RECURRING EMPYEMA.

BY FRANCIS HUBER, M.D.,

New York.

Recurring pleural empyema, according to Dr. J. H. Pryor, is a term "employed to describe a renewed involvement of the previously affected pleura, occurring at an indefinite time after recovery from the primary attack." In his comments upon the case reported (New York Medical Journal, December 21, 1907, page 1,165), Pryor says: "The fact that empyema may recur years after recovery has not received the attention it deserves. It seems to be a very rare affection."

Dr. Park, in a careful search of the surgical literature, found no mention of the subject in the text-books. He found the report of a case by Ayer and another eight years after recovery reported by West. It is claimed that secondary attacks are apt to assume the sacculated or localized form, because of the pathological changes following a preceding severe involvement of a large part of the pleura.

The symptoms may be obscure in some instances, as in the case reported by Pryor. In others, the bulging at the site of the original wound or the physical signs will direct attention at once to the nature of the trouble.

In the above-mentioned article, Pryor, in commenting upon the apparent rarity of the condition, says probably the report of I case will lead to the remembrance or discovery of others.

Roswell Park, in the same vein, writes: "Regarding the rarity of this condition, I cannot believe that it is so uncommon as a search through the Index Medicus would indicate. I believe there must be cases of this kind on record, which are not revealed as such by the title under which they have been published; nevertheless, the fact remains that several pages of both series of the Index Medicus, when carefully searched, failed to show more than two such titles."

In discussing the cases, Park speaks of the interesting and unusual features; and, regarding its pathology, is inclined to regard it as an instance parallel to what one may see in the bones, as far as septic and suppurative disease is concerned. He recalls the fact that bone abscesses subside and remain latent for a long

time, even as long as twenty years, and then are excited into activity, and develop, as it were, afresh.

As to the cause of recurrent attacks, Pryor offers as a conjecture that microbe life remained latent in a pocket formed in the process of healing, and became active under unknown favorable conditions.

The report of Pryor's case has led me to look over my notes. In the cases which have come under my own observation, there was little or no difficulty in making the diagnosis and instituting the proper treatment.

The usual signs of an effusion were present, and in addition there was a more or less distinct bulging at the side of the original incision.

Barney R., about four and one-half years old, was operated upon for pyopneumothorax about seven years ago. In this case a pleural fistula, which appeared to have healed, undoubtedly gave rise to the recurrences which took place after two years and after eighteen months respectively. Recently, after an apparent recovery extending over two years, a slight elevation of temperature, pain in the old cicatrix, followed by a purulent discharge, points to a recurrence. He is still under observation.

Perry C., about three years old, operated upon and discharged cured, returned to the hospital about two and one-half years later, with a sinus which had appeared a short time previously. Several operations were done subsequently. Patient passed from under observation and ultimate result not known.

Rosie A., two years old, entered the hospital February 6, 1906. She had been ill for ten days. February 12th the affected side was incised and drained; the subsequent course was favorable. The patient discharged April 1st with wound healed, pulmonary expansion excellent. December 23d was again admitted with a return, about ten days previously, of her old troubles. At the site of the original incision a small abscess appeared, which was opened, allowing 31⁄2 ounces of pus to escape. Two ribs united with a bony bridge were removed; the cavity packed with sterile gauze. Further progress uneventful. Patient discharged January 30, 1907, in excellent condition.

Male, two and one-half years. Rib resected October 9, 1906. Recovery in about six weeks. Nothing abnormal until February 21, 1907, when rather suddenly a bulging appeared at the site of the former operation. Full recovery after another operation.

A girl, operated upon when about three years old, and who, when discharged, several months later, appeared to have fully recovered, presented herself as an office patient when about fourteen years old, with a purulent pleural effusion; and marked bulging at the site of the old scar. The subsequent course is unknown, as patient simply came for an opinion.

Finally the case of Bennie A. is cited. Bennie A., twentyone months old, admitted November 7, 1907, with this history: Five months before, he had been operated upon in another hospital. He appeared to have recovered in about two months. Three months later he was admitted in a very bad condition, with the left chest full of pus. He was first aspirated because of his precarious state, and three days later a thoracotomy was done.

