PART III.

S P E C I A L REPORTS.

REPORT ON PRACTICE OF MEDICTNE.

By HENRY T. BEWLEY, :M.D. Univ. Dubl. ; F.R.C.P.I. Physician to the Adelaide Hospital; and Lecturer on Forensic Medicine and Hygiene, Trinity College, Dublin.

I . DIAGNOSIS OF AORTIC A ~ E U R Y S M .

I I . F N E U M O T H O R A X FROM GAS-PRODUCING BACTERIA.

I I I . MAN(EUVRES TO E L I C I T A P L E U R A L F R I C T I O N - S O U N D .

IV. T H E T R E A T M E N T OF I N F L U E N Z A I N C H I L D R E N .

V. T H E TREATMENT OF B R O N C H O - P N E U M O N I A I N

C H I L D R E N .

I . T H E E A R L Y DIAGNOSIS OF AORTIC ANEURYSM.

DR. MORITZ SCH)IIDT (Frankfurt a. M.) refers to two very important aids to the diagnosis of aortic aneurysms which have been discovered in recent years--tracheal tugging and the use of X-rays.

Tracheal tugging was present in 19 out of 31 cases which he examined during the last 5 years. I t is best felt when the cricoid cartilage is pushed upwards With the index and middle fingers of the right hand, the head of the patient being bent a little backwards. A pulsation downwards is felt which ought no,t to be confused with the general pul- satory vibration of the larynx that occurs not infrequently in excited patients. Cardarelli presses the larynx over to the left and declares that thereby a pulsation to the right can be felt. Schmidt finds Oliver's method better, but in any case he regards the symptom as one of the most decisive in the :early stages of the disease.

The second important aid to the early diagnosis of aortic aneurysm is illulninat$on by means of the Rentgen rays. This ought to be always employed when possible. In order to dlagnostlcate an aueurysm of the aorta by means of the Rdntgen rays with eertah~ty, l%se,nberg would require evidence of a round tumour pulsating in all directions.

292 Report on Practice of Medicine.

But there are certainly anourysms which show pulsatio,n only in local~sed spots ; in most cases, however, one sees in the RSntgen ray shadow a turn our pulsating in all direc- tions.

Four skiagraphs are printed, showing clearly the position and size of the aneurysm.--Med. Chronicle, March, 1900.

I I . P I ~ ] ~ U ~ O T H O R A X F R O M G A S - P R O D U C I N G BACTERIA.

Finley (Montreal) publishes notes of one example of this rare condition, and refers to reports of threel others. In three of them there was some abdominal disease, and in the fourth there had been a wound of the ' thoracic wall, from whiok the infection probably originated. Of the abdominal cases, one was an appemdicitis, one a tubercular peritonitis, and one a case of sub-diaphragmatic abscess.

The organism found was in two cases the Bacillus a~rogenes capsulatus, and in two cases the Bacillus coli. In all these cases the symptoms developed gradually, and not suddenly, ~rs is usually the case in pneumothorax.

The chemical examination of the gases in these cases is of importance. In some cases much hydrogen was found; in one the amount was so great that the gas as it emerged from the pleural cavity was inflammable. He states that the presence of hydrogen or of other gases not found in the atmosphere is conclusive proof of the pneumothorax having been induced by gas-produci.ng baeteria.--Mordreal Med. Jour., Oct., 1899.

IlL THE PLEURAL FRICTION-SOUND : MAN(EUVRES FOR ITS

~LICITATION.

The main interest of this paper lies in Dr. Abrams' account of various plans which may be adopted to facilitate the recognition of the pleural friction-sound when obscured by other signs, or when it is so slight as to escape observation under ordinary circumstances. Thus the intralatibn of amyl nitrate may cause the clisappearance of r~les or rhonchi previously overpowering the frietion-sound~ Conversely friction may be obliterated and rs remain if the lower part of the chest is fixed by pressure of an assistant's hands (Bruen~). The author describes three methods which he employs, and which he believes to be original : - -

Report on Practice of Medicine. ~93

(1) "The Arm Man~uvre : - -The pa.tient suspends r~spi- ration a~ter fuI1 inspiration, after ordinary breathing, or at the end of e~xpiration. Then the arm oa the affected, side is raised while in extension, either by the p~tient, if intelli- gent, or otherwise by the physician, till it reaches the side of the head. During the time the arm excursions are made the suspected area is auscultated. By the arm manoeuvre, the movement of the parietal against the visceral pleura is opposite in directio~ to that occurring during the respiratory act, and for this reason the pleuritie sound may often be elicited after the sound has b eer~ exhausted in the ordinary act of breathing . . . . . In obtaining the frietion~ sound after this m.ethod, care must be exercised lest the patient breathe. The sound thus obtained can only ema- nate from the pleura, and this fac~ alone establishes its value in .differential diagnosis."

