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J. A. (Joel Asaph) Allen.

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need any extended review of its strong points. This, the third
edition, contains over 300 illustrations, many of which are new^
All show the value of having good illustrations for students to
follow in the study of ^ microscopical science. The book is
expressly designed for students, contains 298 pages, with a good
index, and is cheerfully recommended not only to beginners in
histology but also to advanced students in this subject.

Printing, good paper, and nicely executed cuts help to enhance
the value of the book. W. C. E.



Memoranda of Poisons. By Thomas Hawkbs Tanner, M. D.,
F. L. S. Seventh American, from the last London, edition. Revised
by John J. Reese. M. D. . late Professor of Medical Jurisprudence
and Toxicology in the University of Pennsylvania. Philadelphia :
P. Blakiston, Son & Co. 1892.

This is an old friend and a useful one. The subject of poisons
is of great importance to the general practitioner, who is rarely so
well equipped in this department as to be able to handle emergency
cases with skill and discretion. This book serves as a ready
reminder, and can be carried in the pocket or hand-bag.



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BOOKS BECEIYED. 317

Transactions of the American Gynecological Society. Volume
XVII. For the year 1892. Edited by Henry Clark Coe. M. D.,
Secretary. Small octavo, pp. xxxix. — 498. Philadelphia : Wil-
liam J. Dornan, Printer. 1892.

This handsome volume appears each year with a regularity and
precision that is commendable. It also each year — and the present
one is no exception — contains much valuable literature pertaining to
the diseases of women. No specialist can afford to do without
the book, and no student of gynecology should deny himself the
privilege of its possession.

Operation Blanks. Second edition. Prepared by W. W. Keen, M. D.,
Professor of the Principles of Surgery in the Jefferson Medical
CoUege, Philadelphia.

This blank contains useful memoranda for physician and nurse,
in making preparations for an operation. The fact that a second
edition has been called for, within a short time, indicates the popu-
larity of the method, and we especially commend it to surgeons
and gynecologists who are obliged to invoke the aid of assistants in
some of the preparations for their work.



BOOKS RECEIVED.

A Text-Book of Physiological Chemistry. By Olof Hammarsten,
Professor of Medical and Physiological Chemistry in the University of
Upsala. Authorized translation from the second Swedish edition, and
from the author's enlarged and revised German edition. By John A.
Mandel, Assistant to the Chair of Chemistry, etc., in the Belle vue
Hospital Medical College, and in the College of the City of New York.
First edition ; firstthousand. Octavo ; cloth, pp. x. — 511, $4.00 New
York : John Wiley & Sons, 63 East Tenth Street. 1893.

A Manual for Boards of Health and Health Officers. By Licwis
Balch, M. D., Ph. D., Secretary State Board of Health of New York ;
Health Officer of Albany ; Emeritus Professor of Anatomy and Profes-
sor of Medical Jurisprudence Albany Medical College. Pp. 242.
Albany, N. Y.: Banks & Bros. 1893.

The Principles and Practice of Surgery. By John Ashhurst, Jr.,
M. D., Barton Professor of Surgery and Clinical Surgery in the Uni-
versity of Pennsylvania ; Surgeon to the Pennsylvania Hospital, Phila-
delphia. New (sixth) edition, enlarged and thoroughly revised. In
one octavo volume of 1,161 pages, with 656 engravings and a colored
plate. Cloth, $6.00; leather, $7.00. Philadelphia: Lea Bros.
A Co. 1893.

Duane^s Students^ Dictionary of Medicine. The Students^ Diction-
ary of Medicine and the Allied Sciences. Comprising the pronuncia-
tion, derivation and full explanation of medical terms, together with
much collateral descriptive matter, numerous tables, etc. By Alex-



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318 BOOKS BBCEIVBD.

ander Duane, M. D., Assistant Surgeon to the New York Ophthalmic
and Aural Institute ; Reviser of Medical Terms for Webster^ s Interna-
tional Dictionary. In one square octavo volume of 658 pages. Cloth,
(4.25 ; half leather, $4.50 ; full sheep, $5.00. Philadelphia : Lea
Bros. & Co. 1893.

Chemistry and Physics. By Joseph Struthers, Ph. B., Columbia
College School of Mines, New York ; D. W. Ward, Ph. B., Columbia
College School of Mines, New York, and Charles H. Willmarth, M. S.,
New York. $1.00. The Students' Quiz Series. Philadelphia: Lea
Bros. & Co. 1893.

