hostilities, we may give space to some of these forms for by-laws for the benefit of the many nurses who wish to use them.

THE FEDERAL SUFFRAGE AMENDMENT

Those of our readers who approve of the Federal Suffrage Bill will be interested to know that only one more vote is necessary in the Senate to carry this to a successful issue. Many obstacles are being placed in the way of its coming to a vote this session, and the time for active work is limited.

We heard the statement made by one of the National Committee that President Wilson's eloquent address before the Senate on September 30th in favor of this measure has not yet won a single vote for the cause. This gives some idea of the strength of the opposition.

MISS DELANO GOES TO FRANCE

Red Cross workers everywhere will welcome the announcement which reaches us just as our pages are closing that Miss Delano left Washington on the eleventh of December to sail for France as soon as transportation could be arranged. Miss Delano has been at her post in Washington ever since war broke out in 1914. That the nursing service was ready when the United States entered the war in April, 1917, was due very largely to her vision and effort. While she has had a large group of our most able women associated with her in her office and as Division Directors throughout the country, no one appreciates, better than they, that much of the success of the entire military nursing service has been due to her personal initiative and supervision.

THE INDEX

The index for Volume XVIII may be had on request from the JOURNAL office.

ARTIFICIAL PNEUMOTHORAX IN TUBERCULOSIS

BY ESMOND R. LONG

The Saranac Laboratory, Saranac Lake, N. Y.

It is almost twenty-five years since Carlo Forlanini, at the meeting of the International Medical Congress at Rome, in 1894, spoke on the principle of lung compression and advocated the therapeutic use of nitrogen for this purpose, reporting several cases of his own so treated; and it is just twenty years since our own John B. Murphy described cases he had treated for the collapse of tuberculous cavities by his method of intrapleural injection of sterile nitrogen gas; yet it is only seven or eight years since the procedure has come into anything like general use. So new is it in the public mind, that the nontuberculous laity, if they have heard of it at all, are apt to think of the method as a "new cure." The tuberculous have all heard of it; they hear of everything that offers anything like a new chance.

The theory of artificial pneumothorax is simple enough, and it does not involve "killing the germ," as the writer of a recent florid article in a New York daily would have us believe. The idea back of the procedure is the same as that back of bed rest or of lying, day in, and day out, in a reclining "cure chair,"-functional rest, enforced rest of the affected part. Let us form a mental picture, for a moment, of the lung sliding back and forth in its greased box, the pleural cavity, collapsing and expanding, stretching and relaxing, fifteen times, more or less, a minute, nearly a thousand times an hour, twenty thousand times a day. Let us think of scattered groups of soft cheesy tubercles in a part of or throughout this lung, perhaps a cavity somewhere in the top; let us remember the countless minute drainways, the lymph channels, leading away from the neighborhood of these tubercles and all other parts of the lung, forming a vast interlacing system, with the contained lymph ebbing and flowing, forward and backward, more or less in response to the lung's expansion and retraction. How constant is the menace of extending the infection, how frequent the check to nature's attempt at fibrous investment of the infected areas! Imagine an infected cut across the palm of the hand and ask yourself, What are the chances of first-intention healing if that hand is opened and shut twenty thousand times a day?

Pneumothorax is instituted for the purpose of immobilizing the affected lung. It is accomplished by injecting into the pleural cavity sterile air or nitrogen gas, thus surrounding the lung and shutting it up inside its box. As a rule, complete collapse is not usually estab

lished at one treatment but is done gradually, the usual procedure being to begin with small, frequent injections, 200-300 cc. every few days, and then gradually increase the amount injected and lengthen the interval between doses. The pleural cavity will hold 2000 cc. or more, but in the course of a few weeks or months, much more will be introduced to establish and maintain a collapse, as the gas put in is slowly absorbed. Nature herself is sometimes more daring and she has many times effected a sudden collapse and subsequent cure through the agency of a pleural effusion. The frequent favorable outcome of such cases was known to the acute clinician of many decades ago. The cautious physician, however, never forgets the danger of tearing adhesions, which may overlie a thin walled cavity and, giving way, tear out the wall and open a connection between the pleural space and the tuberculous cavity, thus giving rise to spontaneous pneumothorax and probable empyema. His method is to "play safe," and stretch the adhesions gradually, if possible, but never push them to the limit.

The operation is conducted with the usual precautions of asepsis, and is carried out under local anesthesia, a drop of two per cent novocain solution being injected into the skin at a selected spot between the ribs, through which the hypodermic is passed down through the muscles of the chest wall, an occasional drop being pushed ahead of the point of the needle, until the pleura is reached-the patient is apt to inform you when this tender spot is touched-which is well anesthetized with a few drops before the needle is withdrawn. The needle track is next slightly enlarged with a thin bladed knife and the gas needle, protected by a guard from going too far, is inserted and the pleura punctured. Whether or not the point of the needle is actually within the pleural cavity is determined by the reading of the manometer, or pressure gauge, which is switched in on the rubber hose between the needle and the gas tank. The normal pleural cavity exhibits a negative pressure and the level of the fluid in the gauge rises and falls with each inspiration. The gas in the tank is turned on and a suitable amount injected, the stopping point being determined by the operator's discretion and the reading of the manometer, which records the gradually increasing pressure.

