narily required. In older children or in a prolonged case in a young child, the removal of a portion of a rib under gas ansesthesia is best. Irrigation of the pleural cavity is not necessary. The dressing should be changed once a day and the tube shortened as the lung expands.

The author concluded as follows:

"The disease in every one of the forty-three cases was secondary, and in forty it was secondary to pneumonia. Every child coughed, every one had fever, practically constant, higher in the evening, but rarely going above 103 degrees, F.; every child had accelerated respiration; the chest in each case showing flatness on percussion, and marked changes from the normal in auscultation. Children in whom the disease had existed longer than a week showed marked emaciation.

Dr. Adolph Baron opened the discussion by saying that he wanted to mention what Dr. Kerley, in preparing his paper, had probably overlooked, and that was the necessity for making numerous attempts at aspiration, as one frequently does not draw pus at the first attempt, and the reason for that is the needles used are not of sufficiently large calibre.

Dr. Henry Heiman said that it is generally found by bacteriological examinations of the pus in empyema cases, that the pneumococcus, streptococcus, staphylcoccus, or tubercle bacillus, or any of the mixed forms, are responsible for the lesion. When no bacilli are found in the pus, the empyema is generally of a tubercular nature. When this is found it is always well to inoculate several guinea-pigs for a positive diagnosis. It is at times important to decide what kind of an operation is advisable in certain cases and for children of certain ages. The rule adopted by an institution with which he is connected is to incise all patients under one year of age and to resect all patients over one year. This, of course, is not a fixed rule, but may be varied according to indications. It is also of interest to speak of double empyema. Two such cases came under the speaker's observation within two weeks. One patient was resected on both sides, and the other, being rather marasmic, was incised, but two weeks later the child died of persistent broncho pneumonia and exhaustion. In regard to the empyema necessitatus, one does not see these cases as frequently as formerly, which is almost un

doubtedly due to the fact that great advances have been made in physical diagnosis in children.

Dr. W. E. Luckett said that he desired to emphasize what had already been stated in regard to the use of a large aspirating needle in empyema as well as in other cases. He had frequently demonstrated that it is possible to aspirate the chest with negative results, when pus was surely present. This has been illustrated by inserting the point of an aspirating needle into a clot of fibrim. removed from the pleural cavity, and failure to draw any of the pus into the cylinder of the syringe. He was conversant with the case of a patient who might be alive to day had a large aspirating needle instead of a small one been used. The case was that of a man who had all of the symptoms of a cerebral abscess following an otitis media and mastoiditis. His skull was trephined and the brain aspirated, with negative results. The patient died. At the autopsy it was shown that the aspirating needle had been inserted into the abscess cavity at several points, but the pus was so thick that it did not enter the lumen of the needle. The speaker could not agree with what had been said in reference to an incision through the skin prior to an aspiration. The skin bacillus of Welsh is seldom, or at least not necessarily, pus-producing, unless mixed with some other infectious material, and an incision through the skin does not remove the bacillus from the field of operation. He depends on the ordinary methods of cleansing the skin as for any other operation.

Dr. S. S. Roos asked Dr. Kerley to specify what local anæsthetic he uses in empyema operations on children. From the number of cases of aspiration that he has seen carried out without local anesthesia, and without disturbance to the children, he believed that there is no need of an anaesthetic of any kind.

Dr. Albert Kchn said that the interlobar was the form of empyema diagnosed correctly the least frequently, and this, he thought, was an important point.

Dr. J. A. Bodine said that he had no experience whatever in the diagnosis or treatment of acute pleurisy, especially in children. He called attention to a suggestion made by the late Dr. Van Arsdale in connection with the operation of excision of part of a rib for empyema. It refers to the annoying complica

tion or sequel of osteitis or osteomyelitis of the bone ends when exposed to the discharging pus. The periosteum over the rib is incised and reflected, the proper length of bone excised, and the periosteum sutured in its former position. The incisien is now carried hetween the ribs into the pleural cavity. When the tube is inserted for drainage the flaccid portion of periosteum gives plenty of space, and yet the ends of the bone are protected from infection. As to the sterilization of the skin, it is well known to be impossible. The normal habitat of the staphylococcus is so deep in the skin as to be beyond the reach of either brush or chemicals. If one wishes this little operation of aspiration to be carried out under absolutely sterile conditions, he must nick the skin with a bistoury, preferably under local anæsthesia, and introduce the needle through this nick, and thus avoid any traces of the deeper layers of the skin. It has been his custom to ascertain the pathological cause of empyema; if found to be due to the pneumococcus, the pleural cavity has been treated as a cyst, that is, drained but not washed out; while if the infection was due to a staphylycoccus or streptococcus infection, it is treated as an abscess and irrigated thoroughly.

