- Email: [email protected]
Empyema in Enteric Fever Due to Salmonella Paratyphi B
72
ANNAMALAI ET AL Table l.-Dsy.en Te...ion and Saturadon Meaureme,.,. of Pulmonary Am,.,. Blood Sam""
Sample Site Medial branch apical segmental artery Lateral branch apical segmental artery Right main pulmonary artery
pO! mmHg
SaO!
60.3
89.8
59.7 38.1 35.8
89.7 72.2 68.9
%
expected, although we and others have noted retrograde How in lungs with extensive tuberculosis. U The evidence for reversal of How consists of: (I) motion pictures and serial x-ray films showing backward How of contrast material injected into branches of the apical segmental artery; (2) the failure of the apical segmental artery to fill when a right pulmonary angiogram was performed; (3) the finding that blood from the apical segmental artery had a higher oxygen tension than blood from the main pulmonary artery. The motion pictures were particularly convincing in demonstrating the abnormal hemodynamics for they show persistence of contrast material in the apical segmental artery for long periods, persistence of dye in the smaller vessels (see "dye" stain in Fig 3) and the backward How of contrast material which continued after injection has been completed. It is of interest to note that a routine film taken two and a half months before the lung abscess developed showed normal appearing lung tissue in the right apical area. It seems likely that the hemodynamic changes demonstrated occurred as a result of the severe inHammatory process. The finding of reversal of How strongly suggests that there was little if any respiratory function in this segment at the time of the study, and implies that a left-to-right shunt through the segment via the bronchial arterial system was present. An important point illustrated by this case is that failure to fill a segmental artery dUring infection of contrast material into the main pulmonary artery, does not necessarily indicate that the vessel is obstructed. Failure to fill may be due to reoersal of blood flow in the vessel. This case suggests that when significant parenchymal lung disease is present, reversal of blood How in the segmental artery can occur in a short period of time. This possiblllty should be kept in mind when pulmonary angiograms and lung scans are being interpreted in cases where pulmonary embolism is suspected.
REFERENCES 1 BROCK, R. C.: The Anatomy of the Bronchial Tree with special reference to the surgery of lung abscess, Oxford University Press, New York (revised ed. 1954).
2 FOSTER-CARTER, A. F.: Broncho-pulmonary abnormalities, Brit. T. Tuberc. and Dis. Chest, 40:111, 1946. 3 BOYDEN, E. A.: Segmental Anatomy of the Lung. A Study of the Patterns of the Segmental Bronchi and Related Pulmonary Vessels, Blakiston Div., McGraw-Hill Book Co., Inc., New York, 1955. 4 VIOLA, A. R., Uco, A. V., VACCAREZZA, O. A., DIAz, G., AND VICARIO, D. J.: Pulmonary collateral circulation in chronic lung disease, T. Thorac. and Cardiooas. Surg., 46:232,1963. 5 KNIBBE, P., AND JOHNSTON, R. F.: Unpublished data. Reprint requests: Dr. Johnston, 230 North Broad Street, Philadelphia 19102
Empyema in Enteric Fever Due to Salmonella Paratyphi B* A. Annamalai, M.B.B.S., F.C.C.P., S. Shreekumar, M.B.B.S. and R. Muthukumaran, M.B.B.S.
SalmoneDa Paratyphi B is a rare cause of empyema. Empyema in enteric fever may be a primary manifestation of the bacteremic stage or may be secondary to a primary foens. The infection can spread from adjacent areas such as infected cartilage, rib, lung, liver, parasternal node and subdiaphragmatic abscess or from a distant site such as perforation of small intestine. As a presenting manifestation, empyema is easy to rec0gnize, bot when it is overshadowed by toxemia or complications, the diagnosis may be di8icult or missed. With chloramphenicol therapy the systemic manifestations abate bnt control of the effusion requires repeated aspiration, local instillation of chloramphenicol, steroids, proteolytic enzymes and sometimes open drainage. Fluid in the plenral space which is initially serons or serosangoineons becomes pnrulent later. Organisms isolated from the empyema fluid in an attennated fonn have a high antigenic potency.
