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SIX CASES OF PURULENT BRONCHO-PNEUMONIA ASSOCIATED WITH THE MENINGOCOCCUS.
880
Clinical Notes: AND
MEDICAL, SURGICAL, OBSTETRICAL, THERAPEUTICAL. SIX
CASES
OF
PURULENT BRONCHO-PNEUMONIA ASSOCIATED WITH THE MENINGOCOCCUS. BY J. A. GLOVER,
M.D. CAMB., D.P.H.,
mortality,
CAPTAIN, R.A.M.C.
DURING the examination of the contacts of
We may now review our dates. 1I. was quite convalescent Oct. 12th, when he was moved next to C. C.’s onset of cerebro-spinal fever was about Oct. 20th On Oct. 24th this was definitely diagnosed, and the same day H. was first swabbed and found to be a carrier. N. was found to be a carrier on Oct. 25th; J. on Oct. 26th, all nearly "pure plate " carriers of Type 1. No other Type I. carriers were found among the contacts at either hospital. In my opinion we may consider that C. way undoubtedly infected by H., and that in all probability the purulent broncho-pneumonia from which the six men suffered was due to a mixed infection of pneumococci or Pfeiffer’s bacillus and Type I. meningococci. It was characterised by half the patients dving ; (2) the extreme (1) high purulence and great abundance of the sputum ; (3) the absence of rusty sputum or blood so common in the present epidemic of pneumonia. C.’s recovery was a dramatic proof of the potency of the Medical Research serum. Thirty-six hours after being apparently moribund he was demanding the morning paper, and he has only required two doses, although the first fluid showed many typical on
a
case
of
cerebro-spinal meningitis which occurred recently at the 4th London General Hospital, the following interesting facts were brought to light :The patient C., who subsequently developed cerebro-spinal fever, was admitted to hospital on Sept. 28th from Egypt meningococci. with a long history of malaria and marked wasting. On Oct. 12th he was moved into another ward and placed in the next bed to a man, H. H. was a convalescent and one of the three survivors of a party of six men, all of whom had had severe purulent broncho-pneumonia and whose history will be dealt with later. H. had still a persistent cough. Owing to the fireplace the beds of H. and C. were close together, although the ward was not crowded. On Oct. 20th, after eight days of this close neighbourship, C. began vomiting and later developed other signs of
meningitis.
Efforts to isolate and agglutinate the meningococcus from H.’s sputum have failed, but it is to be remembered that this was only attempted more than a fortnight after convalescence was fully-established.
LOCAL ANÆSTHESIA FOR EMPYEMAS. BY C. W.
MORRIS, M.B., B.S.DURH., M.R.C.S., L.R.C.P.,
TEMPORARY SURGEON COMMANDER, R.N.; CONSULTING ANÆSTHETIST, ROYAL NAVAL
he being desperately ill, was lumbar punctured by me, turbid fluid with plenty of meningococci was obtained, and he has made a splendid recovery with antimeningococcus serum prepared for the Medical Research Committee, only two doses of the pooled I.-II. serum being required. The meningococcus in his naso-pharynx was Type 1., that from the cerebro-spinal fluid not being grown. Owing to the length of time C. had been in hospital it was probable that he had been infected there, and hearing of H.’s history of purulent bronchitis and persistent cough I took several swabs of him, all of which yielded a nearly pure culture of Type 1. meningococcus. The profuse growth from H.’s naso-pharynx contrasted strongly with the slight growth obtained from C.’s, from which the meningococcus was only recovered with difficulty after many swabs. None of the other patients in C.’s ward was a carrier and the only staff contact who was positive was a sister who carried Type II., and who therefore obviously had neither infected nor been infected by either H. or U. With the kind assistance of Dr. T. H. Jamieson I learnt, as stated above, that H. was one of the three survivors of a party of six patients transferred from Holborn Military Hospital, Mitcham, on Sept. 21st, all of whom had developed severe purulent broncho-pneumonia. Followinp, up the other two survivors, I found that N., a great friend of H., but in another ward and on another floor, was also a " pure plate carrier of Type I., and that the third survivor, J., who had been transferred to a convalescent hospital, was also carrying an almost pure culture of Type I. All six of this party had been in hospital in Malta suffering from malaria acquired in Salonika. On August 29th they left there by hospital ship and arrived at Marseilles on Sept. 2nd, where they were 10 days under canvas in a general hospital. This they left on Friday, Sept. 13th, and after three days in a hospital train across France, crossed the channel via Southampton and arrived at Mitcham on Sept. 16th. On Sept. 18th all had high pyrexia. which in On Oct. 24th,
