previously; for though fully exposed they did not contract the disease. However, 77 of the number immunized against diphtheria successfully passed through measles without developing this dread complication. In one nursery, considered safe, no cases of diphtheria developed, and yet none of the patients contained in it (13 susceptible) were immunized. This nursery was at the top of the largest building the administration building-and widely separated from others. In a second nursery, where diphtheria had been occasionally observed, nine children with measles were not immunized, and the third day after the appearance of the rash, four out of the nine had a bloody nasal discharge. Cultures made from this showed the presence of the diphtheria bacillus. It was considered that this nursery would afford a fair control upon the observations in the remainder of the hospital. When the diagnosis of diphtheria was confirmed the four patients mentioned were immediately injected with 2000 units of antitoxin; the five remaining patients were immunized. No further cases appeared in this nursery, and the four children already having nasal diphtheria recovered. The immunizing dose of antitoxin employed was 250 units (antitoxin of the New York Board of Health). No antitoxic rash appeared after the employment of this dose. On two occasions a dose of 400 units was employed for purposes of immunization, with the subsequent appearance of urticaria. No local disturbance or constitutional reaction was observed in the cases immunized with 250 antitoxic units. As regards the accepted period of immunity following the injection of the diphtheria serum, it was interesting to note that in two cases, after respectively 31 and 33 days, pharyngeal diphtheria developed. In these, curative doses of the serum were at once administered, and the patients promptly recovered. A CONTRIBUTION TO THE SURGERY OF EMPYEMA, WITH THE HISTORY OF AN ILLUSTRATIVE CASE.1 BY CHARLES E. LOCKWOOD, M.D., OF NEW YORK. A CASE of empyema having recently come under my observation, and having found myself much involved in doubt as to proper methods of treatment to be pursued during the long course of the affection, I have thought it might be profitable to record my experience, and thus, perhaps, elicit that of others. Pleurisy has been divided into three varieties dependent upon the character of the exudate, whether fibrinous, serofibrinous, or purulent, the last being 1 Read at a meeting of the Medical Society of the County of New York, October 25, 1897. the one which at present especially claims our attention. The subject of empyema and its rational treatment has, during many years, been involved in much obscurity, owing to a lack of knowledge of the etiologic factors which determine the various manifestations of the disease. The consensus of modern opinion seems to be "that every empyema is due to microbic invasion of the pleural cavity.''1 The relative frequency of the different varieties of this disease has been stated to be as follows: "In adults, 50 per cent. of all cases are streptococcic, 25 per cent. pneumococcic, and the remaining 25 per cent. may be divided among several forms, of which the tuberculous is relatively most common. In children the pneumococcus causes at least 60 per cent., possibly 75 per cent. of all cases; most of the remainder are streptococcic or staphylococcic, both tuberculosis and putridity being rare."' The rational treatment of purulent pleurisy demands the immediate evacuation of the pus by means of one of the methods now employed, viz., aspiration, simple incision, thoracotomy with resection, and siphon drainage. It is now believed by many competent observers that each of these methods is useful when applied to properly selected cases. The following is the history of the case observed by me: C. B., a student, aged 16 years. His father died as the result of an accident. His mother is living and well. The paternal grandmother died of cancer of the stomach, and three brothers, one sister, and one uncle of the mother died of phthisis pulmonalis. With the exception of chicken-pox, which he had two years before, the patient had always enjoyed good health up to the date of the illness under consideration. Just previous to this he had been training for a football match, and living upon a restricted diet. On December 10, 1896, while on the cars going from New York to Sing Sing, he had a chill, followed by high fever, the temperature under the tongue being 104.8° F.; pulse, 108; respiration, 28. A careful examination showed acute pneumonia of the lower lobe of the right lung, and also frictionsounds, indicating involvement of the pleura. The disease continued six days, with a morning temperature of about 102° F. and an afternoon rise to about 103° F., respirations averaging 36 to the minute, and pulse 112. At this period his daily diet consisted of about four pints of milk. On the seventh day the temperature dropped to 100.6° F. at midnight, and on the eighth day to 99.2° F. at 3 P.M., pulse and respiration remaining the same as before. On the tenth day the temperature dropped to normal at 3 A.M., and remained so until 9 A. M., rising to 100° F. at 3 P.M. Thereafter, from the eleventh to the 15th day, the temperature was normal or be Whitney, "Twentieth Century Practice of Medicine," vol. vii, Section on Diseases of the Pleura. 