Among the Salmonella organisms, S choleraesuis is known to produce pus in many locations including the pleural space. Typhoid fever causing pleurisy and empyema has been documented. S paratyphi B has been isolated in blood, urine, feces, joint fluid, bone marrow and thyroid. Herewith a case of empyema is reported where S pa.,.atyphi B was grown repeatedly from successive pleural aspirates. CASE REPORT
This 47-year-old plumber who had been in good health
previously entered the hospital for treatment of continuous fever of 15 days' duration. A week prior to admission he had pleural pain on the right side and progressive dyspnea. There was no known contact with tuberculosis and he had not beenimmunized against typhoid. On admission he was very ill. Physical examination revealed massive pleural effusion of the right side with no
°From the Department of Medicine, Madras Medical College and General Hospital, Madras, India.
DIS. CHEST, VOL. 55, NO.1, JANUARY 1969
EMPYEMA IN ENTERIC FEVER mediastinal shift. The liver was enlarged, soft, smooth, tender and palpable 3 em below the costal margin. There was no costochondral involvement. An x-ray film of the chest confirmed the presence of fluid in the right chest. To relieve distressing dyspnea approximately one liter of serosanguineous fluid was aspirated. Laboratory investigations: White cell count was 4,800 mm,3 polymorphonuclears 62, lymphocytes 35, eosinophils 3 percent. Erythrocyte sedimentation rate was 20 mm in one hour. Widal reaction: S typhi H, S typhi 0, S paratyphi A all gave negative results, 1 in 25. S paratyphi B was positive 1 in 1,300. Cultures of the blood, urine and motion aD proved sterile. From culture of pleural fluid, S paratyphi B was isolated on four occasions but the culture was negative for tubercle bacilli and other organisms. The patient was given chloramphenicol 250 mg orally every six hours. On two subsequent occasions about 400 ml of purulent fluid was withdrawn at weekly intervals from both of which S paratyphi B was isolated in culture. He became afebrile after taking 36 gm of chloramphenicol. Due to persistence of fluid in the right pleural cavity open drainage was instituted and S paratyphi B was grown from this fluid. Radiological examination seven weeks after admission showed thickening of the pleura. At follow-up examination after six months there was mildly impaired air entry about the right lung base and radiological examination showed minimal thickening of the pleura. DISCUSSION
Extraintestinal manifestations caused by the enteric group of organisms are more commonly due to S typhi than S paratyphi B. Although several papers have appeared on empyema caused by S typhi very few have been due to S paratyphi B. Though the clinical manifestations of S typhi and S paratyphi B diHer, their mode of entry, spread and some complications have much in common. Infections with S typhi cause a higher mortality than those with S paratyphi B. Most of the deaths in infections with S paratyphi B are due to complications. In 1884, Sahli recovered S typhi from the sputum and Thimm! in 1931 isolated S paratyphi from the same source. Frankel'' was one of the earliest to point out the pulmonary complications of typhoid fever. Stuart and Pullen" reviewing 360 cases of typhoid found that respiratory symptoms occurred in nearly half. Minchin! reviewing 444 cases of typhoid in Madras found that nearly a quarter had respiratory symptoms. A review of the pulmonary manifestations in typhoid shows that bronchitis is almost a constant feature of typhoid fever. In severe bronchitis blood streaking of the sputum or even frank hemoptysis has occurred. Bronchopneumonia and lobar pneumonia although rare have been reported with isolation of pneumococci alone or with S typhi in the sputum. Pulmonary infarction, osteochondritis and in moribund cases, lung abscess has been reported. The incidence of pleural effusion in DIS. CHEST, VOL. 55, NO.1, JANUARY 1969
