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LUNG PUNCTURE: A NEW APPLICATION OF CLINICAL PATHOLOGY.
disorders by buttermilk feeding and by the lacto-bacilline treatment shows that the diet is much more effective when
material obtained is no less valuable in the first than in the second of these two conditions.
starch or sugar is added to the diet. 11. —-ZKMMS. The general conclusions from the above observations afford for The indications lung puncture will vary somewhat and chemical support of the empirical use physiological with of the the desire physician for accurate knowledge of starch in infant feeding and may be summed up shortly as with to the condition of the patient. In brief, regard follows : 1. A diastasic ferment is secreted by the salivary it be said that is indicated : 1. In any the puncture glands and pancreas of new-born infants and even before casemayyielding signs of consolidation of the lung, in which birth. 2. Its amount and activity are slight in the first few careful examination of the sputum fails to reveal the nature 3. The weeks of life and after that rapidly increase. the value of "ocular of the disease. It is, perhaps, glands, notably the pancreas, can be trained by means of a demonstration" rather far to pushing that lung puncture is say the of an the secretion increased amount of starchy diet to indicated in a case of lobar pneumonia, even amylolytic ferment. There is no inherent reason why this when there isstraightforward But it should no sputum for examination. training should not be begun shortly after birth in the case certainly be undertaken in any such case if the desired of the bottle-fed infants instead of waiting until the child clinical course is departed from in any way to the prejudice has attained the age of six months, as so commonly advised of the patient. The puncture will frequently reveal the theoretical Practical has 4. on purely grounds. experience existence of a mixed infection (e.g., B. injlllenzae and pneushown that the usual barley water contains about 2 per cent. when this is not suspected. Two other indications of starch. If mixed with an equal quantity of milk there rnoco(J(YllS) In exist. 2. abscess it is useful to obtain a specimen of will only be 1 per cent. of starch in the mixture. Such an from the actual seat of suppuration, for thereby a knowpus amount is’non-injurious and almost certainly is beneficial, for of the causal microbe is gained, often a matter of it encourages the growth of lactic acid bacilli and the ledge or impossibility when dealing with the difficulty great formation of lactic acid. These organisms are of undoubted 3. In bronchiectases the same comment holds ; sputum. advantage in the prevention of the growth of proteolytic the flora of the sputum is notoriously varied and difficult of bacteria. 5. If a starchy food is used in the first few weeks of life it is advisable to begin with a milk mixture interpretation. III.—c/tMMe. which will not contain more than 0-5 per cent. of starch The mode of performing the puncture follows exactly and to gradually increase the amount as the child of exploration of the pleura. For obvious reasons gets older. Indeed, at any age when a starchy food that Provided is first given it should be in very weak solution and it is advisable to use a good-sized needle. the this be and suffers clean patient quite sharp very slowly strengthened up to as much as 3 to 5 per cent. little discomfort. And if due regard be had to the If the stools become very acid, or if they give a distinct starch reaction, the percentage of starch in the diet must anatomy of the heart, big vessels, and diaphragm no be reduced. 6. Special care must be paid to these con- damage is at all likely to occur. The syringe, of course, siderations in the first two months of life because of the has been recently boiled and contains no disinfectant. The at a point on the surface of the chest deficiency of salivary secretion. Further investigations may puncture is made over an area of lung yielding abnormal physical immediately show that this is a of little as the point possibly importance The needle is inserted into the lung, the piston is pancreatic secretion may be sufficient in quantity and signs. withdrawn about an inch so as to keep up a gentle suction, activity. 