"
view of their history was considered malarial, and on Sept. 21st they were transferred to the Malaria Block of the 4th London General Hospital. All now developed severe purulent broncho-pneumonia and three died, H., N., and J. only surviving after very dangerous illnesses. Dr. Jamieson kindly gives me the following notes :— In all cases there were marked dyspnoea and considerable cyanosis. In all cases the sputum was purulent and copious, and was not rusty or blooa stained. Examination of the sputum showed pneumococci. In two cases there was diarrhoea, and in three albumin was present in the urine. The cause of death in each of the fatal cases was gradual cardiac failure. Two post-mortem examinations were done. Both showed broncho-pneumonia with quantities of purulent secretion in the bronchioles ; in fact, the lungs, when cut into and held up, dripped pus. The sputum throughout had been noted as being very purulent. In none of the cases did any of the symptoms suggest meningitis.
HOSPITAL, HASLAR; AND
L. HORSLEY, M.R.C.S., L.R.C.P., TEMPORARY SURGEON LIEUTENANT, R.N.; ROYAL NAVAL HASLAR.
HOSPITAL,
AT the present time when the influenza epidemic, with its sequela of pneumonia, is subsiding, and the viruslence of the infection is lessening, a large number of the pneumonia cases, who in the earlier stages of the epidemic would have died, are developing empyemas. In view of the very serious condition of many of these patients the administration of a general anaesthetic for the removal of a rib is accompanied by great danger and likely to prove either fatal at the time of the operation or seriously to minimise the chances of recovery. It is on account of these dangers that we have always employed local anaesthesia at the Royal Naval Hospital, Haslar, both before and during the present epidemic, and the experience gained in dealing with 150 cases, of which 85 occurred during the last six months, may prove of interest and use to those who are now faced with like cases. We use a 0 5 per cent. solution of novocaine and sterile water, to which adrenalin chloride 1 in 1000 is added in the proportion of three drops to the fluid ounce, and the following is briefly our technique :The patient is placed in position on the table and the skin preparation made. Three inches of the rib over the site of the empyema are accurately outlined with a blue pencil, and the needle thrust perpenrlicularly through the skin at the posterior end of the marked area, injecting the solution at the same time, until the point touches the rib. The point is then directed down to the lower border and turned into the subcostal groove, and 5 c.cm. injected into the intercostal nerve. Without withdrawing the needle the periosteum on the whole outer surface of this section of the rib, as far forward as can be reached through this puncture, is thoroughly infiltrated, beginning at the posterior end and working forward, paying especial attention to the two edges. The intercostal spaces above and below are injected and then the subcutaneous tissues and skin infiltrated. The needle is then withdrawn and inserted through the analgesic skin in the centre of the marked area, and the periosteum, intercostal spaces, and coverings of the rib infiltrated in a similar manner. One more puncture, again through the infiltrated skin, at the forward end of the marked portion of rib and the same process repeated will complete the infiltration. Should sufficiently long needles be used the whole area can be covered by two infiltrations, one at each end. We find that to ensure the best results some 20c.cm, must be injected at each of the three punctures, and in stout patients larger quantities will be necessary. If the vertical incision rather than that along the rib should be preferred, we carry out the same infiltration, with the addition that we extend
Clinical Notes: AND
MEDICAL, SURGICAL, OBSTETRICAL, THERAPEUTICAL. SIX
CASES
OF
PURULENT BRONCHO-PNEUMONIA ASSOCIATED WITH THE MENINGOCOCCUS. BY J. A. GLOVER,
M.D. CAMB., D.P.H.,
mortality,
CAPTAIN, R.A.M.C.
