon attending to the subsequent part of the history of this poor mortal's case, the reason, why such effects should be produced from such a cause, will very readily occur to those, who have a moderate degree of knowledge of the formation and uses of these parts of the human body. Upon making an incision upon the most prominent part of the space betwixt the 10th and 11th rib, in the cavity of the thorax of the left side, at least eight Winchester quarts of a thin yellow matter, not at all fetid, was discharged upon the spot in a full stream: the matter matter issued thro' the wound by leaps, and was projected at the distance of two yards and upwards from the patient's body: he did not faint during the operation, nor afterwards; but from that moment he grew easy; his symptoms abated; he slept well at night; and the next day he had no bad symptoms, except that his difficulty in breathing was not quite removed. This, indeed, could not reasonably be expected, considering the long disuse and extension which the diaphragm, the intercostal muscles, and the rest of the muscles of respiration, had undergone from the pressure and weight of the confined matter, joined to the injury which the lungs themselves had sustained. He continued with very little alteration till the fourth day, when his respiration became worse, accompanied with bad nights, a quick pulse, a great discharge of foetid matter from the wound, and a flushing in his face. These symptoms remained till the 9th. To-day his breathing was better, his pulse became more calm, the flushings in his face disappeared; but the discharge was considerable in quantity, and he complained of a want of appetite, which, till now, had been tolerably good ever since the operation. On the tenth day, his difficulty of breathing returned; the discharge was very great, and offensive; he had very little sleep last night: in short, he seems greatly upon the decline. 11th, 12th, and 13th, he continued much as on the 10th. 14th and 15th days he has had more sleep than usual; his appetite very bad; cough frequent, and troublesome; discharge very thin, and considerable in quantity. Upon exerting his powers in the act of expiration, to discharge the matter from the cavity, there appeared an an eminence betwixt the 7th and 8th ribs (counting from above) on the anterior lateral part of the thorax, which was very tender; but, upon his ceasing to exert himself, the swelling disappeared. 16th and 17th days, his cough very troublesome; the discharge from the wound was great; the matter very thin, and foetid; he gets very little sleep; his pulse quick, and low; his tongue dry, and parched: in short, to all appearance, he seemed to have a very short time to live. But, notwithstanding these threatening symptoms, he very unexpectedly survived till the 10th of June following (exactly 12 weeks from the time of his undergoing the first operation). In the middle of the month of April next preceding his death, he thought himself much better than he had been for many days before: his discharge at this time was much lessened; but his pulse was very weak, and fluttering. About three weeks before the patient's death, a second opening was made by incision betwixt the 11th and 12th ribs by my colleague Mr. Way, under whose immediate care this poor man was from the day of his admission into the hospital, and who treated him with the greatest humanity and judgment. Three days before the patient's decease, the swelling betwixt the 7th and 8th ribs burst of itself, and discharged at least a pint of matter, that was exceedingly offensive. Upon opening the body, the following particulars were discovered: the right portion of the lungs was greatly ulcerated on its superior part, where it adhered firmly to the pleura: on the inferior part of the cavity, the lungs adhered to the diaphragm; the lobes lobes of the lungs on this side were not so much wasted as I expected they would have been, from the great degree of pressure which they had so long sustained from the prodigious quantity of matter, that was confined in the opposite cavity of the thorax; nor was there any extravasation in the right cavity of the thorax. The lobes of the lungs on the left side were almost entirely destroyed: in this cavity there was near a quart of foetid matter; the whole of its internal surface was ulcerated, and the two inferior ribs were carious in the neighbourhood of the second opening. In every other part the ribs were found; so was the sternum. The pericardium and heart appeared in their natural state. The injury done to the internal surface of the left cavity of the thorax was so great, as to have destroyed almost the whole of the intercostal muscles on that side of the trunk. N. B. It may be worth remarking, that this patient did not any time suffer the least inconvenience from the pressure of the external air, which entered into the cavity of the thorax thro' the incisions, as has been said by authors to have happened in a great degree in the like cases; but as that effect was not produced in this, or any other instances of the like kind, which has come under my inspection, I am inclined to conjecture, that the bad effects of the pressure of the external air, when admitted thro' an opening made into the cavity of the thorax, is such an inconvenience as may rather be supposed to be likely to happen, than has been really known to happen often; the act of breathing having never been in the least suspended, altho' the openings made into the cavity have been very large, and the time taken for dressing the patient (sometimes once, sometimes twice a day) has been very considerable; but, on the contrary, at every dressing, I have observed, that the patient has breathed with greater freedom and ease than he could do before the performance of this operation, or even for some hours before the dressings were renewed. As the matter in this disease lies loosely in the cavity of the thorax, there is no greater danger of wounding the lungs in this operation, than there is of wounding the intestines or omentum, in tapping the abdomen in the ascites; and if the method be pursued, which I have recommended for making the incision thro' the intercostal muscles, there will be no danger of wounding the intercostal artery, which is a circumstance much dreaded by some practitioners, but with no great reason. However, was this to happen, it would probably not be attended with any bad consequences, as the bleeding might very readily be stopped by pressure, or otherwise. Hatton Garden, June 28, 1759. Jof. Warner.