73 typhoid is 0.5 percent to 7.5 percent and in CantegriI's series" has been about 2 percent. According to Correia and Finnoehiaro" the incidence of typhoid empyemata varies from 1 percent to 2 percent of the reported cases of exudative pleurisy. Mortality in typhoid empyemata has been estimated at 15 percent to 20 percent. 7 The pleura may be involved early in the baeteremic stage of the disease or later in the course of the illness from a primary focus. The primary focus may be an infected cartilage, rib, lung, liver, parasternal node or subdiaphragmatic abscess. When pleural involvement is a presenting symptom, it is easily recognized. If it is masked by the toxemic manifestations of the disease or by complications as lung abscess, liver abscess or intestinal perforation, diagnosis becomes difficult. Pleural pain associated with liver enlargement should make one suspicious of empyema. In the early stages liver enlargement is due to bacteremia. Organisms from the liver can spread to the pleura by contiguity or through lymphatics. Spread is more likely from widespread involvement of the liver in the bacteremic stage than from a localized lesion. The liver may be palpable due to enlargement in the bacteremic stage, liver abscess or by mechanical displacement. In enteric fever the spleen usually manifests greater enlargement than the liver but liver enlargement predominates in asplenism and in those cases associated with primary empyema like the present report. Liver abscess is a late complication and it can burst into the pleural cavity resulting in secondary empyema. In our patient early enlargement of the liver and its return to normal size before the empyema cleared up rules out liver abscess as well as displacement. Initial serosanguineous or hemorrhagic fluid becomes purulent," We found serosanguineous fluid in our patient at the first aspiration which on standing changed color to a greenish hue next moming. One wonders if serosanguineous fluid can change color on exposure to the atmosphere. In typhoid fever empyema, S typhi has been isolated alone or along with B COWl from the pleural fluid. Minor and White10 isolated S typhi and B coli from blood and pleural fluid simultaneously in another case. S paratyphi B has been isolated alone from empyema fluid and once along with streptoeocct.s Chloramphenicol administered to our patient did not make much impression upon the purulent effusion. This was evident from the repeated accumulation of the fluid, delayed recovery and the fact that the organism was repeatedly grown from successive pleural aspirates long after systemic administration of chloramphenicol had been commenced.
74
ANNAMALAI ET AL
Positive cultures from the empyema fluid without toxemic manifestations is probably due to the attenuated nature of the organism. The antigenicity of the attenuated organism is high. Is it worthwhile preparing vaccines from such organisms? Radiological examination after recovery of our patient shows evidence of thickened pleura. This can be avoided in the future by local instillation of chloramphenicol, steroids and proteolytic enzymes. ACKNOWLEDGMENT: Our thanks are due to The Dean, Madras Medical College and General Hospital, Madras for permission to publish this report, REFERENCES
1 THIMM, A.: Ein Fall von paratyphosem Lungenabszess, Med. Klin., 27:1069, 1931. Quoted by Minor and White-II 2 FRANJCEL. E. 1.: Zur Lehre von den Affectionen des Respirationsapparates beim Ileotyphus, Centralbl. f KUn. Med., 15:233, 1886. Quoted by Neva. 14 3 STUART, B. M., AND PuLLEN, R. L.: Typhoid: Clinical analysis of 306 cases, Arch. Intern. Med., 78:629, 1946. 4 MINCHIN, R. L. H.: Clinical and prognostic factors in typhoid in India, Indian Med. Gaz., 74:591, 1939. 5 CANTECRIL, E., AND RIEUNAN, G.: Les pleuresies de la flevre typhoide. Gaz. d. Hop., 105:851, 1932. Quoted by Minor and White. IO