Dr. Kerley closed the discussion, answering Dr. Roos' question by saying that he had used ether locally in aspirating for empyema.

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Records, Recollections and Reminiscences.

SOME FACTS OF THE HISTORY OF THE ORGANIZATION OF THE MEDICAL SERVICE OF

THE CONFEDERATE ARMIES

AND HOSPITALS.

BY. S. H. STOUT, A.M., M.D., LL.D.,

Ex-Surgeon and Medical Director of the Hospitals of the Confederate Armies and Department of Tennessee. (Continued from February [1903] Number).

XVII.

In the last number of this serial, "Narrative," the fact of my assignment by special order of General Braxton Bragg, the Commander-in-Chief of the Army and Department of Tennessee, as Superintendeat of all the hospitals of his command, was stated. By that order I was to control all the general hospitals of his department and army under the direction of Medical Director A. J. Foard. My official designation was that of Superintendent of the Hospitals of the District of Tennessee. My official position was the creation of the brain of General Bragg. When he took command of the Army of Tennessee, it seems that the General had determined to fully control all departments of it from his headquarters, and thoroughly to unify and mobilize that army.

In spite of his earnest energy and his resourcefulness, Surgeon D. W. Yandell, Medical Director on the staff of General A. S. Johnson, had not so organized the hospitals, which for the most part were in Nashville, that they could be removed with their official corps intact, after fall of Fort Donelson and the evacuation of the capital of Tennessee. The hospitals there were ordered closed and most of the medical officers serving in them, were directed to report elsewhere for duty. Thus there arose a necessity for the organization anew of general hospitals.

I suppose the Surgeon General must have discovered, after the evacuation of Nashville, that Medical Director D. W. Yandell was overworked, and determined to send him help. Be this supposition as it may, Surgeon Francis Sorrell was sent west to organize general hospitals in General A. S. Johnson's department. The only time I ever met him was in the office of General Meckal, Chief-of-Staff, when I received my order to go to Chattanooga. This was in Decatur, Alabama, Dr. Yandell introduced me to Dr. Sorrell, who immediately gave me the instructions heretofore stated as to what I was expected to do. Of the operations of the general hospitals organized by Dr. Sorrell, under the direction of the Surgeon General, I have little personal or official knowledge. The Doctor impressed me during my short interview with him at Decatur as a clear-headed man, who knew what as an officer he regarded as needed, and knew how the exigencies of the services should be anticipated. But the time that elapsed before the battle of Shiloh was too short to afford opportunity for the medical service in the general hospitals in Mississippi and Alabama to be fully and completely organized. But the patriotism, humanity and skill of the many medical men who rushed to the aid of the sick and wounded before and after the battle, the zeal, industry and motherly and sisterly care given by the women of the South, were unprecedented in any previous war or in any succeeding one in the history of our country. Then, and ever after throughout the war, the women of the South, whether rich or poor, educated or uneducated, whenever or wherever they were in the vicinity of the sick and wounded, whether separated from their commands, suffering on the battlefield or languishing in the hospital, never hesitated to go to their relief. Aged and stately matrons, youthful and inexperienced maidens, who perhaps had never left home the distance of a mile without an escort, undauntedly entered hospital wards or visited in out of the way places sick and wounded Confederate soldiers and administered to them. The soldiers of the war in the Crimea were comforted and cared for by a single Florence Nightingale, and the story of her works has gone sounding down the pages of history, honoring one great and good woman for her work of love; but the Florence Nightingales who ministered to the comfort of sick and wounded Con