7. The evil effects of starch in early life are due to (a) excess; (b) its administration in the form of a more and the needle is then slowly removed whilst the skin is As the or less insoluble emulsion instead of as soluble starch ; ’, supported by the finger and thumb of the left hand. and (e) the substitution of starch for the necessary protein, needle leaves the chest wall two or three drops of bloody fat, and salts. In other words, the mischief results from fluid are seen to spurt from it into the barrel of the syringe. The method of dealing with the material depends somedeficiency of necessary proximate principles of diet rather what upon the amount obtained. Sometimes the amount is than from the presence of starch. so small that it is advisable to utilise the whole of it for Upper Brook-street, W. purposes of cultivation of micro-organisms, the method resolving itself into one of "lung culture." If, however, the quantity admits of this, or if a cytological, rather than a LUNG PUNCTURE: A NEW APPLICATION bacteriological, examination is suggested from the nature of the patient’s illness, films are also prepared from the material OF CLINICAL PATHOLOGY. and stained as in the case of pus. In either case the needle BY THOMAS J. HORDER, M.D. LOND., F.R.C.P. LOND., is inserted into a little sterile salt solution, just sufficient of PHYSICIAN TO THE GREAT NORTHERN CENTRAL HOSPITAL; MEDICAL which is drawn up into the barrel to mix with the lung REGISTRAR TO ST. BARTHOLOMEW’S HOSPITAL. juice, and to enable this to be completely discharged. If a bacteriological examination only be decided upon the diluting fluid may well be a little sterile broth from a I.-General. The mixture of lung juice and diluting culture tube. PUNCTURE of the pleura has long been practised as fluid is now squirted out, partly on a glass slide for film For many years before the a valuable aid to diagnosis. examination and partly on to the surface of an agar slope, birth of bacteriology the procedure yielded important which is incubated at 37 -50 C. As the material removed knowledge. But prior to the advent of the bacterio- from the lung is almost certain to contain a little blood, even logist a "dry"puncture of the chest wall was wholly microbes, such as B. influenz6e, need no other negative in its information. The needle either entered bsemophilous medium than ordinary agar. If the latter, a pleural effusion or it entered the lung. cases. IV.-lll1lstrative small amount fluid which was the very of blood-stained The following cases demonstrate the assistance in brought away by the syringe was neglected. And even to-day it is the rule for this valuable material to be put aside diagnosis and treatment afforded by lung puncture. without examination. As a matter of fact, these few drops CASE 1. Abscess of lung following perforated d?t,(,denaZ of lung juice may yield very important positive information ulcer.-The patient was an International football player, as to the presence of disease within the lung itself and also under the care of Mr. C. M. Hewer of Tarporley, who as to the nature of such disease. During the past four or diagnosed perforation of a duodenal ulcer. The perforation five years I have every now and again employed this method was sutured by Mr. G. P. Newbolt of Liverpool. A week of investigation with extremely useful and interesting results. after the operation signs of pleurisy developed at the base As I can find no reference to such an application of clinical of the right lung, with fever and severe illness. Percussion pathology 1 have thought it well to collect such observations dulness followed at the seat of the pleurisy, but exploration as I have been able to make with regard to it. of the pleura by needles was negative. When I saw the In actual practice a diagnostic puncture of the lung may patient with Mr. Hewer there were marked signs of conbe made under two conditions: (1) a pleural effusion is solidation of the lung, high fever with sweats, intermitting suspected and the result of the puncture negatives this ; or and dilated heart. The condition of the abdomen was satis(2) no fluid is suspected in the pleural sac, but the lung is factory. Four separate punctures with a good-sized needle deliberately punctured for the express purpose of discovering failed to show fluid in the pleura. The lung juice obtained the nature of a disease process within the lung itself. The at the last puncture, however, was dealt with as above
some
1346 on the next morning there was seen to be a A pseudo-crisis occurred on the seventh day, but the temperaand pure growth of streptococcus on the agar slope. ture rose again on the same day, and the signs of consolidaOn the twenty-third day the On further examination the streptococcus was found to be tion remained unchanged. S. fcacalis. Polyvalent anti-streptococcus serum was given temperature was still raised, in an intermittent fashion, and liberally and undoubted benefit resulted. The consolidated the physical signs, as well as a skiagram, showed the lung lung then underwent liquefaction, and large quantities of to be still hepatised. The leucocyte count was 20,000. very foetid pus were expectorated, as much as 1 pints in the Examination of the sputum showed no tubercle bacilli. The day. But the acute and alarming symptoms had passed off. solid lung was punctured, and the blood-stained fluid was Vigorous treatment in the open air, with respiratory anti- submitted to culture. The agar tubes remained sterile. By septics by the mouth and by inhalation, led to complete the twenty-sixth day the temperature was normal and the recovery.1 In this case the lung puncture