6 CORREIA NETO, A., AND F1NNOCHIARO, J.: Empiema tifico (urn caso) operado e eurado, An. Paulist. de Med. Cir., 34:545, 1937. Quoted by Minor and White. 1O 7 JANDL, J.: Uber Typhusempyeme, Zbl. Chir., 64:254, 1937. Quoted by Minor and White. 10 8 ABRAM, J., AND GLYNN, E.: Paratyphoid infections of the pleura, Lancet, 2:283, 1919. 9 MACAIGNE, AND THERY.: Un cas de pleuresie typhoidique, Gaz. d. Hop., 86:2141, 1913. Quoted by Minor and White. 10 10 MINOR, G. R., AND WHITE, M. L., JR.: Some unusual thoracic complications of typhoid and Salmonella infections, Ann. Intern. Med., 24:27, 1946. 11 RAMACHANDRA RAo, N., AND SATTAR, A.: Typhoid pleural effusion, Indian ]. Chest Dis., 9:173, 1967. 12 ROBINSON, G.: The role of the typhoid bacillus in the pulmonary complications of typhoid fever, 1. Infect. tn«, 2:498, 1905. 13 VAN Ecx, E. A., AND BRAT, P.: The isolation of Salmonella species from clinical specimens not usually associated with a Salmonella aetiology, Indian I, Path. Bact., 4:70, 1961. 14 NEVA, F. A.: Pulmonary involvement in typhoid and paratyphoid fevers, Ann. Intern. Med., 33:83, 1950. 15 LANE, C. R. T.: Typhoid empyema 40 years after enteric fever, Lancet, 1:612, 1938. Reprint requests: Dr. Annamalai, 61 Poonamallee High Road, Madras 7, India
SHAKESPEARE IN MINIATURE Shakespeare is, above all writers, at least above all modem writers, the poet of nature, the poet that holds up to his readers a faithful mirror of manners and of life. His characters are not modified by the customs of particular places, unpractised by the rest of the world, by the peculiarities of studies of professions, which can operate but upon small numbers, or by the accident of transient fashions or temporary opinions; they are the genuine progeny of common humanity, such as the world will always supply and observation will always find. His persons act and speak by the influence of those general passions and principles by
which all minds are agitated and the whole system of life is continued in motion. In the writings of other poets a character is too often an individual; in those of Shakespeare it is commonly a species. It is from this wide extension of design that so much instruction is derived. It is this which fills the plays of Shakespeare with practical axioms and domestic wisdom. It was said of Euripides that every verse was a precept; and it may be said of Shakespeare that from his works may be collected a system of civil and economical prudence. Evans, B.: Johnson, Samuel: Essays, Northwestern University, Evanston, Illinois, 1940.
DIS. CHEST, VOL. 55, NO.1, JANUARY 1969
ANNAMALAI ET AL Table l.-Dsy.en Te...ion and Saturadon Meaureme,.,. of Pulmonary Am,.,. Blood Sam""
Sample Site Medial branch apical segmental artery Lateral branch apical segmental artery Right main pulmonary artery
pO! mmHg
SaO!
60.3
89.8
59.7 38.1 35.8
89.7 72.2 68.9
%
expected, although we and others have noted retrograde How in lungs with extensive tuberculosis. U The evidence for reversal of How consists of: (I) motion pictures and serial x-ray films showing backward How of contrast material injected into branches of the apical segmental artery; (2) the failure of the apical segmental artery to fill when a right pulmonary angiogram was performed; (3) the finding that blood from the apical segmental artery had a higher oxygen tension than blood from the main pulmonary artery. The motion pictures were particularly convincing in demonstrating the abnormal hemodynamics for they show persistence of contrast material in the apical segmental artery for long periods, persistence of dye in the smaller vessels (see "dye" stain in Fig 3) and the backward How of contrast material which continued after injection has been completed. It is of interest to note that a routine film taken two and a half months before the lung abscess developed showed normal appearing lung tissue in the right apical area. It seems likely that the hemodynamic changes demonstrated occurred as a result of the severe inHammatory process. The finding of reversal of How strongly suggests that there was little if any respiratory function in this segment at the time of the study, and implies that a left-to-right shunt through the segment via the bronchial arterial system was present. An important point illustrated by this case is that failure to fill a segmental artery dUring infection of contrast material into the main pulmonary artery, does not necessarily indicate that the vessel is obstructed. Failure to fill may be due to reoersal of blood flow in the vessel. This case suggests that when significant parenchymal lung disease is present, reversal of blood How in the segmental artery can occur in a short period of time. This possiblllty should be kept in mind when pulmonary angiograms and lung scans are being interpreted in cases where pulmonary embolism is suspected.
