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appears as a fair indication that the disease remained throughout of an active form. It is likely that the breathing apparatus became involved in the lung tissue first. The pleura became diseased secondarily, because the lung, beneath, was diseased.
And as the pulmonary lesion was septic—the infection, probably streptococci, having been brought in the footsteps of the scarlatinous infection—this caused the pleuritis to become rapidly purulent. Regardless of the four months elapsed, it may therefore be quite possible that the empyema was of rather recent date.
In support of this hypothesis, you might remember that, before operating, we had observed a souffle quite sharp, though distant, and that, soon after the operation, râles could be heard; which would show that the lung was not carnified and unable to dilate. As a last proof, it might be mentioned that the heart, as we remarked, at first pushed over to the right, then receded under the sternum during the month following, did not, however, symphyse itself there; in course of time, it returned to its normal place. Moreover, later on, it exaggerated its position to the left, and this on account of grave structural changes.
Indeed, this deviation to the left is striking. to-day is seen to beat three and a half centimetres below the nipple; in other words, the apex is lowered a whole intercostal space, and beats outside the nipple vertical line; the impulse is strong and, if felt with the hand, it communicates to it a decided thrill, which reminds of the “purring tremor" of Laennec. At percussion, the area of dullness is considerably increased. . Thus, this heart is hypertrophied. The hypertrophy is compensatory to a double valvular lesion. During systole, there is at the apex a marked murmur: mitral insufficiency; and during diastole, at the base, a louder murmur, but soft and prolonged: aortic insufficiency. It is quite natural that the unfortunate young patient, while growing rapidly, should have remained delicate; he is on the way to a cor bovinum
In the beginning, we alluded to this valvular lesion when we compared this case with the first one related, and pointed out that both had a similar organic affection of the heart for their ultimate outcome. To what period does the pathogene
sis of this lesion date and what is it to be connected with as to causation? At the moment of operating-we have insisted on this point—the heart was deviated, but appeared healthy. Scarlet fever then hardly be incriminated; except remotely, on account of its debilitating influence. Most likely the lesion has been the outcome of the infectious pleuritis, although it is difficult to determine the time at which it may have set in and when it became apparent. To settle this point would have required a closer observation than was possible.
If it be granted that the myocardial changes have been the direct consequence of the suppurative pleuritis, then this case differs from the first in that respect; for in the first case the cardiac affection seemed to have developed between the retropharyngeal abscess and the empyema, unless we admit that it coexisted with the later disease.
Thus, in one case (the first), the heart is affected before or at the same time as the pleura; while in the other (the second) it is affected after; but in both, it becomes affected after a suppurative disease of a very severe type.
Thus again, both cases have an eruptive fever for starting point (remote causes), and both terminate in a most grave alteration of the circulatory center (ultimate consequence).
Finally, such cases—as well as the other one reported (of pulsatile abscess of the præcordia)—are not unfair illustrations of the sad systemic influence of severe suppurative diseases; defective health or untimely death, under any ulterior provocation, however slight, being their natural result.
For the ANNALS.
By DR. WALTER ZWEIG,
Assistant in the Policlinic of I. Boas, Berlin.
In February of 1899 Rosenheim (Therapie der Gegenwart) described a new method of treatment for the dysphagia of patients with carcinoma cesophagi and its effects have been determined on the patients in our policlinic. The difficulty of swallowing in these cases is due not so much to the stenosis of the carcinoma but to a spasm, the result of the irritation following the attempt to swallow solid food. In many cases the spasm can be prevented by a very simple method and the patient can then swallow with relative facility. The procedure is as follows:
A lavation of the cesophagus is first made with a soft rubber stomach tube inserted to the place of stricture, with not more than 150 grams of water in order to prevent an eventual dilatation of the esophagus as in most cases the esophagus is the seat of a more or less pronounced catarrh produced by the stagnation of the food. Then 50 grams of olive oil are poured in and the tube withdrawn during the act of pouring, in order to spread symmetrically the oil over the mucous membrane of the esophagus. In cases of especially severe pain, a four per cent solution of eucain acts extremely well instead of oil. After two or three minutes the patient can cautiously eat solid food and this food passes down without much difficulty. This method of treatment can be repeated several times a day and always with good effect.
The value of this method consists:
First, it has a great moral effect on the patients. As they are able to eat solid food several times a day, they become hopeful and are no longer terrorized by the thought of carcinoma.
Secondly, the cachexia may be held in check by the increased amounts of food, which is ingested.
The third advantage is, that the duration of time before the gastrostomia can be prolonged. The gastrostomia, however must always remain the ultimum refugium.
With our material it was impossible to determine if the length of life can be protracted by this method. Six patients have been treated in this manner and the following histories illustrate the effect of this treatment.
1. April 4, 1899, G. M., 63 years old, workman, until October, 1898, always enjoyed good health. He ate during this period all kinds of food, but was forced to swallow a mouthful of water after every particle. Since the beginning of this year solid food cannot be swallowed, but only liquid.
The patient has lost thirty pounds in four months. a great eater and always ate very hastily. He thinks that he may have burnt his æsophagus by a hot drink.
Status præsens: Markedly cachectic; heart and lungs normal; abdomen strikingly retracted; the urine contains a small quantity of albumen, but no sugar. The patient can barely swallow water, while wheat bread is immediately regurgitated with choking. The soft rubber stomach tube meets with an invincible resistance thirty-seven c.m. distant from the teeth. One finds by the esophagoscope at the same distance a very strong pulsating tumor which is irregular and hyperæmic.
Therapy: After lavation of the esophagus by which a great deal of mucus is washed out, fifty grams of olive oil are poured in the manner described. The patient is then able to swallow wheat bread with meat without much trouble. The treatment was continued for two months, in which time he lost only three pounds. He swallowed liquid food and after every oil injection, solid food. Unfortunately the patient passed from our observation after this time.
2. July 19, 1899, Bernard B., 50 years old, farmer. In February of this year, difficulty in swallowing began and gradually increased until now he vomits all solid food.
Status præsens: Strikingly cachectic; the tube meets with an obstruction in the region of the bifurcation; lavation of the csophagus brings out residual milk, raspberries and wheat bread. After an injection of fifty grams of oil he is able half an hour later to swallow wheat bread and eggs.
July 20. Repetition of the procedure. The patient describes himself as “new born.”
July 22. The state of health is subjectively excellent. He returns to his native village and is ordered to continue the lavations at home.
July 28. The patient writes that he is very well contented with the state of his health. He is able to swallow coffee, milk, cakes and pork with caution.
The histories of other cases could be added, but they are practically the same. The success of the treatment is in most cases quickly evident and the method may be employed in all cases of carcinoma esophagi.
ARTERIAL TENSION IN CHILDHOOD.
By HENRY L. K. SHAW, M. D.,
The subject of arterial blood pressure in children is one which has not received the amount of attention it deserves.
The reason for this lies partly in the extreme difficulty of determining it in the small rapid pulse of young children. Most of the clinical instruments designed to measure the pulse tension are too complicated and too difficult of applica
upon children whose restlessness and uneasiness are well known to workers in this branch of medicine. Of its importance there can be no doubt, although very little reference is made to the blood pressure in most text books on children's diseases. Baginsky' calls attention to the role it plays and says that the determination of the pulse tension is