decided relief, although I think the kidney is still as freely movable as at my first examination. When pain is relieved while in a recumbent posture, it is an evidence that, it is due to ptosis of some of the important organs. Cases of pain due to ptosis of the liver and spleen have also been reported. Congestion of the liver may give pain generally because of pressure upon its capsule. It is believed that such congestion may be due to stasis of the intestinal capillaries of the portal vein. 9th. In cases of abdominal pain coming at irregular intervals of weeks or months, and in the absence of any symptom, pointing to the abdominal cavity, it is well to think of cyclic albuminuria. Many of these cases have dyspeptic symptoms, but the characteristic feature is the periodic appearance of albumin in the urine usually in that excreted during the day and the absence of any kidney lesion as dropsy, cardiac, hypertrophy, and high tension pulse. It is probably a vasomotor disturbance in the kidney, and the abdominal pain is due to this cause. 10th. To discuss the acute cases associated with abdominal pain would unduly lengthen this paper, and I shall only briefly mention some acute diseases associated with pain. One most likely to mislead is lobar pneumonia where the pain is referred to the abdomen. While there are other symptoms of acute illness as vomiting, fever and rapid respiration, yet there are cases where for two or three days the seat of lesion in the lungs cannot be located. Still reports a case upon which he could not find any sign upon physical examination until the day preceding the crisis. Morse, of Boston, has reported cases where abdominal section was performed in the belief that the case was one of acute appendicitis. Abdominal pain is usu ally present in ileus, volvulus, strangulation, due to incarceration of the loops of the bowel by peritoneal folds, intussusception, perforation and thrombosis of the loops of the mesenteric artery. In this group of acute cases, pain is an important danger signal but must be studied in the light of other symptoms as shock, collapse, Hippocratic countenance, etc. In these conditions subsidence of pain may easily mislead us with a sense of false security. In conclusion, abdominal pain in children is a symptom so important and due to so many causes that when present should cause the physician to carefully investigate the case. 468 Brandeis Building. GIVE ME YOUR HAND. By Sam S. Stinson. (On hand ordinarily considered clean. Drs. Manol and Give me your hand, dear love, and let me lead Give me your hand, dear love, and let me lift Give me your hand, dear love, and let me pay -Judge. Kansas City Academy of Medicine Meeting every Saturday evening at the Coates House President, S. S. Glasscock, M. D. Censor, B. F. Bohan, M. D. Treasurer, C. B. Hardin, M. D. SOME OBSERVATIONS ON EMPYEMA.* ENOCH says, "the latency of pleurisy is not based on the nature of the disease, but on the carelessness of physicians." The above quotation is my only apology for this paper and is perhaps reason enough as will be shown. First, I would like to say that primary pleurisy with effusion, whether it be serum or pus is rare in children. The vast majority of such conditions. are the direct result of other acute diseases of the chest. That there are often many difficulties presenting, which make a positive opinion impossible, all will agree. But if certain facts regarding the child's thoracic anatomy be kept constantly in mind many of these difficulties will disappear. The first of these is the thinness of the chest wall. Ignoring this fact and precussing such a chest as though it were an adults, will result in confusion and failure, because by so doing you may percuss through a fluid collection to inflated lung and get a resonance. Furthermore, and particularly in the very young, and more especially in the inferior posterior portions of the chest, where the majority of the expiratory muscles are attached the percussion note during crying will be not only dull, but often flat where none exists. Over these same areas, if light and gentle strokes be persisted in until a deep inspiration is taken the dullness will disappear. Of course if the dullness persists it is certainly real. Another point of value is the position of the child. As has already been pointed out, percussion over contracted muscles gives dullness. It is surprising, and this is due to the smallness of the chest, how easy it is to get dullness in a recumbent pcition, this arising from the bed on which the child is lying. So that the ideal position for a young child is upright in the nurse's arms, with chest held tightly against the left shoul and arms either up or down but equal. Older children should be made to sit upright. Auscultation also presents some difficulties. In children up to one year it is often surprising how weak and diminished the aspiratory murmur may be, under perfectly normal conditions; this being due to feeble muscular activity. In older children the vesicular