A Practical Treatise on Diseases of the Skin. For the use of stu-
dents and practitioners. By J. Nevins Hyde, A. M., M. D., Professor
of Dermatology and Venereal Diseases in Rush Medical College, Chi-
cago. New (third) edition. In one octavo volume of 802 pages, with
nine plates, of which three are colored, and 108 engravings. Cloth,
$5.00 ; leather, $6.00. Philadelphia : Lea Bros. & Co. 1893.

A System of Grenito-Urinary Diseases, Syphilology and Dermatology,
by various authors. Edited by Prince A. Morrow, A. M., M. D., Clini-
cal Professor of Genito-Urinary Diseases ; formerly Lecturer on Der-
matology in the University of the City of New York ; Surgeon to the
Charity Hospital, etc. With illustrations. In three large 8vo vol-
umes. Volume II., Syphilology. Pp. xviii. — 917. Sold only by sub-
scription.

Transactions of the An^rican Surgical Association. Volume XI.
Edited by DeForest Willard, M. D., Recorder of the Association.
Philadelphia : Printed for the Association, and for sale by William J.
Doman. 1893.

International Clinics. A Quarterly of Clinical Lectures on Medi-
cine, Neurology, Pediatrics, Surgery, Genito-Urinary Surgery, Gyne-
cology, Ophthalmology, Laryngology, Otology, and Dermatology. By
professors and lecturers in the leading medical colleges of the United
States, Great Britain, and Canada. Edited by John M. Keating, M. D.,
LL.D., Colorado Springs, Col.; Fellow of College of Physicians, Phila-
delphia ; formerly Consulting Physician for Diseases of Women to St.
Agnes^ Hospital ; Gynecologist to St. Joseph^ s Hospital ; Visiting
Obstetrician to the Philadelphia Hospital, and Lecturer on Diseases of
Women and Children, Philadelphia ; Editor Cyclopedia of the Diseases
of Children. Judson Daland. M. D., Philadelphia, Instructor in Clinical
Medicine, and Lecturer on Physical Diagnosis and Symptomatology in
the University of Pennsylvania ; Assistant Physician to the University
Hospital ; Physician to the Philadelphia Hospital and to the Rush
Hospital for Consumption. J. Mitchell Bruce, M. D., F. R. C. P., Lon-
don, England, Physician and Lecturer on Therapeutics at the Charing
Cross Hospital. David W. Finlay. M. D.. F. R. C. P., Aberdeen,
Scotland, Professor of Practice of Medicine in the University of Aber-
deen ; Physician to, and Lecturer on, Clinical Medicine in the Aberdeen
Royal Infirmary; Consulting Physician to the Royal Hospital for
Diseases of the Chest, London. Volume III. Third series. Royal
octavo, pp. xii. — 356. Philadelphia : J. B. Lippincott Co. 1893.

United States Department of Agriculture. Weather Bureau Cur-
rent Chart of the Great Lakes. By Mark W. Harrington, Chief of
Weather Bureau, Washington, D. C. 1893.



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LITBBARY NOTES. 819



Amebican Text-Book of Gynecology. — Mr. W. B. Saunders^
publisher, of Philadelphia, Pa., announces this work as ready for
early issue. It is the joint production of Drs. Howard Eelley, Pry or,
Byford, Baldy, Tuttle, and others who stand before the profession
for all that is progressive in gynecology. The work will contain
operations not before described in any other book — notably, abla^
tion of fibroid uterus. It is designed as a profusely illustrated
reference book for the practitioner, and every practical detail of
treatment is precisely stated.



Mask Twain's Latest — Romance op an Esquimau Maiden. —
A magazine is usually satisfied with one strong feature for the
month. The CosmopoHtany however, presents for November no
less than five very unusual ones. William Dean Howells gives
the first of the letters of the traveler, who has been visiting this
country, from Altruria. We have read Mr. Howell's impression
of the Altrurian ; but in this first letter we have the Altrurian's
impressions of New York, with some comments upon our govern-
ment and society, calculated to awaken the most conservative
minds. The second feature of Th€ Cosmopolitan is the portion
of the magazine given up to color work, no less than ten superb
color illustrations being presented for the first time in magazine
history, accompanying an article by Mrs. Roger A. Pryor on
Changes in Women's Costumes. The third feature is American
Notes, by Walter Besant, who was recently in America, and is
doing the United States for The Cosmopolitan^ a la Dickens. The
fourth feature is an article by General Badeau on The Forms of
Invitation Used by the English Nobility. The article is illustrated
by the facsimile of cards to the Queen's drawing-room, to dinner
at the Princess of Wales, and to many leading houses of England.
Finally, we have a new and very curious story by Mark Twain,
called The Esquimau Maiden's Romance. It is in his happiest
vein, and is illustrated by Dan Beard. The November number
presents the work of many artists, among whom are : C. S. Rein-
hart, Otto Guillonnet, J. H. Harper, 6. Hudson, Franz von Len-
bach, George Wharton Edwards, F. Schuyler Matthews, Dan
Beard, W. L. SonUg, Jr., F. G. Attwood, C. Hirschberg, J. Haber^
Dys, August Franzen, Louis J. Read, J. N. Hutchins, and HamiU
ton Gibson.