DURING the examination of the contacts of
We may now review our dates. 1I. was quite convalescent Oct. 12th, when he was moved next to C. C.’s onset of cerebro-spinal fever was about Oct. 20th On Oct. 24th this was definitely diagnosed, and the same day H. was first swabbed and found to be a carrier. N. was found to be a carrier on Oct. 25th; J. on Oct. 26th, all nearly "pure plate " carriers of Type 1. No other Type I. carriers were found among the contacts at either hospital. In my opinion we may consider that C. way undoubtedly infected by H., and that in all probability the purulent broncho-pneumonia from which the six men suffered was due to a mixed infection of pneumococci or Pfeiffer’s bacillus and Type I. meningococci. It was characterised by half the patients dving ; (2) the extreme (1) high purulence and great abundance of the sputum ; (3) the absence of rusty sputum or blood so common in the present epidemic of pneumonia. C.’s recovery was a dramatic proof of the potency of the Medical Research serum. Thirty-six hours after being apparently moribund he was demanding the morning paper, and he has only required two doses, although the first fluid showed many typical on
a
case
of
cerebro-spinal meningitis which occurred recently at the 4th London General Hospital, the following interesting facts were brought to light :The patient C., who subsequently developed cerebro-spinal fever, was admitted to hospital on Sept. 28th from Egypt meningococci. with a long history of malaria and marked wasting. On Oct. 12th he was moved into another ward and placed in the next bed to a man, H. H. was a convalescent and one of the three survivors of a party of six men, all of whom had had severe purulent broncho-pneumonia and whose history will be dealt with later. H. had still a persistent cough. Owing to the fireplace the beds of H. and C. were close together, although the ward was not crowded. On Oct. 20th, after eight days of this close neighbourship, C. began vomiting and later developed other signs of
meningitis.
Efforts to isolate and agglutinate the meningococcus from H.’s sputum have failed, but it is to be remembered that this was only attempted more than a fortnight after convalescence was fully-established.
LOCAL ANÆSTHESIA FOR EMPYEMAS. BY C. W.
MORRIS, M.B., B.S.DURH., M.R.C.S., L.R.C.P.,
TEMPORARY SURGEON COMMANDER, R.N.; CONSULTING ANÆSTHETIST, ROYAL NAVAL
he being desperately ill, was lumbar punctured by me, turbid fluid with plenty of meningococci was obtained, and he has made a splendid recovery with antimeningococcus serum prepared for the Medical Research Committee, only two doses of the pooled I.-II. serum being required. The meningococcus in his naso-pharynx was Type 1., that from the cerebro-spinal fluid not being grown. Owing to the length of time C. had been in hospital it was probable that he had been infected there, and hearing of H.’s history of purulent bronchitis and persistent cough I took several swabs of him, all of which yielded a nearly pure culture of Type 1. meningococcus. The profuse growth from H.’s naso-pharynx contrasted strongly with the slight growth obtained from C.’s, from which the meningococcus was only recovered with difficulty after many swabs. None of the other patients in C.’s ward was a carrier and the only staff contact who was positive was a sister who carried Type II., and who therefore obviously had neither infected nor been infected by either H. or U. With the kind assistance of Dr. T. H. Jamieson I learnt, as stated above, that H. was one of the three survivors of a party of six patients transferred from Holborn Military Hospital, Mitcham, on Sept. 21st, all of whom had developed severe purulent broncho-pneumonia. Followinp, up the other two survivors, I found that N., a great friend of H., but in another ward and on another floor, was also a " pure plate carrier of Type I., and that the third survivor, J., who had been transferred to a convalescent hospital, was also carrying an almost pure culture of Type I. All six of this party had been in hospital in Malta suffering from malaria acquired in Salonika. On August 29th they left there by hospital ship and arrived at Marseilles on Sept. 2nd, where they were 10 days under canvas in a general hospital. This they left on Friday, Sept. 13th, and after three days in a hospital train across France, crossed the channel via Southampton and arrived at Mitcham on Sept. 16th. On Sept. 18th all had high pyrexia. which in On Oct. 24th,