element is normally very sharp-puerile breathing-and may be mistaken for true bronchial breathing. hen The lack of appreciation of these facts perhaps explains why so many children are sent into the hospital with a diagnosis of pneumonia they have a bowel infection with tended abdomen and the accompanying rapid respiration and fear. To one watching a case from the first and in doubt regarding the diagnosis between pneumonia and pleurisy with effusion the fact that in pneumonia the dullness appears almost at once over the entire affected area, while in pleurisy the dull sound is stinctly circumscribed, low down behind with a gradual spreading ( And further, if the half of the scapu.a is reached the dullness in front will be lower than behind. This latter point being contrary to the findi either in pneumonia or hydro-thro It is generally conceded that children the most trustworthy sign in empyema is a distinct and characte is *Read before the Kansas City Academy of Medicine, October 14, 1911. T tic flatness upon immediate percussion, this flatness accompanied by a sense of resistance to the finger which is equally characteristic and is quite unlike the resistance obtained from the liver or heart. Of course diminished breath sounds are great aids when present but so often in the child sound conduction is so great that one must be very careful in laying too much. stress on this point. Also the displacement of heart or liver are points not to be overlooked. But with such an array of helpful physical findings there is often justifiable doubt, and when so the only recourse is paracentesis. A thoracentesis is, in careful hands, a simple and safe procedure and altogether justifiable, either to confirm a diagnosis or to make one. But to say that it is without danger is far beyond the truth. Huber and Hirsch in an exhaustive study of pneumothorax, say that the production of pneumothorax during paracentesis merits consideration since it occurs more commonly than is generally supposed, and further, because of the absence of severe symptoms and the presence of few physical signs, the condition is frequently overlooked. Stokes says that the introduction of air in this way does not always add to the gravity of the case but is never a matter of trivial moment. But with a good instrument and in the hands of a reasonably careful man who will not oscilate the needle once it is in, the operation is safe and of inestimable value. Of course we fail many times in getting pus when we feel sure pus is there, such failures may be the result of too small a needle or an encapsulated collection which we have missed. But generally speaking, I believe it to be an operation which is too infrequently per formed. Finding cloudy fluid or pus the only procedure remaining is the emptying of the cavity. Whether a portion of the rib is removed at the primary operation depends upon the age of the child and the probable length of time the collection has existed. Most authorities agree that in a recent case in an infant, an opening between the ribs is all that is necessary. The older and undiagnosed of any age, or those with sinuses, require a much more radical operation. But I am quite sure the resulting chest deformities are much greater than should be. The style of operation will depend upon the operator and his experience and the results will bear the same ratio. F. B. Lund, of Boston, has recently published a valuable article on the "Decortication of the Lung in Old Empyema." This article and the pictures accompanying it lead me to think that much may be done that has not been in overcoming the usual chest deformities. However this is greatly out of my province, and I will turn it over to the eminent surgeons here present. Having briefly discussed some of the more important points in the diagnosis. of empyema, I will now as briefly out line the cases referred to in the beginning of this paper. Case 1.-Entered the hospital with a diagnosis of unresolved pneumonia, subsequent to measles. Physical examination on entrance gave the fol lowing picture; extreme emaciation, septic appearance, fluctuating temperature, dyspnea, cough. Inspection of the chest-interspaces obliterated on left side, apex beat at ensiform, and very slight chest movement. Percus sion, the characteristic flatness and sence of resistance. Traube's space flat. Auscultation, distant bronchial breathing heard over this side. The diagnosis of old empyema was confirmed by puncture and the chest was opened and about a quart of pus liberated. Case 2. Entered with a diagnosis. of typhoid, right side very apparently fuller than left but no filling out of interspaces. Heart apex almost to left axillary line. Abdomen distended in its upper portion from liver being pushed down. Percussion note flat and very resistent. Breath sounds in lower half very faint and no tactile fremitus. The diagnosis of empyema was again confirmed by puncture. We could get no satisfactory early history. of this cause. Case 3. An infant eight months old