REFERENCES 1 BROCK, R. C.: The Anatomy of the Bronchial Tree with special reference to the surgery of lung abscess, Oxford University Press, New York (revised ed. 1954).
2 FOSTER-CARTER, A. F.: Broncho-pulmonary abnormalities, Brit. T. Tuberc. and Dis. Chest, 40:111, 1946. 3 BOYDEN, E. A.: Segmental Anatomy of the Lung. A Study of the Patterns of the Segmental Bronchi and Related Pulmonary Vessels, Blakiston Div., McGraw-Hill Book Co., Inc., New York, 1955. 4 VIOLA, A. R., Uco, A. V., VACCAREZZA, O. A., DIAz, G., AND VICARIO, D. J.: Pulmonary collateral circulation in chronic lung disease, T. Thorac. and Cardiooas. Surg., 46:232,1963. 5 KNIBBE, P., AND JOHNSTON, R. F.: Unpublished data. Reprint requests: Dr. Johnston, 230 North Broad Street, Philadelphia 19102
Empyema in Enteric Fever Due to Salmonella Paratyphi B* A. Annamalai, M.B.B.S., F.C.C.P., S. Shreekumar, M.B.B.S. and R. Muthukumaran, M.B.B.S.
SalmoneDa Paratyphi B is a rare cause of empyema. Empyema in enteric fever may be a primary manifestation of the bacteremic stage or may be secondary to a primary foens. The infection can spread from adjacent areas such as infected cartilage, rib, lung, liver, parasternal node and subdiaphragmatic abscess or from a distant site such as perforation of small intestine. As a presenting manifestation, empyema is easy to rec0gnize, bot when it is overshadowed by toxemia or complications, the diagnosis may be di8icult or missed. With chloramphenicol therapy the systemic manifestations abate bnt control of the effusion requires repeated aspiration, local instillation of chloramphenicol, steroids, proteolytic enzymes and sometimes open drainage. Fluid in the plenral space which is initially serons or serosangoineons becomes pnrulent later. Organisms isolated from the empyema fluid in an attennated fonn have a high antigenic potency.
Among the Salmonella organisms, S choleraesuis is known to produce pus in many locations including the pleural space. Typhoid fever causing pleurisy and empyema has been documented. S paratyphi B has been isolated in blood, urine, feces, joint fluid, bone marrow and thyroid. Herewith a case of empyema is reported where S pa.,.atyphi B was grown repeatedly from successive pleural aspirates. CASE REPORT
This 47-year-old plumber who had been in good health
previously entered the hospital for treatment of continuous fever of 15 days' duration. A week prior to admission he had pleural pain on the right side and progressive dyspnea. There was no known contact with tuberculosis and he had not beenimmunized against typhoid. On admission he was very ill. Physical examination revealed massive pleural effusion of the right side with no
°From the Department of Medicine, Madras Medical College and General Hospital, Madras, India.
DIS. CHEST, VOL. 55, NO.1, JANUARY 1969
EMPYEMA IN ENTERIC FEVER mediastinal shift. The liver was enlarged, soft, smooth, tender and palpable 3 em below the costal margin. There was no costochondral involvement. An x-ray film of the chest confirmed the presence of fluid in the right chest. To relieve distressing dyspnea approximately one liter of serosanguineous fluid was aspirated. Laboratory investigations: White cell count was 4,800 mm,3 polymorphonuclears 62, lymphocytes 35, eosinophils 3 percent. Erythrocyte sedimentation rate was 20 mm in one hour. Widal reaction: S typhi H, S typhi 0, S paratyphi A all gave negative results, 1 in 25. S paratyphi B was positive 1 in 1,300. Cultures of the blood, urine and motion aD proved sterile. From culture of pleural fluid, S paratyphi B was isolated on four occasions but the culture was negative for tubercle bacilli and other organisms. The patient was given chloramphenicol 250 mg orally every six hours. On two subsequent occasions about 400 ml of purulent fluid was withdrawn at weekly intervals from both of which S paratyphi B was isolated in culture. He became afebrile after taking 36 gm of chloramphenicol. Due to persistence of fluid in the right pleural cavity open drainage was instituted and S paratyphi B was grown from this fluid. Radiological examination seven weeks after admission showed thickening of the pleura. At follow-up examination after six months there was mildly impaired air entry about the right lung base and radiological examination showed minimal thickening of the pleura. DISCUSSION