2 Ibid. low normal at 9 A. M., and then gradually rose to 100° F. by 9 P.M. Physical examination now showed pleurisy with effusion. On the sixteenth day the temperature was normal at noon and 102.4° F. at midnight. On the seventeenth day at 6 A.M. the temperature was 99° F., and at 9 P.M., 103° F., and the patient suffered considerably from dyspnea and pain in the right side, respiration rising to 32 and pulse to 120 at 6 P.M. On the eighteenth day, December 28, 1896, I saw him with Dr. Madden of Sing Sing, who had been in daily attendance, and it was decided to aspirate the chest to relieve the patient and ascertain the nature of the effusion. From the character of the symptoms the latter was suspected to be purulent. Accordingly, I aspirated the chest under proper antiseptic precautions between the fourth and fifth ribs on the right side, and drew away twenty ounces of so-called laudable pus, much to the patient's relief. On the nineteenth day the temperature was normal at 9 A.M., and rose to 101° F. at 6 P.M. An examination of the sputum by Dr. Harlow Brooks on December 29th showed the presence of the diplococcus of pneumonia, a few pus-cells, but no tubercle bacilli. From the twentieth to the twenty-second day the morning temperature was about 98.8° F.; evening temperature, 101° F.; pulse, 100; respiration 20. On the twenty-third day, with a morning temperature of 98.8° F., there was a rise at midnight to 100° F. On the twenty-fourth day the chest was again aspirated between the fifth and sixth ribs, and twenty ounces of pus removed. January 4, 1897, the patient was brought from Sing Sing to New York, and bore the journey well. On January 5, 1897, it having been decided that an opening should be made to secure proper drainage and the skin surface of the chest having been properly cleansed and treated with applications of corrosive sublimate 1-1000, an incision was made by Dr. W. T. Bull on the right side in the axillary line through and parallel to the fibers of the latissimus dorsi muscle over the eighth and ninth ribs, and portions of these ribs, about one and one-half inches in length, were removed by first lifting up the periosteum and sliding it off, and then with a chisel and hammer cuts were made in the ninth rib, which was then cut through with the bone-forceps. The portion of the eighth rib was also cut through in the same manner. The pleural cavity was opened, and a large quantity of pus and fibrinous material removed. The cavity was irrigated with sterilized water and two rubber tubes (with perforations) three and one-half inches. in length and about one-third inch in diameter were introduced, with a silk ligature tied through them from end to end as a precautionary measure in case of breakage. A large safety-pin was placed at the external end of the tubes, and a dressing of sterilized gauze and cotton applied and held in place by a folded towel over which were fastened strips of adhesive plaster by means of tape connected with the pieces of plaster. On January 6th, the day after the operation, the temperature at 4 A. M. was 98.4° F., and at 4 P.M. Dr. J. B. 99.8° F.; respiration, 24; pulse, 108. Walker dressed the wound, removing the soiled. gauze as often as it became saturated with discharge, and substituting fresh sterilized gauze, the change of dressing being made three times in each twenty-four hours. On account of sleeplessness the patient was given trional in 10-grain doses, and for the relief of pain 4 grain of codein was administered. Action of the bowels was secured by means of two cascarine tablets given each night. On January 7th, 8th, and 9th the wound was dressed as before, the average morning temperature being normal or subnormal, and at 4 P.M., 99.2° F., respiration 20, pulse 96. January 10th the tubes were removed, cleaned, and the usual dressing applied, the temperature being 98° F. at 4 P. M. and 100° F. at 12 P.M. January 11th the dressing was changed twice; there was considerable discharge, and the temperature at noon was 98.4° F. and at 8 P.M., 100.8° F. From January 12th to the 15th the dressing was reapplied as usual, the morning temperature being 98.4° F., evening temperature about 100.8° F. On January 16th the tubes were removed and the wound irrigated, for the first time since the operation, with sterilized normal salt solution; tubes cleaned and reinserted; temperature at 8 A.M., 98.9° F., 8 P.M., 102.8° F.; pulse, 115; respiration, 20. From January 17th to the 24th irrigation of the cavity with sterilized normal salt solution was continued once daily, and the morning temperature averaged on each day about 102° F., and on one of these days I remarked that the evening temperature seemed to have gone persistently higher since the irrigations of the chestcavity had been employed, although the patient had freely taken a most nourishing diet. From January 25th to February 1st the same treatment was continued, the temperature retaining the same characteristics, and the patient now complained of night-sweats; the spleen was found to be somewhat enlarged. There was an anemic murmur audible over the base of the heart. There was also slight edema of the lower portion of the legs, and I feared amyloid degeneration. I will here state that on January 17th Dr. Harlow Brooks of the Carnegie Laboratory wrote me as follows: "I did an autopsy to-day upon the guinea-pig which I inoculated with the pus from your case of empyema, and I find no evidence of tuberculosis. I find the cultures made from the pus to be a mixed growth, largely composed of pneumococci." It may also be stated that the Wolff bottles for promoting expansion of the lung had daily been used by the patient, and that a careful examination of the urine revealed nothing abnormal. Realizing that some measure must be taken to prevent further absorption