was not per- general condition was excellent. Injections of fibrolysin formed deliberately but during the search for an empyema. were given ; the patient left the hospital in good health but But the important information obtained from the examina- with the lung still solid. tion of the lung juice in this instance, proving as it did the V. Conclusion. presence of a pulmonary focus of infection by streptococci I have Altogether punctured the lung for diagnostic derived from the bowel, led me to employ the method Those above cited serve to show in some 14 cases. directly in other cases where there was doubt as to the purposes the kind of information that can be elicited by this mode of nature of the disease in the lung. examination. It may possibly be found of service in sus. CASE 2. Abscess of lung following inoomplete abortion.-A pected cases of acute pulmonary tuberculosis, in which conwoman, aged 30 years, came under observation 14 days after dition sputum is so commonly absent. In one such case I a miscarriage, suffering from fever, rigors, acasmia, and the affected lung, but failed to demonstrate the punctured shortness of breath. The uterus was curetted and treated tubercle bacillus in films prepared from the material with antiseptics without improvement. A week later signs of obtained. At a time when vaccine therapy appears to be so consolidation appeared at the base of the right lung in front, in dealing with many localised infective conditions promising with local pain and cough. There was no sputum. Exploratory the prompt isolation of the causal micro-organism becomes puncture of the lung drew off two or three drops of blood- a point of paramount importance. When the affected organ stained pus, and these yielded a pure culture of Staphylo- is the lung the particular investigation here referred to may The signs persisted and the patient grew be the sole means of coccus aureus. obtaining the necessary culture from worse. An operation was advised, but it was considered that which to the vaccine. prepare the indications for resection of a rib and exploration of Harley-street, W. Death occurred a week after the lung were insufficient. the puncture was made. Post-mortem examination showed an abscess situated in the right lower lobe of the lung close THE DYSPEPSIA OF OLD AGE. to the pleura. The pus from the abscess gave a pure culture BY W. SOLTAU FENWICK, M.D. LOND., of S. aureus. SENIOR PHYSICIAN, THE LONDON TEMPERANCE HOSPITAL. CASE 3.-Appendicectomy; general periConitis; pneumonia. -A child, aged 5 years, was admitted to the Great Northern Central Hospital under the care of Mr. E. C. Stabb. LaparAFTER 65 years of age functional disorders of digestion otomy revealed a gangrenous appendix, which was removed. become extremely common, and even when no abnormal The child did very well until the tenth day, when signs of symptoms exist old people usually suffer from an enfeebled peritonitis and pneumonia appeared. Puncture of the lung or capricious appetite and find that they can only avoid was undertaken, and a few drops of bloody fluid were indigestion by the observance of a limited dietary. As the obtained which gave a copious growth of pne1tmooooai, result of a laborious statistical inquiry into the relative B. eoli, and B. injhtenzae. The proof of the mixed infection of of various forms frequency dyspepsia at different periods of the lung was very striking. A dose of pneumococcus of life, Samuel Fenwick found that 21 per cent. of all persons vaccine was given, but the child was obviously in a over 65 years of age suffered more or less from chronic desperate condition at the time and died four days later. indigestion. My own investigations, while generally conCAsE 4. Jlycosis f1tn,qoides,. streptooooooal and staphyl(). firming this estimate, have been more directly concerned with coccal infeotion of tlie skin; extensive pne1tmon’ia.-A man, the causation of the digestive complaints met with in aged 38 years, who had suffered for several years from advanced life, and seem to indicate that out of every recurring attacks of mycosis fungoides, came under observa- 100 cases of chronic dyspepsia in persons over 65 years tion with a large axillary abscess due to staphylococcus of age 66 are secondary to organic disease of some infection. There were also present several superficial foci of organ of the body, while the remaining 34 owe important streptococcal infection on the chest and limbs. The abscess their symptoms to a progressive degeneration of the was incised, scraped, and drained. A spreading pneumonia secretory structures of the stomach and intestines. In the developed, but whether this was streptococcal or staphylo- former class the disorder of digestion usually takes the coccal in origin was uncertain. Lung puncture gave a little form of a chronic gastritis due to disease of the kidneys, blood-stained fluid which both in films and on culture showed prostate gland, heart, lungs, liver, pancreas, chronic gout, abundance of ,Staph,ylocoocos aureits. Two small doses of the or inefficient mastication, while in about 7 of the 66 killed staphylococcus were given as vaccine, but the condi- cases, or in 10 ’ 6 per cent. of the entire number, longtion proved to be the usual mode of termination of this continued hypersecretion due to chronic ulcer in the uncommon skin disease. vicinity of the pylorus, gall-stones, or diseased appendix is CASE 5. Er,ysi,velas; bronollOpnt1tmonia.