And what are the indications and contraindications for this method of treatment? The one primary necessity before it can be attempted at all is, of course, an opposite lung good enough to do the usual work of two. Fortunately the lungs, like all other organs of the body, have a large measure of what the physiologist Meltzer calls "factors of safety." A lung with no disease below the third or fourth rib can usually stand up under the strain when the opposite one is

put out of business. It should be mentioned in passing that (in man) the mediastinum is stiff enough to prevent the pressure on the side of the collapse from being exerted to any great extent against the opposite side. The heart may be displaced somewhat, but this is not likely to become serious. The type of case commonly selected is that in which there is progressive and fairly extensive disease in one lung and little or none in the other. If there is not too much consolidation around them, cavities collapse promptly and well. Many a stubborn hemorrhage has been controlled by the collapse of the cavity responsible for it. Much consolidation is a contraindication to the use of the treatment, the tissues being too stiff to collapse. The commonest bar to success is the pleural adhesion which prevents the pleural envelope of the lung and the pleural surface of the thoracic wall from separating. Many cases cannot "take gas" because "they have adhesions," but we must remember that a lung with tuberculosis of any length of standing, without adhesions, is practically non-existent; it is their location and type that determine success or failure. Fibrinous adhesions stretch or slowly give way; fibrous are more serious; basal adhesions are likely to be a serious bar. Not always, by any means, can a complete collapse be effected; yet the partial collapse may be of distinct value. Marked continuous shortness of breath, of course, rules the operation out. A patient finding difficulty getting enough air into two lungs to satisfy his body needs is not apt to derive much benefit from the physiological removal of one of those.

The effects of the treatment may be thought of as: first, immediate, and second, ultimate. In favorable cases a sudden drop in the temperature is an early sequel; the compression inhibits the accumulation of toxic matter, and absoption is correspondingly cut down. The expectoration, momentarily increased, later decreases. With these benefits the patient's general condition improves. The ultimate effect, the desired effect, is fibrosis, scarification, of the infected regions, which the tissues may accomplish if given a fair chance, and this is a time consuming process. Gas cases must expect to continue the treatment a long time, perhaps through life, with frequent (three to six weeks) injections of gas to replace that absorbed. They must expect to drop in regularly at their respective service stations, so to speak, for their supply of necessary, if not free, air. Yet this does not mean that they are crippled or altogether disabled. Many, many cases are "working on gas." Even in the most favorable cases, only after many months should the lung be permitted to re-expand. Yet it is interesting to know that Forlanini, the originator of the measure, has successfully treated both lungs of the same case by this method, compressing the second some time after the first and worst

lung had been collapsed, healed by this lengthy process, and finally allowed to re-expand to undertake the load while the other one underwent similar treatment. A fairly frequent complication should be mentioned, pleural effusion. This is not necessarily serious, and even may be beneficial, as is pointed out above.

Without going too deeply into statistics we can say that the method long ago established its place among the useful tools of medicine. A large number of clinicians have reported their personal experience with it, and the general conclusion from their observations is that a good half of the cases so treated show improvement. Two years ago, W. C. Farmer, (Texas State J. M., December, 1916) gave the following analysis of 1145 cases treated by twenty-five American observers:

Floyd of Boston, one of the leading men in the field, states that 50 per cent of all cases do well, showing marked improvement or clinical arrest, quoting the figures of Sachs, Shortle and others (Boston Medical and Surgical Journal, March 14, 1918). and we must not forget that in spite of a present tendency to collapse early cases, by far the greater number so treated in the past, cases on which these statistics are based, have been advanced, often even desperate cases.

SOME EXPERIENCES IN ACTIVE SERVICE-FRANCE BY GRACE E. ALLISON, R.N.

Chief Nurse, Base Hospital No. 4

PART I.

Although the organization of Base Hospital No. 4, U. S. A., was begun several months previous to the declaration of war, the advanced notice of the impending mobilization came very unexpectedly on April 29, 1917, and gave us little time in which to make preparations for our indefinite period of service over-seas. Almost every member was engaged in some responsible field of work. However, it seemed that every one was concerned in our interest and welfare and rallied to our assistance. The Daughters of the British Empire, the Lady Board of Managers of the Lakeside Hospital, the Cleveland Red Cross Chapter, the Lakeside Alumnae, and many other kind friends offered many gifts which have contributed much to our comfort dur