of septic matter, I asked Dr. Janeway to see the case with Dr. W. T. Bull and myself, and after a careful examination he expressed the opinion that he was unable to find any evidence of tuberculous consolidation or chronic pneumonia; that there was considerable thickening of the walls of the pleural sac, and an anemic murmur at the base of the heart, and also that the spleen was somewhat enlarged. His diagnosis was that the fever SURGERY OF EMPYEMA. was septic, and he recommended irrigation of the chest-cavity with a solution of carbolic acid in warm water (1 to 1000) and careful observation of the effects, being sure to measure the quantity introduced and compare the same with the amount returned, so as to leave no residue in the chest-cavity. He remarked that he had seen septic fever of this character abate under such treatment. cavity was irrigated with the above-mentioned soluThe chesttion of carbolic acid at 6 P.M. on February 2d, with no bad effect. On February 3d the chest-cavity was irrigated with a solution of carbolic acid, and in order to improve the general nutrition it was recommended that the patient take three milk punches daily, each containing 1⁄2 ounce of whiskey, and also a teacupful of beef juice three times a day and as much nourishing food as possible. One or two teaspoonfuls of Gudes' solution of pepto-manganate | of iron after meals was added to the medication. His temperature on the evening of February 3d was 103° F.; pulse, 112; respiration, 24. On February 4th the temperature remained normal all day, the same treatment being continued, and we had an illustration of Sir Joseph Lister's principle that the untoward consequences of operations are frequently due not to the operation itself, but to the poisoning of the wound by the products of decomposing discharges and poisoning of the tem generally by absorption of these products. The sysdecomposition is due to low organisms introduced from without, and may be eliminated by the use of such substances as will prevent their development or destroy them when present." The only question is whether it is safe to use such agents in a suppurating pleural sac immediately after an operation or during the following few weeks. ing the first ten days following the operation, thorIn this case, durough drainage was secured by means of proper tubes and sterilized dressings frequently changed, with the effect that septic fever still continued. Irrigation with sterilized normal salt solution was then used, with the result that the fever was increased and did not abate until the carbolized water was used. I may add that owing to the fact that air was drawn into the cavity through the external opening, as was shown by the patient breathing and whistling through it, decomposition was produced by the introduction of low organisms with the air. On February 5th the tubes were removed, cleaned, and the cavity irrigated with carbolized water, the temperature remaining normal, but the patient had a profuse perspiration during the night. On February 6th and 7th the same treatment was continued. On Fedruary 8th the two tubes were removed and the cavity irrigated with carbolized water and a single perforated tube, one-half inch in diameter and three inches in length was introduced in the opening. There has been no rise of temperature above normal since February 2d. opening in the chest was observed to be growing On February 9th the smaller. There was some difficulty in inserting the large tube; patient daily takes three milk punches with one-half ounce of whiskey in each, three tum [MEDICAL NEWS blers of beef juice, one ounce and a half of Gudes' pepto-mangan, and three pills containing 1 grain of powdered iron, -grain of strychnin,-grain of arsenious acid, and -grain of phosphorus, and also a most nourishing diet. February 11th to 13th, temperature normal; same treatment continued. On February 14th the large one-half inch tube was diameter and three inches in length inserted; irrigaremoved, and a smaller tube, one-quarter inch in tion continued; temperature normal; drainage perfect; treatment continued. February 18th, the patient took an hours' ride in a carriage. On February 22d, he went home. February 26th: Temperature normal during the twenty-four hours; no pain; patient walked around the block in the open air. pansion, as he shows a tendency to stoop over and bottles and an elastic exerciser to promote lung exHe is using the Wolff lean toward the right side, due to contraction of the pleural cavity. I will add that during all this period particular attention was paid to the diet, the patient taking daily one pint of beef juice, a bottle of beer with his dinner, and three milk punches each containing onehalf ounce of whiskey. gating the sinus with carbolized water and removing March 1st: Dr. Walker dressed the wound, irrithe one-quarter-inch tube. On coughing only about twenty drops of pus was expelled. A new perforated rubber tube one-eighth of an inch in diameter and two inches in length was now inserted, and the wound dressed with sterilized gauze. dressing have been continued. March 8th: The same method of irrigation and in the dressing when the latter was removed, and it The tube was found was not reinserted. The sinus was now one and one-quarter inches in depth, and it was wiped out piece of gauze put in the opening. March 9th: A with cotton saturated with carbolized water, and a piece of gauze saturated with balsam Peru was inserted. March 13th: Sinus one and one-eighth inches in depth. A solution of nitrate of silver sixty grains to the ounce was applied to