--An infant, aged the cause of the constant indigestion. The true dyspepsia 7 months, was admitted to the Great Northern Central of old age, which depends upon a series of retrograde Hospital under my care, suffering from extensive erysipelas changes in the alimentary tract, has hitherto received little of the scalp. Several small superficial abscesses developed, or no attention, and I am consequently obliged to rely upon and from these a pure culture of Streptooooous pyogenes was my own observations for the following notes upon the subject. obtained. The condition improved under treatment by antiPathology. streptococcus serum. There developed later several vesicles Some years ago, while pursuing with von Recklinghausen on the scalp, and from these a growth of S. aureus was obtained. Patches of consolidation also appeared in the a histological investigation of stomachs taken from persons lower lobe of the right lung. Puncture of one of these areas who had died from different complaints, I was much struck The infant was by certain morbid appearances presented by the organ in the revealed a pure staphylococcal infection. case of old persons who had died either from an accident or effect. but without good accordingly vaccinated, CASE 6. Delccyed mesolzcteon in pneumonia; negative lung some acute disease and in whom the other viscera of the .pil,,notitlre.-A young man, aged 20 years, was admitted to the body were quite healthy. Further investigations have fully Great Northern Central Hospital under my care on the second confirmed these earlier impressions, and it is now quite day of his illness, suffering from pneumonia, with consolida- certain that with advancing age a progressive degeneration tion of the right lower lobe and some associated bronchitis. affects the secretory structures of the entire digestive canal. Although after the age of 50 these changes are fairly careful examination will often detect their 1 This case was fully reported by Mr. Newbolt in the Liverpool constant, existence at a much earlier period, and in one instance Medico-Chirurgical Journal for January, 1907.
described, and
copious
-
material obtained is no less valuable in the first than in the second of these two conditions.
starch or sugar is added to the diet. 11. —-ZKMMS. The general conclusions from the above observations afford for The indications lung puncture will vary somewhat and chemical support of the empirical use physiological with of the the desire physician for accurate knowledge of starch in infant feeding and may be summed up shortly as with to the condition of the patient. In brief, regard follows : 1. A diastasic ferment is secreted by the salivary it be said that is indicated : 1. In any the puncture glands and pancreas of new-born infants and even before casemayyielding signs of consolidation of the lung, in which birth. 2. Its amount and activity are slight in the first few careful examination of the sputum fails to reveal the nature 3. The weeks of life and after that rapidly increase. the value of "ocular of the disease. It is, perhaps, glands, notably the pancreas, can be trained by means of a demonstration" rather far to pushing that lung puncture is say the of an the secretion increased amount of starchy diet to indicated in a case of lobar pneumonia, even amylolytic ferment. There is no inherent reason why this when there isstraightforward But it should no sputum for examination. training should not be begun shortly after birth in the case certainly be undertaken in any such case if the desired of the bottle-fed infants instead of waiting until the child clinical course is departed from in any way to the prejudice has attained the age of six months, as so commonly advised of the patient. The puncture will frequently reveal the theoretical Practical has 4. on purely grounds. experience existence of a mixed infection (e.g., B. injlllenzae and pneushown that the usual barley water contains about 2 per cent. when this is not suspected. Two other indications of starch. If mixed with an equal quantity of milk there rnoco(J(YllS) In exist. 2. abscess it is useful to obtain a specimen of will only be 1 per cent. of starch in the mixture. Such an from the actual seat of suppuration, for thereby a knowpus amount is’non-injurious and almost certainly is beneficial, for of the causal microbe is gained, often a matter of it encourages the growth of lactic acid bacilli and the ledge or impossibility when dealing with the difficulty great formation of lactic acid. These organisms are of undoubted 3. In bronchiectases the same comment holds ; sputum. advantage in the prevention of the growth of proteolytic the flora of the sputum is notoriously varied and difficult of bacteria. 