MARCHI 15, 1919J ARTIFICIAL DOUBLE PNEUMOTHORAX.CA T A.flRTI .

I5, JOR~ 0

entirely a lung which is already almost incapable of Quaantity of Gas Removed and Changes in Pressure.
function is physiologically a vile damnunm; but from the Quantity of Gas Pressure after
point of view of restraining the output of toxins it may be Removed. Removal.
an enormous gain. Initial pressure ...4-... ... ... - 12
400 cm.
CM. , ... ... + 6
600 C.cm. ... ... ... ... + 4
915 c.cm. ... ... ... ... + 1
1,175 c.cm. ... ... ... ... + 1
A CASE OF 1,325 c.cm. ... ... ... ... 2
ARTIFICIAL DOUBLE PNEUMOT IORAX. As soon as a negative pressure was obtained the operatio'i
was discontinued, but, as is shown in the xt-ray plate, a con
BY siderable quantity of gas still remainied on the right side. The
ARCHIE McCALLUM, M.B., gas was withdrawn at the same site as it was introduce in
previous operations-namely, the eighth initercostal space in
TEMPORARY SURGEON LIEUTENANT R.N. the anterior axillary line on the right side.
IN a recent edition of a popular textbook on plhysiology before A study of the two x-ray plates slhowing tlle conditions
the following sentence appears in the chapter on the The patency and after the withdrawal of the gas was iustructive.
mechanism of breathing "A perforation of the chest wall quite well defined between the riglht and left pleural spaces was,
would mean that the lung on that side would no longer be fluoroscope. Tole extent at the time, when viewed tllrough tho
of use; a similar injury on the other,side (double pneumo- lung was shown by the ofmottling the involvement of the riglht
thorax) would cause death." This statement, along with adhesions in botlh lungs were well marked, of the orgain. TIe
the impression so many, as well as myself, have always accounted for the mtarked depression of tlhe diaphragmi and probablv
entertained, that the so-called vacuum in the parietal both sides. Even after witlhdrawal of the gas the left lung oli
"space>' must be retained on at least one side of the slhowed a triangular transparent area indicating sonic
thorax, seemed at variance with tlle continued viability of retention.
thje patient in tlle following case. Besides the physiological featuLres menltioned and t1hc
From the use of artificial pneumotliorax in the treatment anatomical peculiarity of a patency between the pleural
of pulmoxinary tuberculoeis it is well known that one lung spaces, wlliclh, of course, nmay have been the result of a
may be ve'ry greatly collapsed withl little or no embarrass- tuberculous perforating the " partition " between the
ment to respiratioll. Tflriougli a fluoroscope the lung, spaces, therefocus
wlichl is under great collapse, can be seen to undergo a pensability ofisthe the furtlher lesson conveyed of the indis-
fluoroscope, or x rays, in conjunctioni
limited respiratory movement, and even when there is a with the use of artificial pneumothorax, if the dangers of
decided positive pressure of gas this lung does not entirely compressing a healtlhy lung sanme time as coni-
cease to function. I was, however, not a little surprised to pressing the diseased one are toatbethe avoided.
find a patient breathing quite comfo;rtably and moving
about the grounds of the institution with no embarrass-
ment, althouglh, in the routine treatment of a case of
pulmonary tuberculosis by artificial pneumothorax, I had EPIDEMIC PNEUMIONIC INFl,UENZA AS SEEN
produced a double pneumothorax of some considerable
size, througlh a patency existing between the riglht and IN 1NIALAYA.
left pleural spaces. fBy

Mr. C. was considered a suitable patient upoIn whom an G. WAUGH SCOTT, M.B.,
artificial pneumothorax should be produced in order to rest the ESTATES MEDICAL OFFICEII, SUNGEI SIPUT, FEDERATED
right lung:, vwhich was extensively involved and gradually MALAY STATES.
