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Medical Societies.OXFORD MEDICAL SOCIETY.

TREATMENT OF EMPYEMA. I

AT a meeting of this Society held last month at theRadcliffe Infirmary, the President, Dr. E. MALLAM,being in the chair, Mr. F. J. HATHAwAY (Windsor)read a paper on this subject. He began by pointingout that the treatment of empyema-namely, incisionand drainage by a tube--had not changed for the last100 years. He hoped that soon the open drainageof a chest with a sucking wound would be looked onas a surgical abomination. The post-war surgeon wasnot satisfied with the eradication of disease or pusalone, but put before himself a higher ideal, namely,restoration of function, provided he ran no risk ofsepticaemia. In the case of the knee-joint, peritoneum,and pleura immediate closure of wounds had beenmore than justified by restoration of function. As regards empyemata, Mr. Hathaway pointed outthat the structure of the pleura was peculiar in thata rigid thorax was associated with a collapsiblelung ; in the treatment of empyema with collapsedlung, it was therefore essential that the lung shouldbe encouraged to expand as fully and as early aspossible, for it was not until the lung fully expandedthat pleural suppuration would end. This full andearly re-expansion of the lung could only be producedby immediate closure, because this method did awaywith the two great hindrances to lung expansion-namely, the effects of atmospheric pressure andsecondary infection.

After quoting his own experience in gunshotwounds of the chest as surgeon to a casualty clearingstation, he briefly reviewed the history of such wounds, Ipointing out that even in the thirteenth century ’,Henri de Nondeville immediately closed the chestin order to avoid a " sucking wound." With the era ’’,,of gunshot wounds proper, Felix Wurtz, in 1563, ’,recommended that chest wounds should be closed,as also did Guthrie and Baron Larrey in the nine-teenth century. During the American Civil War, ’,the Franco-Prussian War, and the South African War Ithere was no improvement till after the first year ofthe late war, when the era of immediate excision ofgunshot wounds, introduced by Sir Henry Gray, ofAberdeen, led the way for the immediate closure ofwounds of the chest, abdomen, and joints.As an important point bearing on the treatment

of empyemata Mr. Hathaway described the cripplingeffects on the lung of adhesions, even in a simplehsemothorax. Mr. James Berry had laid down asan axiom that " a good surgeon is one who knowswhen to use a drainage-tube and when to remove it."Mr. Hathaway went further in saying " a goodsurgeon is one who realises that restoration of functionis more important than the use or abuse of a drainage-tube." The historical treatment of empyema byHippocrates, Galen, and Lister was then outlined bythe speaker, it being pointed out that Prof. Schede,of Hamburg, was the first to insist on the necessityfor the whole hand to be introduced into the pleuralcavity for the removal of clots and adhesions.Mr. Hathaway then dealt with the method of

immediate closure of pneumococcal empyemata.Early and complete restoration of lung functioncould only be satisfactorily accomplished by completeoperation-i.e., by freeing the pleura of all adhesions.The three most important points in the technique ofoperation were :-

1. Bacteriological examination of pus after aspiration.He did not advocate the immediate closure in any butpneumococcal cases. In a mixed staphylococcal andpneumococcal infection, or in pure staphylococcal or purestreptococcal cases, he advocated the use of a " passage-tube," also called a rubber " dam," with closure of greaterpart of wound or use of Carrel-Dakin treatment.

2. Sufficiently large incision and resection of one, or

section of two, ribs in order to allow the whole hand to be

introduced into the pleural cavity, the object being to removepus and fibrinous clots and especially the adhesions on thevisceral pleura which would cripple lung expansion.

I 3. After operation, daily aspiration of the fluid, put intothe chest, with an aspirating syringe between the lips of thewound. This was quite painless. The fluid used to fill upthe pleural cavity was either a 2 per cent. suspension ofiodoform in paraffin or more frequently flavine. Dailybacteriological examination of the aspirated fluid wascarried out until the fluid became sterile, when the aspira-tion could be stopped.

Mr. Hathaway cited his own cases, nine since 1917 ;11 cases lately done by Mr. P. H. Mitchiner at theMiddlesex Hospital: and the better results claimed byMr. R. T. Timberg at the Physico-therapeutic Depart-ment of St. Thomas’s Hospital, as regards early lungexpansion and freedom from scoliosis. He alsoquoted papers by Dr. J. A. Nixon and Mr. J. A. Blake, 2of New York, both of whom advocated immediateclosure in suitable cases. Dr. Nixon, in fact, had statedhis belief that the time would shortly come whenopen drainage of the chest would be looked on as asurgical abomination.