5. If a starchy food is used in the first few weeks of life it is advisable to begin with a milk mixture interpretation. III.—c/tMMe. which will not contain more than 0-5 per cent. of starch The mode of performing the puncture follows exactly and to gradually increase the amount as the child of exploration of the pleura. For obvious reasons gets older. Indeed, at any age when a starchy food that Provided is first given it should be in very weak solution and it is advisable to use a good-sized needle. the this be and suffers clean patient quite sharp very slowly strengthened up to as much as 3 to 5 per cent. little discomfort. And if due regard be had to the If the stools become very acid, or if they give a distinct starch reaction, the percentage of starch in the diet must anatomy of the heart, big vessels, and diaphragm no be reduced. 6. Special care must be paid to these con- damage is at all likely to occur. The syringe, of course, siderations in the first two months of life because of the has been recently boiled and contains no disinfectant. The at a point on the surface of the chest deficiency of salivary secretion. Further investigations may puncture is made over an area of lung yielding abnormal physical immediately show that this is a of little as the point possibly importance The needle is inserted into the lung, the piston is pancreatic secretion may be sufficient in quantity and signs. withdrawn about an inch so as to keep up a gentle suction, activity. 7. The evil effects of starch in early life are due to (a) excess; (b) its administration in the form of a more and the needle is then slowly removed whilst the skin is As the or less insoluble emulsion instead of as soluble starch ; ’, supported by the finger and thumb of the left hand. and (e) the substitution of starch for the necessary protein, needle leaves the chest wall two or three drops of bloody fat, and salts. In other words, the mischief results from fluid are seen to spurt from it into the barrel of the syringe. The method of dealing with the material depends somedeficiency of necessary proximate principles of diet rather what upon the amount obtained. Sometimes the amount is than from the presence of starch. so small that it is advisable to utilise the whole of it for Upper Brook-street, W. purposes of cultivation of micro-organisms, the method resolving itself into one of "lung culture." If, however, the quantity admits of this, or if a cytological, rather than a LUNG PUNCTURE: A NEW APPLICATION bacteriological, examination is suggested from the nature of the patient’s illness, films are also prepared from the material OF CLINICAL PATHOLOGY. and stained as in the case of pus. In either case the needle BY THOMAS J. HORDER, M.D. LOND., F.R.C.P. LOND., is inserted into a little sterile salt solution, just sufficient of PHYSICIAN TO THE GREAT NORTHERN CENTRAL HOSPITAL; MEDICAL which is drawn up into the barrel to mix with the lung REGISTRAR TO ST. BARTHOLOMEW’S HOSPITAL. juice, and to enable this to be completely discharged. If a bacteriological examination only be decided upon the diluting fluid may well be a little sterile broth from a I.-General. The mixture of lung juice and diluting culture tube. PUNCTURE of the pleura has long been practised as fluid is now squirted out, partly on a glass slide for film For many years before the a valuable aid to diagnosis. examination and partly on to the surface of an agar slope, birth of bacteriology the procedure yielded important which is incubated at 37 -50 C. As the material removed knowledge. But prior to the advent of the bacterio- from the lung is almost certain to contain a little blood, even logist a "dry"puncture of the chest wall was wholly microbes, such as B. influenz6e, need no other negative in its information. The needle either entered bsemophilous medium than ordinary agar. If the latter, a pleural effusion or it entered the lung. cases. IV.-lll1lstrative small amount fluid which was the very of blood-stained The following cases demonstrate the assistance in brought away by the syringe was neglected. And even to-day it is the rule for this valuable material to be put aside diagnosis and treatment afforded by lung puncture. without examination. As a matter of fact, these few drops CASE 1. Abscess of lung following perforated d?t,(,denaZ of lung juice may yield very important positive information ulcer.