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establish drainage. I have so far been able to effect a cure in every empyema following pneumonia by simply making an incision between the ribs and inserting as large a tube as the intercostal spaces will admit. This operation may be done easily under cocain anesthesia. This is important, because many of these patients are not good subjects for general anesthesia so soon after having had pneumonia. I have never had to remove any portion of the rib to get good drainage and effect a cure. In no case should irrigation be practiced. I have used various antiseptic solutions to wash out the cavities in a few cases, and I believe they retarded the recovery in each case where used. I try to promote the discharge of pus by having the patient cough while I change the dressings, and while in various positions. I have the patient lie on the affected side with the tube down as much as possible. I also encourage getting out of bed early. They do better when up and moving around than when they stay in bed. Plenty of good food is the best internal remedy.
On May 20th, 1901, I read a paper before this society reporting five cases of empyema following pneumonia, including patients of both sexes, varying in ages from ten months to forty-five years, all of which were drained by simple incision, with recovery in each case. During the discussion of the paper the question, "How much deformity would result?" was asked. I still see all of these patients occasionally, and the degree of lowering of the shoulder of the affected side and of spinal curvature is now very slight. In only one of the cases is it noticeable except on the closest scrutiny.
I will recite the three following cases as examples of serous and purulent pleurisy as sequelæ of pneumonia:
Case I. White, female, aged 10 years, a patient of Dr. Ferry's, and reported through his courtesy. When first seen had had fever for three days following slight chill. At first examination found entire right side of chest fixed, dull, absent vocal fremitus, breath and voice sounds diminished. Temperature 103°F.; pulse 140; delirious. These conditions remained about the same until the tenth day, when the temperature dropped to 101°F., with pulse 140. This continued for three days, when two pints of serum were withdrawn. Temperature soon dropped to normal and pulse came down gradually. Re
covery rapid and complete. This was a serous pleurisy which arose during the course of pneumonia and which prevented the usual defervescence at the ninth day.
Case II. White, male, aged 19. Taken with pneumonia of the left lower lobe January 11th, 1903. He was seen by me first on March 17th, 1903. He had had fever continually from the onset of the pneumonia to the time of my first visit. I found him with a temperature of 99°F., pulse 140, respirations 30. The entire left chest markedly bulging and fixed, with the intercostal spaces obliterated. Heart displaced to the right of the sternum. Absolute flatness over the entire left side. Bronchial breathing and brouchophony were present. On aspiration clear serum filled the syringe. On the following day I put a needle in the same place and attempted to remove all the fluid. After drawing off about two ounces of clear serum the fluid ceased to run. I pushed the needle further in and pus began to flow and continued until two pints had been drawn. This relieved the dyspnea somewhat, and two days later a large quantity of pus was evacuated by intercostal incision and a tube inserted. The improvement was immediate and continued, but the slight temperature lasted until April 24th, four weeks after the first operation, when I outlined a distinct area of flatness in the upper portion of the front of the left side and made another incision under cocain and evacuated about two ounces of pus; a small tube was put in and recovery was immediate and complete.
Case III. White, female, aged 12. Pneumonia of the left lower lobe beginning November 27th, 1903. Rather violent, but temperature dropped to 100°F. on the ninth day. Pulse remained rapid and temperature rose to 101°F. two days after the crisis, and continued until the operation on December 13th, seventeen days after the beginning of the pneumonia. In this case the pus was walled off in front of the upper left lobe. The incision was made in the fifth interspace in the anterior axillary line. The tube was removed January 10th, 1904, about four weeks from the time of operation. Recovery uneventful.
1. The pain in pneumonia is due to pleurisy and may interfere with the recovery of the patient. It should be relieved by cold or hot applications or morphin.
2. During the pneumonia the pleura may fill up with serum or pus-most often serum-and add to the danger of death before the crisis is reached. If enough to interfere with
breathing it should be removed by aspiration. This fluid may form in the pleura covering the sound lung.
3. When lobar pneumonia fails to end by crisis, always look for a pleural effusion.
4. Post-pneumonic serous effusion should be removed by aspiration unless very small. If purulent, an intercostal incision should be made and a drainage tube inserted between the ribs.
5. No acute empyema should ever be irrigated. Bronchial breathing is sometimes heard through pleural effusions, especially in empyema in children.
299 Main Street.
PROGRESS OF MEDICINE.
UNDER CHARGE OF B. F. TURNER, M.D.
Visiting Physician St. Joseph's Hospital.