becoming Worse, whilst no definite actiVe lesions were found in
the left lung.:. PNEU-2ONIC INFLUENZA broke out duing r thfe onth U
The first four introductions of nitrogen were of small
amounts, averaging about 250 c.cm. each time; and these October, 1918, amnongst the Tamil iabour orce, on a rubber
probably went into pockets between adhesions, judging from estate-of whiclh I was in medid4l charge, and was very
the oscillations and readings of the water manometer. But .on fatal.,
the fifth inittoduction a defiaite pocket of gas between the base Lobar pneumnonia is' endemic in Malaya, and causes a
of the lung and the diaphragm was discernible through the fairly large proportion of tile deaths among all classes of
fluoroscope. the community. Tlhus it may easily lhappen tljat tile first
few cases in an epideric of this kind are regarded merely
Pressures (JVrtatei Manomneter), andtl Accomtpanying Almouints as an unusual inicidence of ordinary lobar pneumyjonia. In
of Gas' Intr-oduiced. this way valuiable time may be lost ere precautions against
the spread of the epidemic are taken.
Treatment. Interval-.!
Treatmen.
Intervl. Gas. Pressure Pressure
at Start. at Finish. Wlhile the disease produces a-true pneumonia, thblere are
man y sy' ptoms whic-h. serve to distinguish it ftog the
ordinary lobar type of that disease,.
Initial -
4 Oxyg
en cc100m.

(Nitrogen 250 c.cum. -8 +10 The onset is usually heralded by a rise of teilperature
Second ... 1 day N 300 C.cm.
with lhacking couglh and a pain, whiclh is almost invariably
-3 +10 located by thie patient in tlle front of tile chest, and not at
Third ... 6 days N 235 c.cn. -20 +10 one side or another as in lobar pneumonia. The onset of
Fourth ... 4 , N 260 C.C111. -8 +20
this pain is preceded by sore tlhroat and a nasal discharge;
the latter persists durinag tlle illness. The cougiling is
Fifth ... 3 N 450 c.cn. -9 -4 painful, but the cough is not of the kind usually found in
Sixth ... 4 N 425 c.cm. -6 0 ordinary pneumonia. It is deep and full, and pain excitedl
is muchl niore generalized. The coughing occurs in long
Seventh ... 8 ., N 700 c.cmn. -4 +6 bouts, and in the intervals tllere is great exlhaustion witlh
Eighth ... 2 ,, N 800 c.cn. -4 +8 the vocal breathing or groaning present in most grave
Ninth ... 8 ,, N 1,000 c.n. +5 +12
illnesses. Tle facies is marked by an anxious look,- whiclh
persists even after delirium has set in. The complexion is
a yellowish-grey. The nostrils are dilated, and the red-
After the eighth treatment the area above the diaphragni on dened mucous memnbrane coated with encrusted haemor.
the left side showed a slight transparency w)th the fluoroscope, rhagic discharge is a notable feat,ure in severe cases. Tle
but after the-'ninth treatment a very diseinct pneumothorasx sputum is rusty and of the nummular form at first,
was seen on both- right and ;left sides, lifting the bases of both but
lungs away from the diaphragm. The highest part of the bases very speedily becomes more profuse and greenislh-
of the lungs was at.the level of the fourth intercostal space in yellow, t1hough- remaining glutinous. Prfuse epistaxis is
the mid-cl&v*cuir line. The patient said he was " a little short common.and of uinfavourable import. Haematemesis amd
of breath,"'. sia felt that he "hUad gas on the stomach," but, haemoptysis have botlh been seen in very severe oases,
as stated betQre, being &i''ip " patient, be continued to Walk always as a terminal plhenomenon.
about the gr%uixds;with little discomfort. / The. temperatur.e iexliibits a much. greater 4igxal
It was obvibus. that the comtipuance of the artificial pneumo-
thorax Wpm net. advisable * -so the next day I Withdrew the gas variati'on 1than in lob&- pneumonia, 'varying betweeap990
by reversing the method of its introduction," and 1030 F., and ustaWl'y touching both these Iinfit is
 3o06' Ta,rf1lr,IrIg J MORGAN'Sf BACILLUS IN CHRONIC DISCHARGING WOUNDS.
each twenty-four lhours. Delirium usually sets in. mucl
e.t-lier than in lobar pneuLmonia, but it is very rar6ly
violent or maniacal, even in alcolholics, but is of a
iuttering type, as in. typhioid.