-The patient was an International football player, as to the presence of disease within the lung itself and also under the care of Mr. C. M. Hewer of Tarporley, who as to the nature of such disease. During the past four or diagnosed perforation of a duodenal ulcer. The perforation five years I have every now and again employed this method was sutured by Mr. G. P. Newbolt of Liverpool. A week of investigation with extremely useful and interesting results. after the operation signs of pleurisy developed at the base As I can find no reference to such an application of clinical of the right lung, with fever and severe illness. Percussion pathology 1 have thought it well to collect such observations dulness followed at the seat of the pleurisy, but exploration as I have been able to make with regard to it. of the pleura by needles was negative. When I saw the In actual practice a diagnostic puncture of the lung may patient with Mr. Hewer there were marked signs of conbe made under two conditions: (1) a pleural effusion is solidation of the lung, high fever with sweats, intermitting suspected and the result of the puncture negatives this ; or and dilated heart. The condition of the abdomen was satis(2) no fluid is suspected in the pleural sac, but the lung is factory. Four separate punctures with a good-sized needle deliberately punctured for the express purpose of discovering failed to show fluid in the pleura. The lung juice obtained the nature of a disease process within the lung itself. The at the last puncture, however, was dealt with as above
some
1346 on the next morning there was seen to be a A pseudo-crisis occurred on the seventh day, but the temperaand pure growth of streptococcus on the agar slope. ture rose again on the same day, and the signs of consolidaOn the twenty-third day the On further examination the streptococcus was found to be tion remained unchanged. S. fcacalis. Polyvalent anti-streptococcus serum was given temperature was still raised, in an intermittent fashion, and liberally and undoubted benefit resulted. The consolidated the physical signs, as well as a skiagram, showed the lung lung then underwent liquefaction, and large quantities of to be still hepatised. The leucocyte count was 20,000. very foetid pus were expectorated, as much as 1 pints in the Examination of the sputum showed no tubercle bacilli. The day. But the acute and alarming symptoms had passed off. solid lung was punctured, and the blood-stained fluid was Vigorous treatment in the open air, with respiratory anti- submitted to culture. The agar tubes remained sterile. By septics by the mouth and by inhalation, led to complete the twenty-sixth day the temperature was normal and the recovery.1 In this case the lung puncture was not per- general condition was excellent. Injections of fibrolysin formed deliberately but during the search for an empyema. were given ; the patient left the hospital in good health but But the important information obtained from the examina- with the lung still solid. tion of the lung juice in this instance, proving as it did the V. Conclusion. presence of a pulmonary focus of infection by streptococci I have Altogether punctured the lung for diagnostic derived from the bowel, led me to employ the method Those above cited serve to show in some 14 cases. directly in other cases where there was doubt as to the purposes the kind of information that can be elicited by this mode of nature of the disease in the lung. examination. It may possibly be found of service in sus. CASE 2. Abscess of lung following inoomplete abortion.-A pected cases of acute pulmonary tuberculosis, in which conwoman, aged 30 years, came under observation 14 days after dition sputum is so commonly absent. In one such case I a miscarriage, suffering from fever, rigors, acasmia, and the affected lung, but failed to demonstrate the punctured shortness of breath. The uterus was curetted and treated tubercle bacillus in films prepared from the material with antiseptics without improvement. A week later signs of obtained. At a time when vaccine therapy appears to be so consolidation appeared at the base of the right lung in front, in dealing with many localised infective conditions promising with local pain and cough. There was no sputum. Exploratory the prompt isolation of the causal micro-organism becomes puncture of the lung drew off two or three drops of blood- a point of paramount importance. When the affected organ stained pus, and these yielded a pure culture of Staphylo- is the lung the particular investigation here referred to may The signs persisted and the patient grew be the sole means of coccus aureus. obtaining the necessary culture from worse. An operation was advised, but it was considered that which to the vaccine. prepare the indications for resection of a rib and exploration of Harley-street, W. Death occurred a week after the lung were insufficient. the puncture was made. Post-mortem examination showed an abscess situated in the right lower lobe of the lung close THE DYSPEPSIA OF OLD AGE. to the pleura. The pus from the abscess gave a pure culture BY W. SOLTAU FENWICK, M.D. LOND., of S. aureus. SENIOR PHYSICIAN, THE LONDON TEMPERANCE HOSPITAL. CASE 3.