"
view of their history was considered malarial, and on Sept. 21st they were transferred to the Malaria Block of the 4th London General Hospital. All now developed severe purulent broncho-pneumonia and three died, H., N., and J. only surviving after very dangerous illnesses. Dr. Jamieson kindly gives me the following notes :— In all cases there were marked dyspnoea and considerable cyanosis. In all cases the sputum was purulent and copious, and was not rusty or blooa stained. Examination of the sputum showed pneumococci. In two cases there was diarrhoea, and in three albumin was present in the urine. The cause of death in each of the fatal cases was gradual cardiac failure. Two post-mortem examinations were done. Both showed broncho-pneumonia with quantities of purulent secretion in the bronchioles ; in fact, the lungs, when cut into and held up, dripped pus. The sputum throughout had been noted as being very purulent. In none of the cases did any of the symptoms suggest meningitis.
HOSPITAL, HASLAR; AND
L. HORSLEY, M.R.C.S., L.R.C.P., TEMPORARY SURGEON LIEUTENANT, R.N.; ROYAL NAVAL HASLAR.
HOSPITAL,
AT the present time when the influenza epidemic, with its sequela of pneumonia, is subsiding, and the viruslence of the infection is lessening, a large number of the pneumonia cases, who in the earlier stages of the epidemic would have died, are developing empyemas. In view of the very serious condition of many of these patients the administration of a general anaesthetic for the removal of a rib is accompanied by great danger and likely to prove either fatal at the time of the operation or seriously to minimise the chances of recovery. It is on account of these dangers that we have always employed local anaesthesia at the Royal Naval Hospital, Haslar, both before and during the present epidemic, and the experience gained in dealing with 150 cases, of which 85 occurred during the last six months, may prove of interest and use to those who are now faced with like cases. We use a 0 5 per cent. solution of novocaine and sterile water, to which adrenalin chloride 1 in 1000 is added in the proportion of three drops to the fluid ounce, and the following is briefly our technique :The patient is placed in position on the table and the skin preparation made. Three inches of the rib over the site of the empyema are accurately outlined with a blue pencil, and the needle thrust perpenrlicularly through the skin at the posterior end of the marked area, injecting the solution at the same time, until the point touches the rib. The point is then directed down to the lower border and turned into the subcostal groove, and 5 c.cm. injected into the intercostal nerve. Without withdrawing the needle the periosteum on the whole outer surface of this section of the rib, as far forward as can be reached through this puncture, is thoroughly infiltrated, beginning at the posterior end and working forward, paying especial attention to the two edges. The intercostal spaces above and below are injected and then the subcutaneous tissues and skin infiltrated. The needle is then withdrawn and inserted through the analgesic skin in the centre of the marked area, and the periosteum, intercostal spaces, and coverings of the rib infiltrated in a similar manner. One more puncture, again through the infiltrated skin, at the forward end of the marked portion of rib and the same process repeated will complete the infiltration. Should sufficiently long needles be used the whole area can be covered by two infiltrations, one at each end. We find that to ensure the best results some 20c.cm, must be injected at each of the three punctures, and in stout patients larger quantities will be necessary. If the vertical incision rather than that along the rib should be preferred, we carry out the same infiltration, with the addition that we extend