entered at the suggestion of a physician with the vague diagnosis of being weak, not thriving and bowels in bad condition. This child was in a pitiful state, emaciated to a degree, very apparently septic, cough, insisted upon lying on left side. Inspection, left chest full but interspaces not obliterated; heart's apex at left of sternum; abdomen very distended. Light percussion gave the usual flatness and resistance. The breath sounds were remarkably loud, probably being transmitted from the other side. This child died the same night, following a severe coughing spell and the discharge of a large quantity of pus of a very foul odor, from the mouth. lung had ruptured and the child. drowned in its own pus. The Case 4. The odor about the child was frightful, extremely emaciated, restless, coughing constantly and expectorating large quantities of foul smelling green colored pus. Both chest cavities were hypo-resonant, the interspaces of the left side were somewhat more filled out than the right. I punctured the bases of both sides and from each got foamy green pus. This little patient died in a few hours. Undoubtedly it had had an empyema perhaps of the left side, being neglected it had ruptured through the lung and in this way involved the other side. -- Case 5. This was a boy eight years old who lived at the Inst. Church at which place he was taken acutely ill with right lower lobar pneumonia. He had a typical crisis on the fifth day. By the end of another week the temperature was up again and he complained of shortness of breath and some pain on the right side with a marked desire to lie on that side. The cough became more troublesome than it had been during the primarily illness. Introducing a needle pus was obtained and the chest opened and drained (no rib being removed). The lung was not bound down and the boy made a very rapid recovery with no chest deformity save the slight scar behind. The only case we have had which did not leave the hospital with an unsightly deformity and a practically useless lung. Case 6. Came to my office with a diagnosis of liver abscess, a girl six years old and sick for over six months. Had had pneumonia and complained of shortness of breath pain and general indisposition since, with fever. In July a July a fluctuating tumor appeared over the liver in the mammary line, this was opened and foul smelling pus escaped, in this manner a discharging sinus was established. On inspection the chest was found to be markedly depressed in its upper half, little or no motion on inspiration. Flatness and resistance were marked. A diagnosis of neglected empyema was made and a puncture performed to confirm it. A portion of a rib was removed behind and about a pint of pus escaped. The sinus in front quickly closing. This chest is still draining and I feel sure a decortication of the lung will be the only means of liberating the lung. I shall hope for a free discussion from the surgical as well as medical side. DISCUSSION. DR. FRANK NEFF: Empyema is being freely discussed now in literature here and abroad. The doctor laid special stress on the diagnosis of these cases as pneumonias. These particular cases are most often mistaken for pneumonia. The books disagree on paracentesis. Some claim the needle will aid in the absorption of the fluids. I don't believe it. Paracentesis should be performed when? Some say not until other diagnostic signs make a definite diagnosis. The physicial signs in empyema are interesting. A case where the breath sounds were apparently present, as in pneumonia, where tactile, tangible fremitis could be felt, the oscillating character of the temperature, and the fact that pneumonia has not resolved, pointed almost exclusively to empyema, which has proven on paracentesis. The interchange of the vocal fremitis in empyema is interesting. Fluid in the chest does not obscure fremitus, and hinder breath sounds. Fluid is a good transmitter of sound. We have here lungs much compressed. This compressed lung conveys sounds and is responsible for this unusual fremitis. A pneumonia that has not resolved should be regarded with suspicion as it may develop fluid in children. Did the doctor mention delirium? Delirium is not particularly common in pneumonia, but is common in empyema. Bulging of the intercostal spaces is a late symptom and diagnosis is easy at this late date. The one sided empyema is interesting. How it takes place as an ordinary sequel of pneumonia is hard to understand. Last year I saw one case, and although the bacillus of influenza had not been found, the clinical history had been that of a typical case of influenza. This I think followed a grippe infection. DR. S. C. MERRIMAN; The doctor impressed me with mistaken diagnosis. I have wondered why these cases were SO often overlooked. Is it because the child is improperly examined? I have seen mistakes. I saw one case diagnosed by several as a tubercular lung. One thing to watch for is the small quantity of pus we find in the plural cavity. It is easy to overlook