(2) "The Decubital Manoeuvre : - -Let the patient lie on the affected side for ane or two minutes, then direct him to rise quickly and suspend respiratio.m Now auscultate the affected area, as the same time directing the patient to take a d, eep breath. One error is likely to suggest itself by this method, and that is, the creation of a telectatic crepitation. If, however, the lungs have been fully expanded prior to the execution of the decubital manoeuvre and the lateral posture is only of short duration, the dar~ger of misinterpret,as will be reduced to a minimum. This method is based on the fact that the positiorL adopted by the pats approximates the two layers of the pleura.. "

(3) "Pressure in an Intercostal Space :--l~ressure with the stethoscope usually intensifies the friction-sound. I f pressur~ is made in an intercostal space, and not on a rib, we can more certainly approximate the costal to the visceral pleura. To carry out this method successfully the arm on the side to be auscultated is first raised; this act materially widens the intercostal spaces."-- Med. Cb'oniele, May, 1900.

IV. ON THE TREATMENT OF INFLUENZA IN CHILDREN.

Dr. It. B. Sheffield (New York) calls attention to the use of benzoate of sodium. He says it almost acts as a specific,

294 ReTort on Practice of Medicine.

and its use has not obtMned the attention i t deserves. He began to use it five years ago, when a child with a severe attack of acute articular rheumatism was ral3idly cured with sodium benzoate and salol. Encouraged also by the fact that largo doses are well borne by children, he decided to employ it in influenza, an epidemic prevailing about ~hat time. The results were exceedingly satisfactory, most of the symptoms having subsided within forty-eight hours. Since then sodium benzoate has formed, his remedy not alone in influenza but in all its complicatians as well. Occasionally it is found necessary to administer small doses of acetanilide for reduction of high temperature and relief of pain, and, when the latter is severe, also a little codeYn. He states tha t after ha~dng given acetanilide to thousands of patients in diverse diseases he has yet to see any untoward results following its use, provided proper caution is taken in prescribing a moderate dose. Where any depression is to be feared a small dose of caffein is a safe addition. Whenever " rheumato id" pains predominate he combines the just-mentioned drugs with sale.l, which acts at the same time as an intestinal antiseptic. Thus, when he is called upon to treat a case of the grippe of moderate severity he orders :

1~ Sodium benzoate, Salol, i of each - 1�89 grain Acetanilide,

1 Caffein, - - ~ ,, M. Make one powder. Sig. : One powder every three hours to a child six

years old, or, if the pain is severe and the child is kept awake, add one-twelfth grain of code~'n sulphate to each powder. ~Vhere children refuse to tak~ powders he pre- scribes the following mixture, again adding code~'n if necessary : - -

r~ Sodii benzoat. } Antipyrin. I ~ - - 5ss. Liquor ammon, anisat, l Syr. scilla~ comp. ~ ~ - 5ij Syr. althaeae - - f~jss. Aqua~ anisi - - q. s. ad fgij.

M. Sig. : One drachm every three hours to a child six years old.--N. York Med. Jour., June 30, 1900.

Report on Practice of Medicine. 295

V. T H E TR~EATMENT OF B R O N C I - I 0 " P N E U M O N I A I N C H I L D R E N .

Dr. D. A. l:[odghead, from a study of twenty-five cases, reports very favourably on the use of calomel and bella- donna. Other medication is stopped, poultices removed, the child is wrapped in soft, loose clothing, and water is substituted temporarily fen milk. The room is t(~ be kept at an even temperature, and the atmosphere is not sur- ,charged with moisture. Calomel in on%tenth of a grain doses is given every hour until a free movemelrt of the bowels is obtailmd, and, alternating half-hourly with the calomel, two drops of the tincture o.f belladonna. As ~m- prove~aent begins the belladonna is reduced to drop dos,,s hourly. The temperature falls, respirations become less rapid and are deeper, rattling and larger r'Xles disappear; the moist r'Xles become few and feeble; pulse and cough improve, and the patient can sleep and take nourishment, In the patient whose case is specially cited, belladonna rash beesme well marked, after which the .drug was gradually withdrawn. Calomel is of value as a cathartic, even early in the disease, but the belladonna is not effective until the disease is well established, when the early, dry, congested state of the bronchi has given place to the superabundant mucus and mucopurulent secretion. Ammonia combina- tions liquefy and tend to increase the amount of secretion ; belladonna diminishes them, stimulates respiration, thus aiding elimination. A child under five years expectorates but little. An advantage in this method of treatment is the discarding of steam-tent, ice-pack, &e. Both drugs sug- gested above are well borne by children.--The Pacific Medical Journal, 1899, Vol. XLI I . , No. 6, p. 326, and Amer. Journal of 3fedical Science, April, 1900.

(To be continued.)

snoHor'oRr~ HIXTUX~.

M. GxY (Jut. de Mdd. de Bordeaux) uses the following formula :-- Bromoform, 1 gram. 20 i chloroform, 0 gram. 80 ; rum, sufficient quantity to make 120 cc. mixture. One teaspoonful of the mix- ture contains five centigrammes of bromoform and three centi- grammes of chloroform,