THE RADICAL CURE OF FEMORAL HERNIA
Asthenic types of the disease are associated with a variety of micro-organisms. Croupous pneumonia, or that due to the pneumococcus of Frankel, is usually preceded by a rigor, is attended by physical signs pointing to consolidation of lung, runs a definite course, and reaches a crisis within nine days, but it is seldom a disease that becomes epidemic. When it assumes this character it is more than likely that the malady is not due to the pneumococcus alone but to other micro-organisms as well,
... nd therefore the result of a mixed infection. The industrial school to which I was called by the visiting medical officer is in the neighbourhood of Newcastle-upon-I Tyne. It has accommodation for 200 boys and is nearly I always full. During the month of April of the particular I year in question the only entries in the log-book were one case of Pott's fracture, one case of skin disease, and three cases of abscess. On May 17th two boys, aged 13 years respectively, were seized with pneumonia ; five days later (May 22nd) other three boys, also aged about 13 years, were added to the list; ten days later (June lst) a sixth case occurred in a boy 14 years of age ; on June 5th two more cases in boys aged nine and 12 years respectively and on Jane 23rd the ninth case occurred. This boy, aged 15 years, had complained of headache in the afternoon but so slight did his ailment seem that it was not considered necessary by the governor to summon the medical officer. During the night the nurse, who was attending to some boys in the dormitory, gave him at his own request a drink of milk, A few hours later the ]ad was found dead in bed. On the following day I made a necropsy. The body was that of a well-nourished boy. R;gor mortis was passing off. There were no signs of external bruising. The pericardium contained a small quantity of tree fluid. On the surface of the heart were numerous small petechial hæmorrhages. The heart itself was healthy. There was a small quantity of serous fluid in the left pleural cavity. The base of the left lung was adherent to the diaphragm. On section the lower lobe of the left lung was found to be the seat of the early stage of pneumonia. Beyond being slightly adherent to the diaphragm the right lung presented nothing abnormal. The stomach contained about two ounces of grumous fluid its mucous membrane as well as that of the intestine was healthy. The liver was large but healthy. The spleen was very much enlarged and pulpy. The kidneys were congested There were no enlarged glands in the mesentery and no signs of tubercle or of peritonitis. Beyond being paler on its surface than usual the brain presented nothing abnormal. The blood was extremely fluid. The opinion come to by the medical officer and myself was that the boy had died in collapse in the early stage of pneumonia. A bacteriological examination of the blood and fluids was unfortunately not made. Looking back upon the history of the outbreak it will be observed that in all eight cases of pneumonia occurred between May 18! h and June 5th-i.e., in 18 days-and that the ninth, the last and only fatal case. occurred 15 days later. In the expectoration of one of the first two boys who fell ill tubercle bacilli were found in the fourth week, yet this lad not only made a good recovery, but three years after the illness is reported to be quite well and strong and earning his living as a labourer at some iron works, In none of the other cases were tubercle bacilli found. The after histories of these lads obtained four years subsequently are interesting. The youths are all quite well. In their clinical aspects the illnesses were ordinary croupous pneumonia. There was nothing unusual or peculiar in the course they ran. In trying to determine the came of the outbreak we were struck by the fact that most of the cases occurred in one large dormitory in which the sleeping accommodation was overcrowded and the ventilation of the room was defective. The window lighting of this ward, too, was deficient. A new range of windows was put in the blank wall. The other points were at once attended to. Since then not only have there been no fresh cases of pneu monia but the health of the boys has been remarkably good. I am but giving expression to the opinion of my confrèress when I say that it is no uncommon thing when pneumonia is prevalent in a town for the disease to break out and to linger in certain streets compared with others. A little while ago I was asked to see in consultation in a neighbouring town several ca-es of pneumonia in succession within the space of three weeks. Most of the cases occurred in one street in houses not far distant from each other, also in two or three adjacent streets. Similar outbreaks have occurred in institutions, such as schools, barracks, &c., and not a few of these have been traced to the escape of sewer air into the sleeping rooms. When several cases of pneumonia have thus occurred in close succession there has generally been overcrowding as well. The fact that death occurred in the case above mentioned within 24 hours of the commencement of the illness rather removes the case from the category of ordinary pneumonia, for in croupous pneumonia it is rare for death to occur before the third or fourth day. Much depends in any case upon the virulence of the microbe and the resistance of the indi. vidual. Irritant gases when respired provoke acute bronchial and pulmonary congestion but non-irritant gases are not considered to have any such effect and yet I have found animals die from acute congestion of the lungs after the inhalation of carbon monoxide, which is not usually regarded as an irritant, and men are known to have died from a similar cause, the only gross lesion found after death being acute inflammation of the lungs. What there is in sewer air over and above the gas itself or combination of gases to cause pneumonia we need not discuss. It is for our present purpose enough to know that sewer air can cause pneumonia. Typhoid fever and intestinal toxins from improper food, as in the Middlesbrough epidemic of 1889, are also causes of pneumonia and so too is influenza. There was nothing in the outbreak at the reformatory school to suggest an influenzal origin. The rapidity of development, the crowding of the cases into a brief period of time. and the fact that most of them occurred in one dormitory, all point to the cause or causes having been in the dormitory itself, an opinion confirmed by the disappearance of the malady after the ventilation had been improved and certain structural alterations and rearrangement of the sleeping accommodation had been effected. The condition of the lung found in the boy, accompanied by petechial haemorrhages on the surface of the heart, recalls some other form of toxæmia than that caused by the pneumococcus, but since under the term pneumonia are included, as already stated, many diseases, not all of them due to one and the same microbe, it is impossible in the present state of our knowledge to do other than include the above under the wide category of pneumonia. Newcastle-upon-Tyne.