Inoculation Experiments on Anthropoid Apes
with Syphilitic Virus.
Lassar (Cor. Med. Press & Circ., vol. 77, no. 3374) at a recent meeting of the Berlin Medical Society said that twenty years ago he had inoculated animals with syphilis, but his experiments, like those of others, had had negative results. Roux and Metschnikoff had more recently experimented with highly developed apes, and he himself had inoculated a chimpanzee four or five years of age, which had been healthy and lively in confinement. The patient from whom the virus had been taken had been inoculated whilst being tattooed on the arms, and at the time the material was taken had swelling of the glands and an amphora. The inoculation was done on October 22d, and on several places in the skin. No local reaction took place. After a fortnight, however, infiltrations appeared over both eyebrows; these speedily broke down, and the part took on the appearance of a chancre. These sores showed scarcely any tendency to heal, and were even now almost unchanged. A little higher on the head, about the middle of the forehead, appeared what must be called a papule. Other
phenomena appeared at a distance from the inoculation spots. Roundish patches, raised at the edge and depressed in the center, appeared on the palms of the hands and soles of the feet and around the anus. At the same time the hair got light in patches as in the human subject.
The symptoms were beginning to appear less marked than at first. As such animals did not breed in captivity, the carrying out of such experiments was rendered more difficult. A second ape was inoculated from the first on December 1st, but the animal was already suffering from tubercle of the intestines. At the site of the inoculation a weakened form of infection could at most be determined.
Adrenalin in Treatment of Cardiac Toxemia of Pneumonia.
Henry L. Elsner (New York Med. Jour., Jan. 2, 1904) directs attention to the appalling mortality from pneumonia due to the resulting cardiac toxemia. The prime factor in this disease is a toxemia with obstruction in the pulmonary circuit, leading to cardiac asthenia. Marked changes occur in the right half of the heart, with far-reaching degenerative changes in the muscle, heart-clots, and vasomotor paralysis.
Three remedies meet the indications presented by the circulatory changes due to paralysis of the vasomotor centers, the dilated condition of the arteries and the weakened heart. These are strychnin, digitalis and suprarenal extract or adrenalin, its active principle. Adrenalin acts on the heart and blood vessels favorably; it does not act on the vasomotor center. Hence, it may be used to assist strychnin. When the vasomotor center is exhausted and blood-pressure study proves the inefficiency of strychnin, adrenalin may still be administered, and, in some cases which seem unpromising, when combined with the method of stimulation about to be suggested, we may carry the patient beyond the critical period to a safe recovery. Suprarenal extract, or adrenalin, has seemed to the author to act as a needed food in all infections where there is danger of myocardial degeneration. He reports a case of pneumonia, in a woman, the mother of five children, in whom it had been impossible to raise a continually lowering blood pressure with strychnin. The systolic blood pressure
was almost immediately raised by the repeated administration at short intervals of fifteen minims of a one to one thousand solution of adrenalin hypodermatically, and the patient was saved.
Differential Diagnosis of Typhoid Fever in its Earliest Stages. W. C. Rucker (Am. Jour. Med. Sc., vol. 127, no. 1) says:
1. There is no single symptom on which alone an early diagnosis of typhoid fever can be made. It is only by careful consideration of the symptom-complex that a clinical diagnosis can be arrived at.
2. The most trustworthy, as well as the earliest, sign of typhoid fever is the presence in the circulating blood of the bacillus of Eberth.
3. The demonstration of the bacillus of Eberth in the blood is not beyond any fairly well-equipped laboratory.
4. The bacillus of Eberth is found in the feces later than in the blood, but with comparative ease. The presence of the bacillus typhosus in the feces is of great value as a corroborative sign.
5. The presence of the bacillus typhosus in the rose spots is a trustworthy sign, but has no advantages over the examination of the blood from other localities.
6. The serum reaction of Widal is seldom demonstrable during the earliest stages of typhoid fever. It is of value only in the higher dilutions.
UNDER CHARGE OF W. B. ROGERS, M.D.
Professor of the Principles and Practice of Surgery and Clinical Surgery,
A Year's Work in Appendicitis.
R. Winslow (Maryland Med. Jour., vol. 47, no. 1) reports his observations deduced from a series of forty-six cases of appendicitis, or conditions due, or supposed to be due, to appendicitis, operated on in twelve months. Of these cases, forty-four recovered and two died. Twenty-six were males and twenty females. The youngest was a 3-year-old boy and the oldest a 63-year-old woman, both making good recoveries.