Extraintestinal manifestations caused by the enteric group of organisms are more commonly due to S typhi than S paratyphi B. Although several papers have appeared on empyema caused by S typhi very few have been due to S paratyphi B. Though the clinical manifestations of S typhi and S paratyphi B diHer, their mode of entry, spread and some complications have much in common. Infections with S typhi cause a higher mortality than those with S paratyphi B. Most of the deaths in infections with S paratyphi B are due to complications. In 1884, Sahli recovered S typhi from the sputum and Thimm! in 1931 isolated S paratyphi from the same source. Frankel'' was one of the earliest to point out the pulmonary complications of typhoid fever. Stuart and Pullen" reviewing 360 cases of typhoid found that respiratory symptoms occurred in nearly half. Minchin! reviewing 444 cases of typhoid in Madras found that nearly a quarter had respiratory symptoms. A review of the pulmonary manifestations in typhoid shows that bronchitis is almost a constant feature of typhoid fever. In severe bronchitis blood streaking of the sputum or even frank hemoptysis has occurred. Bronchopneumonia and lobar pneumonia although rare have been reported with isolation of pneumococci alone or with S typhi in the sputum. Pulmonary infarction, osteochondritis and in moribund cases, lung abscess has been reported. The incidence of pleural effusion in DIS. CHEST, VOL. 55, NO.1, JANUARY 1969
73 typhoid is 0.5 percent to 7.5 percent and in CantegriI's series" has been about 2 percent. According to Correia and Finnoehiaro" the incidence of typhoid empyemata varies from 1 percent to 2 percent of the reported cases of exudative pleurisy. Mortality in typhoid empyemata has been estimated at 15 percent to 20 percent. 7 The pleura may be involved early in the baeteremic stage of the disease or later in the course of the illness from a primary focus. The primary focus may be an infected cartilage, rib, lung, liver, parasternal node or subdiaphragmatic abscess. When pleural involvement is a presenting symptom, it is easily recognized. If it is masked by the toxemic manifestations of the disease or by complications as lung abscess, liver abscess or intestinal perforation, diagnosis becomes difficult. Pleural pain associated with liver enlargement should make one suspicious of empyema. In the early stages liver enlargement is due to bacteremia. Organisms from the liver can spread to the pleura by contiguity or through lymphatics. Spread is more likely from widespread involvement of the liver in the bacteremic stage than from a localized lesion. The liver may be palpable due to enlargement in the bacteremic stage, liver abscess or by mechanical displacement. In enteric fever the spleen usually manifests greater enlargement than the liver but liver enlargement predominates in asplenism and in those cases associated with primary empyema like the present report. Liver abscess is a late complication and it can burst into the pleural cavity resulting in secondary empyema. In our patient early enlargement of the liver and its return to normal size before the empyema cleared up rules out liver abscess as well as displacement. Initial serosanguineous or hemorrhagic fluid becomes purulent," We found serosanguineous fluid in our patient at the first aspiration which on standing changed color to a greenish hue next moming. One wonders if serosanguineous fluid can change color on exposure to the atmosphere. In typhoid fever empyema, S typhi has been isolated alone or along with B COWl from the pleural fluid. Minor and White10 isolated S typhi and B coli from blood and pleural fluid simultaneously in another case. S paratyphi B has been isolated alone from empyema fluid and once along with streptoeocct.s Chloramphenicol administered to our patient did not make much impression upon the purulent effusion. This was evident from the repeated accumulation of the fluid, delayed recovery and the fact that the organism was repeatedly grown from successive pleural aspirates long after systemic administration of chloramphenicol had been commenced.