In conclusion, Mr. Hathaway claimed that theimmediate closure of pneumococcal empyemata wasnow established, and that if the technique ofearly and complete operation were carried out themutilating operation of Estlander would no longer benecessary later. Convalescence would be shortened andthe physico-therapeutic results would be much betterthan they ever were with the use of a drainage-tube.

ZMSCMSSMW.In the discussion which followed Dr. W. COLLIER

spoke of the value of washing out the pleural cavityin cases which were not improving with ordinarydrainage. Mr. H. A. B. WHITELOCKE emphasised theimportance of the respiratory diaphragmatic move-ments in thoracic as well as in peritoneal drainage.Dr. A. G. GIBSON, Dr. W. STOBIE, and the PRESIDENTalso took part.

NORTH OF ENGLAND OBSTETRICALAND GYNECOLOGICAL SOCIETY.

HEART DISEASE IN PREGNANCY.A MEETING of this Society was held at Manchester

on Dec. 15th, 1922, with Mr. HAROLD CLIFFORD, thePresident, in the chair.

Mr. A. LEYLAND ROBINSON (Liverpool) read a paperon Heart Disease in Pregnancy and said that theconclusions formed by Angus Macdonald in 1878 werein the main surprisingly applicable at the present time,although some modifications had to be made in viewof the results of recent cardiological research. Thelatter had shown that cardiac murmurs did notnecessarily indicate serious disease and that manysystolio bruits were innocent if not actually physio-logical. The myogenic theory of heart conductivityhad been demonstrated and a rational explanationprovided for many types of formerly obscure cardiacirregularity. The discovery of auricular fibrillationhad brought to light an important mechanism in theproduction of heart failure. Prognosis was now deter-mined by the efficiency of the heart muscle and itscapacity for work. A pregnant woman with heartdisease was primarily a heart case, but the influenceof pregnancy on cardiac disease and the specialdangers of labour formed a problem of great importanceto the obstetrician.Pregnancy affected the heart and circulation in

several ways : (1) An increased output of blood wasdemanded by the growing tissues (uterus, breasts) andby the placental circulation ; (2) the uterine tumourproduced certain mechanical effects by simple pressureon the base of the lungs and on the heart itself whichwas dislocated upwards and rotated to the left; asa result the pulmonary circulation was impeded andthe right heart embarrassed. Pregnancy, therefore-and in particular labour with its severe muscular

1 Bristol Med.-Chir. Journal, 1921.2 Annals of Surgery, April, 1922.

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effort-implied cardiac strain and called up the reservepower of the heart; in health that reserve was quiteadequate, but in disease such physiological responsemight be impossible and heart failure would thenoccur.

Mr. Robinson referred to 39 cases from the LiverpoolMaternity Hospital comprising 26 mitral stenosis,6 mitral regurgitation, 2 aortic regurgitation, and 5functional cardiac disease. Five of these patients died :four from mitral stenosis, and one from aortic regurgita-tion and mitral stenosis. The effect of treatment wasshown by the result in 17 cases of mitral stenosis(10 with severe and 7 with advanced disease). Of 12women who received careful pre-natal supervision,1 died (a difficult breech delivery), and 5 women whoreceived no such treatment all died. Accuratecardiological diagnosis was essential before undertakingtreatment, as many systolic bruits and arrhythmiashad no pathological significance and no treatment wasrequired. In the presence of organic disease, rest andprolonged observation were of first importance ; thephysiological activities of the patient must be limitedand made to conform with the capabilities of the heartmuscle. The appearance of signs of incipient heartfailure (such as the persistence of crepitations at thepulmonary bases) indicated that the cardiac reservewas being seriously encroached upon and demandedspecial treatment.Drugs of the digitalis group were chiefly called for

by auricular fibrillation, whilst heematinics, regulatedexercise, and nourishing food were of great value inimproving the tone of the cardiac muscle. The termina-tion of pregnancy might be called for under specialcircumstances. In early pregnancy, for the incipientheart failure of aortic disease for compensation oncebroken could not be restored by treatment or for a pro-gressive decompensation in mitral stenosis when therewas no response to digitalis. In advanced pregnancythe induction of premature labour was permissible Ifor mild cases with full compensation, but was definitely ’,contra-indicated in the presence of heart failure near

’’

term. The conduct of labour was a great responsibilityand required careful consideration. During deliveryper vias naturales morphia was extremely helpful inreducing the voluntary efforts of the patient and forcepsmight be employed to expedite delivery.