The pulse is by far the best guide as to progress in
these cases. It fails in volume and increases in rate to
ai remarkable degree, almost as soon as the patient becom-ies
Ni. The rate rises to about 120, and in many cases tljat
late was maintained almnost to the very end, witlh the
pressure steadily fallina. The respiratory rate is nmore
variable, ranging fromt 40 to 60, or hjighier. The breatlhing
(liffers from that in pneutnonia. Tlle breatlhs are deeper,
and are not cut slhort in tlle way co nmonly seen in lobar
pneumonia. The principal differences from ordinary
Pnieumonia observed on auscultation are that practically
nto areas of complete absence of breath sounds are found,
ai td(l the fact that all parts of botlh lungs are affected. Over
thle sternum &nd inner margins of the lungs loud bronclhitic
i ;^mles are lheard, and further out, and towards both bases,
coarse crepitations everywhere, witlh occasional patches of
loud pleuritic rubbing. The sounds indicate a severe
general bronchopneunionia with pleurisy. Percussion
le,veals areas of dullness in several parts of botlh lungs, or
there may be a board-like dullness over a large area on
botlh sides. The intercostal spaces are drawn in with
itispiration. Deep and rapid breathing of the air-hunger
type is frequently seen, and is of the gravest significance.
Thl'e great quantity of sputum gives trouble very early in
(el irium, owing to the absence of efforts to clear the throat
whlle coughing goes on. This leads to an accumulation
Of sputum in the throat whlich is very troublesome. The
blood in these cases showed marked leucocytosis, especially
(f polyrnorphonuclear leucocytes.
Most of my patients were malarial subjects, and about
50 per cent. showed pardsites in tlle blood, either active
reproductive forms or crescents, but the course of the
d isease did not seem to be affected, the mortality being
e(lual- in those with parasites and thlose without.
Post nortem tlhe lungs were either entirely or in great
lpAt liepatized. The pleura was covered witlh pus exudate,
ujid there were many soft adlhesions and free pus in tlle
pleural cavity; thle liver slhowed signs of early fatty
(logeneration, but the otlher viscera were not markedly
a ifected. There did not appear to be any characteristic
( hange in tlle spleen, tllough enlargement due to this
specific disease might have been present and not dis-
tin guishable, owing to the analarial enlargement present.
Tlhe course of the disease was generally short. The
mortality was very.high, and no treatment appeared to be
of the slightest avail.
I tried the injection of saline intravenously and intra-
e-(lularly.and by the rectum, and quiinine by various routes.
I also tried novarsenobenzol intravenously, and exllibited
salicylates and expectorants, besides giving the usual
stimulant dietary, but the course was unaffected. The
condition seemed to be one of severe toxaemia from the
very commencenent.
A,s with plague, typhus, and many otlher of the gravest
e-lidemic ailments, prophylaxis should be given the first
a ld. greatest attention.
'THE OCCURRENCE OF MORGAN'S BACILLUS
IN CHRONIC DI;SCHARGING WOUNDS.
BY
HAROLD E. WHITTINGHAM, M.B., CH.B.GLASG.,
MAJOR R.A.F., M.S.,
BACTERIOLOGIST, R.A.F., CENTRAL HOSPITAL, HAMPSTEAD.
'T'iis following observations were made on wound infections
oc.curring in a Poor Law infirmary. Here it was noticed
ti at- certain deep wounds, which were moderately- clean
oui admnission, gradually went from bad to worse in spite
of careful treatment. These cases ultimately developed
clhronic discharging sinuses, the dischlarge lhaving a peculiar
o(iour ver.y like that of a bacillary dysentery stool. Several
of these patients were obviously suffering from a toxaemia;
blood cultures performed were negative.