74
ANNAMALAI ET AL
Positive cultures from the empyema fluid without toxemic manifestations is probably due to the attenuated nature of the organism. The antigenicity of the attenuated organism is high. Is it worthwhile preparing vaccines from such organisms? Radiological examination after recovery of our patient shows evidence of thickened pleura. This can be avoided in the future by local instillation of chloramphenicol, steroids and proteolytic enzymes. ACKNOWLEDGMENT: Our thanks are due to The Dean, Madras Medical College and General Hospital, Madras for permission to publish this report, REFERENCES
1 THIMM, A.: Ein Fall von paratyphosem Lungenabszess, Med. Klin., 27:1069, 1931. Quoted by Minor and White-II 2 FRANJCEL. E. 1.: Zur Lehre von den Affectionen des Respirationsapparates beim Ileotyphus, Centralbl. f KUn. Med., 15:233, 1886. Quoted by Neva. 14 3 STUART, B. M., AND PuLLEN, R. L.: Typhoid: Clinical analysis of 306 cases, Arch. Intern. Med., 78:629, 1946. 4 MINCHIN, R. L. H.: Clinical and prognostic factors in typhoid in India, Indian Med. Gaz., 74:591, 1939. 5 CANTECRIL, E., AND RIEUNAN, G.: Les pleuresies de la flevre typhoide. Gaz. d. Hop., 105:851, 1932. Quoted by Minor and White. IO
6 CORREIA NETO, A., AND F1NNOCHIARO, J.: Empiema tifico (urn caso) operado e eurado, An. Paulist. de Med. Cir., 34:545, 1937. Quoted by Minor and White. 1O 7 JANDL, J.: Uber Typhusempyeme, Zbl. Chir., 64:254, 1937. Quoted by Minor and White. 10 8 ABRAM, J., AND GLYNN, E.: Paratyphoid infections of the pleura, Lancet, 2:283, 1919. 9 MACAIGNE, AND THERY.: Un cas de pleuresie typhoidique, Gaz. d. Hop., 86:2141, 1913. Quoted by Minor and White. 10 10 MINOR, G. R., AND WHITE, M. L., JR.: Some unusual thoracic complications of typhoid and Salmonella infections, Ann. Intern. Med., 24:27, 1946. 11 RAMACHANDRA RAo, N., AND SATTAR, A.: Typhoid pleural effusion, Indian ]. Chest Dis., 9:173, 1967. 12 ROBINSON, G.: The role of the typhoid bacillus in the pulmonary complications of typhoid fever, 1. Infect. tn«, 2:498, 1905. 13 VAN Ecx, E. A., AND BRAT, P.: The isolation of Salmonella species from clinical specimens not usually associated with a Salmonella aetiology, Indian I, Path. Bact., 4:70, 1961. 14 NEVA, F. A.: Pulmonary involvement in typhoid and paratyphoid fevers, Ann. Intern. Med., 33:83, 1950. 15 LANE, C. R. T.: Typhoid empyema 40 years after enteric fever, Lancet, 1:612, 1938. Reprint requests: Dr. Annamalai, 61 Poonamallee High Road, Madras 7, India
SHAKESPEARE IN MINIATURE Shakespeare is, above all writers, at least above all modem writers, the poet of nature, the poet that holds up to his readers a faithful mirror of manners and of life. His characters are not modified by the customs of particular places, unpractised by the rest of the world, by the peculiarities of studies of professions, which can operate but upon small numbers, or by the accident of transient fashions or temporary opinions; they are the genuine progeny of common humanity, such as the world will always supply and observation will always find. His persons act and speak by the influence of those general passions and principles by
which all minds are agitated and the whole system of life is continued in motion. In the writings of other poets a character is too often an individual; in those of Shakespeare it is commonly a species. It is from this wide extension of design that so much instruction is derived. It is this which fills the plays of Shakespeare with practical axioms and domestic wisdom. It was said of Euripides that every verse was a precept; and it may be said of Shakespeare that from his works may be collected a system of civil and economical prudence. Evans, B.: Johnson, Samuel: Essays, Northwestern University, Evanston, Illinois, 1940.
DIS. CHEST, VOL. 55, NO.1, JANUARY 1969