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320 MISCELLANY.

Sousa's new march, The Manhattan Beach March, has been pur-
chased by The Ladies* Home Journal^ and its full piano score will
be printed in the Christmas issue. The composer claims for it a
superiority over either his popular Washington Post or High
School Cadets marches.



Mii^cdPPar^.



The Health Commissioner of Buffalo, Dr. Ernest Wende, has
issued the following circular to the members of the medical pro-
fession :

Hereafter membranous croup and diphtheritic croup will be
considered identical to diphtheria by this department, and physi-
cians will be required to report all cases at once by telephone. In
^ase of death, funerals must be private, and take place within
twenty-four hours.

Report all cases of whooping-cough.

Physicians are not permitted to remove placards. Whenever
the case has recovered (and desquamation ended), so that all danger
from contagion or infection has passed, and thorough disinfection
has been exercised, this department will cause the removal of the
placard upon the request of the attending physician and his state-
ment to the above effect.

Attention is called to Chapter XIV., Section 108, of the City
Ordinances, by which pupils are excluded from school as follows :

Scarlet Fever — Three weeks from the last case in dwelling.

Measles — Two weeks from the last case in dwelling.

Diphtheria — One week from the last case in dwelling.

Physicians are requested to be as explicit as possible in filling
out birth and death certificates, so that the records of the registrar
may contain all necessary data.

The hearty co5peration of the profession is desired, so that the
efficiency of this department may be brought to the highest
standard.



Notice to Contributoks. — We are glad to receive contributions
from every one who knows anything of interest to the profession. Arti-
cles designed for publication in the Journal should be handed in before
the first day of the month. The Editors are not responsible for the
views or opinions of contributors. All communications should be
addressed to the Managing Editor, 284 Franklin St., Buffalo, N. Y.



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Buffalo Medical 1^ Surgical Journal

Vol. XXXIV. JANUARY, 1894. No. 6.

©rigiaaf (ifonnnnumcatlioru&.



EMPYEMA.^

Bt JOHN PARMENTER, M. D.,

Professor of Anatomy and Adjunct Professor of Clinical SnrKery, Medical Department,
UniverBity of Buffalo ; Surgeon to Fitch and Children's Hospitals ; Assistant Sur-
geon to Buffalo General Hospital ; Fellow of the American Surgical
Association, etc.

OuB ideas of empyema have undergone much change in the last
few years, in that we now appreciate, as we did not formerly, how
many and yaried are the etiological factors which produce this
disease. This change is due, in large part, to bacteriological
investigation and its lessons, with the result that we now have a
yery clear and probably definite understanding of the pathology
of empyema. Fluid within the pleural cayity may become puru<
lent from either direct or indirect infection, and right here it will
be timely to adopt a classification of purulent pleurisies based upon
etiological considerations, and that of Courtois-Suffit is, it seems to
me, the completest and the simplest of any yet offered. He divides
purulent pleurisies into two distinct groups, viz., pure and mixed
forms. In the pure forms only a single microbe is the active
agent, and this may be an ordinary pus-producing microbe, or it
may be a specific microbe which is accidentally pyogenetic in
character. In the mixed forms two or more kinds of microbes
have invaded the pleural cavity, either simultaneously or in suc-
cession.

Pure Forms of Empyema, — 1. Empyema from the pneumocoo-
cus. This forms about twenty-five per cent, of purulent pleurisies
(fif{y per cent, in childhood). Inasmuch as the pneumococcus
exists normally in various cavities, it can be the cause of anempy*



1. Read before the Section of Surgery, Buffalo Academy of MedioinCf NoveQiber 7,
1808.



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322 % PABMBNTEB : EMPYEMA.

ema withoat a preceding pneumonia. In fact, the pneamococcua
may cause abscess in various places in the human body.

2. Empyema from the streptococcus. This microbe is the
common agent in suppuration, and as it exists normally in the
body cavities and all around us, it is no wonder that it can occa-
sion an empyema. This it does do, however, not usually primarily,
but rather in the course of infectious diseases not due to the strep-
tococcus itself, such as scarlatina or grip. Here, as elsewhere, the
streptococcus varies in activity and virulence. It seems to reach
the pleura through the lymphatics after having been developed in
parts more or less remote.