-Appendicectomy; general periConitis; pneumonia. -A child, aged 5 years, was admitted to the Great Northern Central Hospital under the care of Mr. E. C. Stabb. LaparAFTER 65 years of age functional disorders of digestion otomy revealed a gangrenous appendix, which was removed. become extremely common, and even when no abnormal The child did very well until the tenth day, when signs of symptoms exist old people usually suffer from an enfeebled peritonitis and pneumonia appeared. Puncture of the lung or capricious appetite and find that they can only avoid was undertaken, and a few drops of bloody fluid were indigestion by the observance of a limited dietary. As the obtained which gave a copious growth of pne1tmooooai, result of a laborious statistical inquiry into the relative B. eoli, and B. injhtenzae. The proof of the mixed infection of of various forms frequency dyspepsia at different periods of the lung was very striking. A dose of pneumococcus of life, Samuel Fenwick found that 21 per cent. of all persons vaccine was given, but the child was obviously in a over 65 years of age suffered more or less from chronic desperate condition at the time and died four days later. indigestion. My own investigations, while generally conCAsE 4. Jlycosis f1tn,qoides,. streptooooooal and staphyl(). firming this estimate, have been more directly concerned with coccal infeotion of tlie skin; extensive pne1tmon’ia.-A man, the causation of the digestive complaints met with in aged 38 years, who had suffered for several years from advanced life, and seem to indicate that out of every recurring attacks of mycosis fungoides, came under observa- 100 cases of chronic dyspepsia in persons over 65 years tion with a large axillary abscess due to staphylococcus of age 66 are secondary to organic disease of some infection. There were also present several superficial foci of organ of the body, while the remaining 34 owe important streptococcal infection on the chest and limbs. The abscess their symptoms to a progressive degeneration of the was incised, scraped, and drained. A spreading pneumonia secretory structures of the stomach and intestines. In the developed, but whether this was streptococcal or staphylo- former class the disorder of digestion usually takes the coccal in origin was uncertain. Lung puncture gave a little form of a chronic gastritis due to disease of the kidneys, blood-stained fluid which both in films and on culture showed prostate gland, heart, lungs, liver, pancreas, chronic gout, abundance of ,Staph,ylocoocos aureits. Two small doses of the or inefficient mastication, while in about 7 of the 66 killed staphylococcus were given as vaccine, but the condi- cases, or in 10 ’ 6 per cent. of the entire number, longtion proved to be the usual mode of termination of this continued hypersecretion due to chronic ulcer in the uncommon skin disease. vicinity of the pylorus, gall-stones, or diseased appendix is CASE 5. Er,ysi,velas; bronollOpnt1tmonia.--An infant, aged the cause of the constant indigestion. The true dyspepsia 7 months, was admitted to the Great Northern Central of old age, which depends upon a series of retrograde Hospital under my care, suffering from extensive erysipelas changes in the alimentary tract, has hitherto received little of the scalp. Several small superficial abscesses developed, or no attention, and I am consequently obliged to rely upon and from these a pure culture of Streptooooous pyogenes was my own observations for the following notes upon the subject. obtained. The condition improved under treatment by antiPathology. streptococcus serum. There developed later several vesicles Some years ago, while pursuing with von Recklinghausen on the scalp, and from these a growth of S. aureus was obtained. Patches of consolidation also appeared in the a histological investigation of stomachs taken from persons lower lobe of the right lung. Puncture of one of these areas who had died from different complaints, I was much struck The infant was by certain morbid appearances presented by the organ in the revealed a pure staphylococcal infection. case of old persons who had died either from an accident or effect. but without good accordingly vaccinated, CASE 6. Delccyed mesolzcteon in pneumonia; negative lung some acute disease and in whom the other viscera of the .pil,,notitlre.-A young man, aged 20 years, was admitted to the body were quite healthy. Further investigations have fully Great Northern Central Hospital under my care on the second confirmed these earlier impressions, and it is now quite day of his illness, suffering from pneumonia, with consolida- certain that with advancing age a progressive degeneration tion of the right lower lobe and some associated bronchitis. affects the secretory structures of the entire digestive canal. Although after the age of 50 these changes are fairly careful examination will often detect their 1 This case was fully reported by Mr. Newbolt in the Liverpool constant, existence at a much earlier period, and in one instance Medico-Chirurgical Journal for January, 1907.
described, and
copious
-