its walls and it was dressed with a piece of gauze dipped in thioform. From March 14th to March 30th the sinus was daily dressed by cleansing with carbolized water, and a small piece of gauze saturated with balsam of Peru was inserted and then covered with a pad of gauze which was held in place by strips of adhesive plaster. April 2d: The patient went to the country, and April 26th: The patient was seen by Dr. W. T. May 15th: I made careful measurements of pa tient's chest with the following results: On the right side a line drawn from the spinous processes of the dorsal vertebræ, on a line with the nipple, to a marked point on the middle of the sternum measured, on inspiration, 154 inches, on expiration, 1434 inches. The same measurement on the left side, on inspiration was 163% inches, on expiration, 15 inches. Measurement of the whole chest over the same line: Inspiration, 311⁄2 inches; expiration, 291⁄2 inches. This shows a difference between the two sides on inspiration of 5% of an inch, and on expiration of 4 of an inch-a good showing, it seems to me, in consideration of the circumstances. Summary. The points of interest in connection with this subject and the history of the case observed by me are as follows: 1. The necessity of securing the highest point of nutrition in cases of pneumonia to sustain the vital activity and power of the body-cells to enable them to limit the ravages of the pneumococcus. 2. The importance of an early operation in empyema as affecting the prognosis, owing to the results of delay in allowing the increase of fibrinous effusion into the pleural cavity and thickening of the walls of the pleural sac, thus hindering healthy repair and lung expansion after evacuation of the pus. 3. The marked effect of irrigation of the suppurating pleural cavity with a solution of carbolic acid (1-1000), and thorough drainage in arresting the septicemia after its duration of four weeks following the operation, thus demonstrating the principle of the importance of preventing the entrance of low organisms into a suppurating cavity, or of destroying them after entrance in order to prevent or arrest septic poisoning. 4. The evidence given in this case by a characteristic temperature on the sixteenth and seventeenth days of the illness and on following days which pointed to purulent infection, although it has been shown that pus accumulation may occur in the chest with no sign of fever. 5. That in the case described there was evidently a perforation of the lung, thus allowing communication between the bronchi and the pleural sac which favored putrefaction, and that in such cases, characterized by putrid pus, carbolized irrigations are necessary. To sum up my ideas after a limited experience and a careful review of the literature of the subject, aspiration is found to give twenty per cent. of cures, as shown by Holt's cases, and is sometimes efficient in children, tuberculosis, and in other cases which in the present state of our knowledge it is difficult to differentiate, and is, therefore, an uncertain method of treatment. Simple incision with drainage and without resec tion, according to some statistics, gives equally good results as thoracotomy with resection, and reliable testimony seems to recommend it as particularly adapted for the disease in infants and in the debili tated, as the operation can be done without a general anesthetic, local anesthesia being sufficient, though further facts are needed, as Dr. Morrison says, before its position can be established. Thoracotomy with resection, when performed early, so as to secure thorough and efficient drainage, and combined with proper after treatment of the wound thus preventing the entrance of germs and the avoidance of irrigation, if possible, would seem by the now accumulated experience of many observers to offer the best prospect of a successful issue in the majority of cases. Still, that antiseptic irrigation may prove useful in certain instances, is, I think, proved by the course of events related by me. Siphon drainage would seem, according to the results obtained, to be a justifiable procedure under certain conditions. RATIONAL GYNECOLOGY. BY JOHN H. KELLOGG, M.D., Kneading with the Closed Fist.-(Fig. 11.) With the closed fists used in alternation work along the whole course of the colon, beginning at the upper end of the cecum and directing the movements upward to the lower border of the ribs to a point midway between the umbilicus and the sternum, at which the median line is crossed, then down on the opposite side, ending at a point close to the pubic bone, and just to the left of the median line. The rate of movement should not be more than thirty per minute or two seconds for each hand. Care should be taken not to release the pressure upon the bowels with one hand until the other hand has been placed in position just in advance and close to it. Care must be also taken to follow the curves of the colon. Kneading with the Thumbs.-(Fig. 12.) With the fingers behind and the thumbs in front, grasp the loin on each side between the thumb and the fingers. The right hand should thus grasp the lower end of the cecum, while the left hand grasps the upper part of the descending colon just beneath the ribs. Movements are then executed in an upward direction with the right hand, and in a downward direction with the left, the operator facing the patient's feet. Mass Kneading.-(Fig. 13.) Still another procedure of value in abdominal massage is what may be termed "mass kneading," in which the operator endeavors to seize the abdominal contents with both |