3. Empyema from the bacillus tuberculosis. Effusions due to
the bacillus tuberculosis are usually serous in character, — at least
in the beginning. The change to a purulent effusion, as seen in
cases where repeated aspiration has been made, is explained by
infection of the tubercular foci with pus microbes, and their
introduction into a cavity already changed by disease, and in this
way changes the type of inflammation and the character of the
effusion. Very often the bacillus tuberculosis cannot be discovered,
(Ehrlich notwithstanding, he claiming that it can be demon-
strated in all cases,) but the pus is highly infective. Therefore,
while the presence of the bacillus is conclusive of the tubercular
nature of the effusion, its absence does not have any significance.
Tubercular pus does not easily putrefy, and in this particular
differs from that of the other forms.

4. Empyema due to the encapsulated bacillus of FriedlUnder,
and to the typhoid bacillus of Eberth. These forms are very
rare.

Mixed Forms of Empyema. - ^ 1. Empyema due to the pneumor
coccus and the streptococcus together. In these cases we have a
preceding pneumonia, followed by pulmonary suppuration due to
the streptococcus.

2. Empyema due to the typhoid bacillus and the streptococ-
cus. Here, again, the streptococcus causes secondary infection.

3. Empyema due to the bacillus tuberculosis and the strepto->
coccus, or the staphylococcus, or both together. Such forms are
seen where a cavity has ruptured into the pleural space, and the
pleura has become directly infected. In these cases even the
tubercle bacilli can only occasionally be found.

4. Empyema, putrid or gangrenous. In addition to the
streptococcus and the staphylococcus, the micro()rganisms of



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PABMENTEB : SMPTEMA. 323

putrefaction are active agents in producing this form of empyema.
These latter organisms enter through the respiratory passages and
the parenchyma of the lung, and feed on the products of coagula-
tion necrosis. Usually, this occurs in a sub-plenral portion of the
lung in or about one of the fissures between the lobes of the lung.
These saprophytic bacilli may, however, be introduced during
aspiration, the wound having become septic. In these cases the
pus is extremely fetid, thin, and contains large shreds of fibrin.
The symptoms are always severe.

ZHfferentiation of the Various Forms of Empyema. — Can
these various forms be differentiated ? Is it necessary or desirable
to do so ? In answer to the first question, it must be confessed at
the outset that reliance upon so-called clinical symptoms alone is
apt to be misleading, and that bacteriological investigation can
alone determine conclusively the nature of the disease. (The pos-
sible exception of tubercular empyema must here be noted.) How-
ever, certain symptoms are significant. For example, given a case
occurring in youth and following a pneumonia, and in which the
symptoms are moderate, with a more or less even range of temper-
ature, the probabilities are in favor of such an empyema being
due to the pnenmococcus. Again, empyema due to the strepto-
coccus and the mixed forms of the same, are consequent upon
diseases such as scarlatina, grippe, typhoid fever, and the like.
They form the great bulk of purulent pleurisies in adult life and
advanced childhood. Finally, tubercular empyema is the typical
latent purulent pleurisy. There may be no febrile reaction, and
the chest be very full of fluid. In these cases we find the pleura,
oftentimes, very much thickened, and the lung in an atalectatic
condition, as seen after operation. Family history is, of course,
significant. To resume, then, while we may find symptoms afford-
ing some clue to the causation of an empyema, we can only be
certain when such symptoms are corroborated by the results of a
bacteriological examination. To the second question it may be
replied, that it is always well to cultivate the power to interpret
clinical manifestations fully and accurately, and particularly for
those who have neither the skill nor the facilities for using bacteri-
ology as an adjuvant in diagnosis. Furthermore, our haste to
afford relief is measured, in part, by the nature of the cases ; thus
empyema from the streptococcus, or putrid, purulent pleurisy,
demands speedy and energetic treatment in the former cases
usually, in the latter, invariably.



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324 PARMENTEB : BMPTEMA.

Diagnosis, — It wonld seem that physical diagnosis had become
sufficiently deyeloped and diffused among practitioners to insure a
fairly accurate estimate of the nature of the commoner forms of
thoracic disease, and yet empyema, in its most typical and
pronounced form, is constantly overlooked or misinterpreted.
The following remarks of DaCosta are full of truth and wis-
dom :

Were the chest more often carefully explored, we should cease to
hear of patients, whose pleural cavity is full of pus, being pronounced
incurable consumptives because they are emaciating and have hectic
fever and clubbed nails ; or being treated for disease of the heart, on
account of displacement of that organ, and of dyspnea and edema ; or
being dosed with mercury for an imaginary disorder of the liver ; or
being subjected to long courses of quinia and arsenic to check a rebel-
lious ague, which the chilly sensations and paroxysms of fever at times
simulate.