In explanation of such recurring attacks, the writer cannot add anything new to the remarks, or comments, of Park and Pryor. It is often a difficult question to decide when to remove the drain after an operation for empyema. If taken out too early, a little pocket may remain in a quiescent state, the superficial stricture healing nicely. We can readily conceive that as long as the general health remains good no symptoms may arise and no disturbances follow, until some accident or lowered resistance causes the old process to light up. In this manner we may readily explain the recurrences within two or three months, or after apparent cure. In other instances, in addition to the thickening of the pleura, there are abundant adhesions and pockets; while the greater part of the cavity may be obliterated and become innocuous, small foci may subsequently, at longer or shorter intervals, cause a lighting up of the original process and thus lead to a so-called recurrence.

ABSCESS OF THE LUNG DUE TO WIRE NAIL TWO INCHES LONG IN RIGHT BRONCHUS.-OPERATION. RECOVERY.

BY FRANCIS HUBER, M.D.

New York.

WITH SURGICAL COMMENTS BY DR. HENRY M. SILVER.

In the Philadelphia Medical Journal, May 3, 1902, the writer. presented "A Case of Foreign Body in the Lung-Diagnosis Confirmed by Radiography." The case unfortunately terminated unfavorably. In the present instance the results were favorable, and as many points of interest were present it is considered desirable to place the details on record.

Isie B., two and one-half years old. Was admitted to the Children's Ward in Beth-Israel Hospital, September 21, 1906.

History of summer complaint during the entire summer of the preceding year. Six months ago had measles, followed by pneumonia, ill about six weeks. Four weeks ago had a second. attack of pneumonia, from which he recovered in about a week's time. As to further points bearing upon his condition, it is claimed that he has not been well for the past six months. Was supposed to have had whooping cough months ago, coughed considerably, expectoration mucopurulent. At no time was any blood brought up. Occasionally he would vomit after a coughing spell. More or less temperature had been reported. Has lost flesh, appetite is capricious, sweats profusely at times. Dyspnea present and cyanosis is quite marked.

Since admission the most prominent symptoms have been a paroxysmal cough, particularly marked when he becomes excited or lies on the healthy side. Vomiting occurs now and then, generally after coughing spells. The temperature has been of a septic type, ranging between 99°F. and 103°F., attended by irregular sweating and prostration. Loss of flesh and strength has continued. The dyspnea is pronounced and cyanosis of mucous membrane exists. Sputum (negative for tubercle bacilli) was distinctly purulent with excess of polynuclear cells. Prior to admission to the hospital several exploratory punctures had been made by the physician in charge with unsatisfactory results-the

diagnosis resting between an encysted or interlobar empyemia and abscess of the lung.

Examination of nose and mastoid negative. Teeth and gums in good condition. Tongue dry and slightly coated. Throat negative. Conjunctivæ negative, no glands enlarged at angle of jaw. Pupils react to light and accommodation.

Physical Examination.-Chest fairly well formed. Expansion limited on the right side. Heart not displaced. Anteriorly, marked dullness over upper lobe of the lung on the right side, increased fremitus above, bronchial voice and breathing approaching the cavernous type. Posteriorly above, decided dullness and bronchial breathing. Over rest of right lung are found diminished breathing, voice and fremitus, with dull percussion note. Left lung not involved.

lobe.

DIAGNOSIS.-Abscess of lung involving upper and middle

October 2d. Radiograph taken, but interpretation was not satisfactory.

October 6th. Exploring syringe introduced posteriorly in seventh inter-space, revealed a few drops of pus.

October 7th. Resection of rib (8). Lung was explored in various directions, but we failed to locate the abscess.* Gauze drain introduced and usual dressing applied.

Progress, as far as wound is concerned, satisfactory. On this day, October 26th, the physical signs simulated extensive consolidation of upper and middle lobe, due to occlusion of the opening. In a few days, as the abscess gradually emptied, the usual signs of a cavity reappeared.

November 14th. Fluoroscopic examination revealed wire nail in trachea and right bronchus, beautifully shown on plate.

When the mother was closely questioned, she now remembered that eight months ago the little one, while playing with some nails, suddenly had a distinct and characteristic suffocative spell, which soon passed over. The subsequent symptoms have been detailed above.

• Exploratory puncture has been considered the crucial test, although authors differ widely as to its value and significance as a negative manifestation. Such was J. B. Murphy's teaching in 1898. Tuffier says exploratory puncture is permissible but often deceptive, and when negative the puncture is to be made many times. He has made two to twelve punctures in each case and yet failed to locate the cavity in 17 per cent. of the cases of gangrene, 17 per cent. of the abscesses and 33 per cent. of the bronchiectasis. He claims that the procedure is harmless when done at the time of operation. Foul gas in the syringe is just as positive A radiograph may materially aid us in locating the purulent process.

as pus.