CultAires made from wound discharges of six of these
cases revealed the presence in all of an organism identical
with- Morgan's No. 1 bacillus.' This organism was the
predominant one in most instances, but othAer organisms,
stilchas staeptoeocous and staph;ylocoocus, were nurmerous.
[MARCHA 15, 19x9
Autogenous vaccines of Morgan's bacillus, given in two of
these cases, greatly improved the wound and general toxic
condition of the patient.
Whlere did this infection with Morgan's bacillus occur?
Was it the cause of this chronic wound infection?
The points to decide were: (1) What. organisms were
present in tlle wounds on admission to the hospital ?
(2) Wlhat organisms gained entrance to the wounds during
residence in the lhospital ? (3) The source of any infection
developing wlhilst in hlospital.
Technique.
Immediately on adinission to hospital swabbings were
taken from wounds of twenty cases. Cultures were made
aerobically in broth, on agar, blood agar and MacConkey's
bile-salt-lactose-neutral. red-peptone-aagar, and incubated at
370 C., and on gelatine plates at room temperature tor
seventy-two hours. Anaerobic cultures were made in
glucose broth incubated at 3700. for four days. At weekly
intervals, for as many weeks as the patient was detained' in
lhospital, the above procedure was repeated. The stools of
thiese cases were examined on two consecutive days for
organismns of the dysentery group.
Results Obtained.
From the swabs taken on admission various micro-
organisms were found, often a mixed flora, chiefly Strepto-
coccuts viridans and Staphylococcu8 aureus and albus, in
olne case B. p)yocyaneus, and in another B. perfringens.
In none of the cases could Morgan's bacillus be isolated.
Examinlation of pus fromn these wounds wlhilst in residence
in hospital revealed the presence of Morgan's No. 1 bacillus
in five out of tlle twenty cases-that is, 25 per cent. These
organismns made their appearance in two weeks after
adrnission in four of the cases, and in the third week in
the remaining one. This was the only modification found
of the admission flora except in one instance, where
Staphylococcus pyogenes aureus was superimposed.
Morgan's bacillus soon became the predomiinant organism
in the five infected cases. In this connexion two agar
platings Imight be mentioned. One plate developed 205
Morgan's bacillus and 26 streptococcus colonies, the other
plate 226 col3nies of Morgan's bacillus and. 51 of Staphylo-
coccus pyogenes albus, after incubation for forty-eight hours
at 370 C. The characters of this Morgan-like bacillus'
were fairly constant in all the cases observed-namely,
a short Gram-negative, bacillus, non-motile or feebly
motile, fermenting glucose with the production of acid and
a little gas, although in some there was no gas formed;
slight acid production in maltose. Lactose, saccharose,
mannite, and dulcite were unchanged. Litmus milk was--
rendered slowly alkaline from the second day without
previous acidity. Indol production was distinct in all
except one case. This latter organism corresponded closely
with Ey-re's No. 9.2
As regards the source of infection with this bacillus,
all the cases which developed this condition occurred- in
two wards widely separated and under different medical
officers. The sterilized dressings used in thle wards were
examined on two occasions, with negative results. Stools
of all cases proved to be negative to organisms of the
dysentery group.
Agglutination reaction of the bacilli isolated with the
patient's own serum yielded negative results, except in one
case, wlhere there was a positive reaction to a dilution of
1 in 40 in half an lhour at 37° C.
Treatment.
Woounds infected with Morgan's No. 1 bacillus responded
slowly, if at all, to ordinary surgical drainage and anti-
septic dressing. In four cases treated by. autogenous
vaccine tllere was- ma-ked improvement of -the local and
general condition. The septic type of fever and odour
began to disappear usually abouti three to four dAys after
the first inoculation. Four to five inoculations were found
to be sufficient. The dosage of vaccines employeb wasl:
First dose ... 100 million Morgan's No. 1 baciltis.
Second dose ... 200
Third dose ... 300 ,, ,
Fourth-dose ... 400-
Fifth dose ... 500
Sixth.dose ... 6000 . .. .
In two casesz thiere was a marked local an4 general
reaction after the flrst inoculation, but when- thi~pssd'