I have seen the disease mistaken for every one of those DaCosta
enumerates. I recall, particularly, one case in which the diagnosis
was made of neuralgia of the liver, and that, too, by a practitioner
of good average ability, who had evidently been misled by the fact
that the pain was over the liver, and that a normal temperature
existed, and yet I withdrew five quarts (by careful measurement)
of pus from her right pleural cavity. Equally glaring mistakes
have, doubtless, been noted by many who have seen cases as coun-
sel. Such being the case, we should learn carefully the signs which
indicate pleural effusion. The classification of signs as given by
Powell seems to me good. It is :

1. Cardinal signs :

(a) Percussion dulness ; {b) displacement of the heart ; (c)
annulled vocal fremitus ; (d) diminished and altered or absent
breath sound.

2. Subordinate or supplementary signs :

(a) Increased semi-circumference of chest ; {h) intercostal bulg-
ing, elasticity or fluctuation ; (c) skodaic resonance ; {d) altered
voice sound ; (e) displacement of abdominal viscera ; (f) signs in
the other lung ; [g) cardiac displacement bruits.

8. Signs indicative of nature of fluid :

(a) Pectoriloquie aphonique (Bacelli) ; {b) temperature signs ;
(c) other pyrexial or septic phenomena.

The presence of the cardinal signs is alone necessary for diag-
nosis. They are common to both serous and purulent effusions.



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PABliSNTEB : EMPYEMA. 325

The subordinate signs are not essential for diagnosis, and any
or all of them may be wanting.

A few words aboat some of the more important of the signs :

Dulness, — The dulness is absolute and toneless. It is flatness.
Its limits are determined by light percussion, thus avoiding the
resonance of contiguous parts. These limits, of course, vary with
the amount of the effusion. When moderate, there is usually a
triangular space of resonance in the upper part of the thoracic
cavity, the apex of the triangle being at the stern o-clavicular joint,
and the upper level of the effusion, instead of being a water level,
is a slanting line, which, beginning at the sternal border, runs
gradually upward and across the chest, to reach its highest level
in the axillary line, where it begins to descend in its course across
the posterior portion of the cavity, in a line similar to and slightly
lower than anteriorly. When the effusion is extreme, flatness is,
of course, universal. The lower limit of the effusion, where the
same is even considerable, corresponds with the arch of the dia-
phragm, which is still preserved.

Displacement of Heart toward the Sound Side, — This sign
must always be present, except in rare cases where the heart *has
become fixed by adhesions of the pericardium, consolidation of
the opposite lung, etc. It occurs immediately^, and keeps pace
with the effusion. It is sometimes difficult to fix the exact loca-
tion of the heart, but this can usually be done by percussion and
ausculation.

Absence of Vocal Fremitits, — This is due to the presence of
the fluid between the lung and the chest wall. This fluid is a bad
conductor. To determine this sign, light palpation should be
employed, using the finger tips only to better exclude vibrations
from neighboring parts.

Absence of Breath Sounds, — While this sign may be, and
usually is, a very significant one, it may be wanting, or, to put it
in another way, the breath sounds may be present and a large
effusion as well. When present, they may closely resemble those
of pneumonia. Voice sounds, as well, may be conducted over the
whole side, and whispering exaggerated even to pectoriloquy,
according to Powell.

Subordinate or supplementary signs :

Increased Semi-circumference of the Chest, — Although the
chest generally looks larger on the affected side, there may be lit-
tle or no difference to actual measurement. The relative enlarge-



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326 PABMENTBB : BBCPYEMA.

ment, when present, is increased during deep expiration. It must
be remembered, however, that the total circumference is always
increased in effusion. When the affected side is markedly larger
than the sound, it denotes a large effusion. The shape is changed,
the cystometer showing it to be more rounded.

Intercostal Fulnesa or Fluctuation, — This is an inconstant
sign, more often found in children than in adults. It is more com-
mon in purulent than in serous effusions.

Egophony occurs very often in pleural effusions, and is chiefly
of use in differentiating this condition from consolidation, which
so often have a resemblance to each other.

Skodaic Mesonance. — This sign is of value as an index of the
pressure within the thorax and of the advisability of operative
interference. When the pleural cavity is completely filled with
fluid, skodaic resonance is, of course, abolished.

Displacement of Abdominal Viscera. — This sign occurs late



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 33 of 78)