this. It is not hard to diagnose empyema where there is a quart of pus, but where there is a couple of ounces it is more difficult. In one case I pointed out the place to the surgeon and he found one ounce of pus. I believe everyone should diagnose them with care. In another case I diagnosed a small quantity of pus but the surgeon refused to operate. I am sure the pus was there. Resection of the rib is the thing to do when the diagnosis is made. DR. B. H. ZWART: This paper is of value if we consider what has been said. Empyema, and, in fact, all pleuritic effuusions are often times difficult in determination. When there is a great amount of fluid the diagnosis is easier to make, but it is well to bear in mind the difference in the signs brought out by Dr. Hunt. These points are forgotten by those in general practice who do not see many of these cases. Physicial signs in children are different; the filling of interspaces is more often seen. They are susceptible to this. Where there is a small amount of pus, we do not have the loss of tactile fremitis. and vocal fremitis. The reliable evidence of a pleuritic exudate is the recurring chills and fever. I have resorted to puncturing the chest walls, where I could detect no reliable physical sign of empyema. Often times I have found empyema. I do not believe there is any danger in carefully puncturing the chest wall. I do not see why we should be guarded in our diagnosis if we do not get pus. I do not think we should be satisfied to let the case go if we suspect it. We do not need to push a needle in and wander about with it. The needle should simply puncture the chest wall. If you do not find it at one puncture, make several. I have never seen a puncture, properly made, cause trouble. We may have a mixed exudate and we may often puncture properly and fail to get the pus. On one occasion I punctured the chest of a youth. I failed with the needle, and then put in the scalpel, and failed to get anything but a slight exudate. In the course of 36 to 40 hours I saw the youth, and he said, "Doctor, it is broken loose," he was drenched with pus. It seems there was a plug of fibrin that held the pus back. Empyema is easily diagnosed in children. It is not easy to diagnose in adults. The reason we generally fall down is because we are not careful enough in our diagnosis. This paper has given us the difference in the physicial signs in children and adults. DR. GEORGE M. GRAY: To me there is no great difficulty in making a diagnosis in these cases. The difficulty in those cases is with a circumscribed empyema. In the ordinary cases that follow pneumonia, pleurisy, or pleuropneumonia, the history of the case, and an ocular inspection of the chest is generally sufficient. The voice sounds and fremitus is of great importance. Where there is effusion of any extent in the chest there is some alteration in the voice sounds. With effusion on one side the other luug has more work to do. The respiratory murmur is more marked, and there is a difference in the two sides. Most cases of empyema are late cases. Empyemas are not always due to pneumonias or pleurisies. We see them due to infections of the pleural cavity frequently. I saw a child with a severe appendicitis. It recovered from the appendicitis but remained sick. Several weeks after the appendicitis it had a large purulent effusion in the peritoneal cavity. A child 14 months old had a suppurative, gangrenous appendix and was operated on the third day of the attack. The child did well for a few days and then began to run temperature. Nothing about the appendix to indicate trouble there. On later examination we found a large purulent effusion in the left lung cavity. Incision between the ribs is not justified in many of these cases; it allows entrance of air, and infection many times. Resection of one and one-half inches of the ribs at a point giving free drainage is best. Washing out of the pleural cavity? These cases do not do well where irrigation is resorted to. Even in children I would resect the rib and not irrigate, depending on free drainage. As far as deformity is concerned, in time it almost entirely disappears. DR. REYNOLDS: Regarding the surgery of these cases I think the aspirating needle should be thrown away, for every time you puncture you are making a place for infection. In regard to the deformity I do not believe that the resection of the ribs has a great deal to do with it. DR. CHAMBERS: When empyema is well established, even in spite of the irregular physical signs in children, the diagnosis should be fairly easy. The interesting thing in this discussion is that with a typical history, the irregular temperature, recurrence of chills, etc., knowing that there is pus in the child's lining, in carefully going over the chest one is not able to outline this collection of pus. It is possible that in some of these infections following pneumonia that the infections may be of a scattered character. However, there will remain cases that are extremely doubtful,and |