Caesarean section would give better results, particularly in the case of a primipara where (1) the diseasewas severe and the heart barely compensated and thereserve poor, or (2) if there was the least reason tosuspect delay or difficulty in delivery. Although manycardiac patients successfully passed their one or moreconfinements and the immediate result appeared to ’,be satisfactory, the strain on the heart was rarely ’,transient, but usually prolonged and sometimes per-manent and irremediable. Apart from parturition ’many cardiac diseases were naturally progressive, asendocarditis, which was prone to occur, might converta quiescent lesion into an active and progressive one.It was, therefore, doubtful whether repeated preg-nancies should be allowed, and if not, the question ofsterilisation would have to be cautiously consideredin those cases where it was not possible to preventconception.The paper was discussed by Dr. DOBBIN CRAWFORD

(Liverpool), Prof. W. E. FOTHERGILL (Manchester),and Dr. J. E. GEMMELL (Liverpool).

MIDLAND MEDICAL SOCIETY.

THE fourth ordinary meeting of the session was heldin the Medical Institute, Birmingham, on Dec. 20th,1922, Dr. C. E. PURSLOw, the President, being in thechair, and about 40 members present.

Exhibition of Cases.Mr. A. W. NUTHAIL showed a father and two

daughters, who exhibited the combination of bluesclerotics and multiple fractures. The father had over30 fractures, and both daughters had fractured several

bones. Mr. Nuthall reviewed the literature of thisinteresting condition. The cases were discussed byDr. A. P. THOMSON, who knew of four familiesexhibiting the same symptoms. He stated that inthese cases the fractures were frequent up to the age of10 years, and later much less so.

Dr. J. G. EMANUEL showed a man of 52, who forsome years had suffered from attacks of a rare form ofparoxysmal tachycardia. In the attacks, which lastedfrom 2 to 3 hours up to 3 to 4 days, the pulse was slow,34 per minute, consisting of runs of 2, 3, 4, or 5regularly spaced beats at a rate of 82. These runswere separated by pauses of 3 to 7 seconds in whichno beats could be felt at the wrist and no heart soundswere audible over the preecordium. The electro-cardiogram showed that the silent pulse periodscorresponded to paroxysms of ventricular extra-systoles arising in the right ventricle at the rate of173 per minute, as many as 17 being counted in asingle paroxysm. In the paroxysm the ventricle drovethe auricle with a reversed heart-block of 2 : 1 andsometimes 3 : 1. During the intervals between theattacks the pulse was regular, at a rate of 60 to 66per minute. A similar case was described in Heart.1These cases were clinical counterparts of theparoxysmal tachycardia experimentally produced bySir Thomas Lewis by ligature of the right coronaryartery. 2 Dr. Emanuel’s case was discussed byMr. W. H. BUNTING, Dr. K. D. WiLKiNSON, andDr. G. H. MELSON.

Pasteurisation of lblilk.Dr. JOHN ROBERTSON, M.O.H., Birmingham, read a

paper on the Pasteurisation of the Milk-supply inBirmingham, emphasising the following points :About 75 per cent. of the milk-supply in Birminghamwas at present pasteurised or sterilised in order toprolong the life of the milk. Several firms sterilisedmilk in bottles. Milk should be efficientlypasteurised, then cooled to a temperature of 40° F.,and bottled in a bottle which has been sterilised.Such milk was safer than any other variety of milk,pathogenic organisms-tubercle, enterio fever, scarletfever, sepsis, &c.-being killed. No contaminationcould take place until after the bottle had been openedin the consumer’s house. Probably less damage tovitamins was caused than by nursery heating. Thekeeping properties were better. Because the milkwas clean, safe, and of good quality more milk wasused. Dr. Robertson’s paper was discussed by Dr.MELSON and Dr. J. J. R013B.

DEVON AND EXETER MEDICO-CHIRURGICAL SOCIETY.

Exhibition of Cases.A MEETING of this Society was held at the Royal

Devon and Exeter Hospital on Dec. 21st, 1922, Dr.G. P. HAWKER. the President, being in the chair.

Dr. F. A. ROPER showed a boy, aged 11, whosecondition pointed to deficiency of posterior lobe ofpituitary gland (? Frohlich’s syndrome). There was nohistory of injury during parturition or of prenatatinfection. The boy weighed 14 lb. at birth, hadsteadily gained in weight, but had never been able towalk owing to an affection of the muscles not unlikethat resulting from anterior poliomyelitis. The knee-jerks were absent, but other reflexes were normal andthe hand grasp up to the average. There were noocular symptoms and intellectually the boy was bright.The skin was thin and clear. Wassermann reactionhad proved negative. The sugar tolerance was appre-ciably raised, an ingestion of 250 g. being possiblewithout production of glycosuria. X ray showed thepituitary fossa to be normal or possibly smaller thannormal.The PRESIDENT showed a case of Optic Atrophy in

a young woman. The disease was unilateral and the

1 Heart, 1912-13, iv., 128. 2 Ibid., 1909-10, i., 98.