Balloon pneumoplasty, 1926.

Evelyn’s problem is intermittent pain — her knee, in particular. Sometimes the pain is in her hip, but then it is much milder. “It’s not so bad that I would take anything for it, Doctor. I’d just like it diagnosed.” A little more history, a physical, and I realize that my 80-year-old patient has the hips and knees of someone decades younger. This is referred pain from her facet joints and lumbar discs. She has scoliosis. But what’s this? A deep puncture scar on her back, on the right side. I ask her about it. “Oh, that,” she explains. “I was 8 years old. I had empyema, and the surgery was done on the kitchen table.” Now this is really interesting to me. Had she been given an anesthetic? Yes, and it was horrible. She can still recall the rubbery smell of the chloroform mask. Who did the surgery? Was a specialist called in? No, the local GP did it. His name was William Hamilton. In the 1920s in Canada the specialty of respirology was still decades in the future. Chest radiography was expensive, an exciting new “fancy” technology. Did Dr. Hamilton have a Bowles stethoscope, patented in 1897? If so, how did he use it? Rappaport and Sprague’s authoritative description of the “physiologic and physical laws that govern auscultation” would not be published for another 15 years. What clinical skills would allow this doctor to diagnose empyema as he examined the cachectic 8-year-old lying on the kitchen table? Did he gently place his hands on her thin chest, checking for tactile vocal fremitus? Did he listen for egophony? Did he search for whispering pectoriloquy? These techniques were described in detail in the leading textbooks of the day — Bartholow’s Treatise on the Practice of Medicine and Osler’s Principles and Practice of Medicine. How carefully he must have percussed before stabbing deep into the chest of the critically ill child. Was he thinking of Osler’s surgery to drain his own empyema, only 7 years earlier? In medical school, had he been taught the complications of pneumonia, based on Osler’s description of 105 cases at the Montreal General Hospital? Today, a child with empyema would have a very modern (and expensive) set of investigations, especially in a teaching hospital. Blood work, blood gas testing, blood cultures, more cultures “to be sure,” radiographs with the patient in various positions to “observe” the fluid moving (or not), a pleural tap for further work-up (including cultures), antibiotics, more expensive antibiotics, possibly a CT scan of the chest and perhaps an immunologic work-up. Perhaps the patient would make a good teaching case: “Why has this young girl experienced this complication, at this time, in this setting, and why do you say this is empyema, not chylothorax?” In the end, a very neat, sterile stab would be made by a specialist to drain the offending pus, followed, of course, by the insertion of a drainage tube. The contrast between then and now is not really what compels me to record my patient’s story. In truth, as I finish the examination Evelyn remarks, “You know, somebody should write this up.” The most intriguing details are left to the last. There was the year away from school, during which her devoted parents helped her, their only child, to recover. She was nursed at home by 2 graduates of the Toronto General Hospital School of Nursing, at $5 per nurse per 12 hours. Evelyn remembers a crude chest tube, dressings and liberal doses of cod liver oil. This seems to be congruent with Bartholow’s advice to administer “[a] succession of flying-blisters, [and] painting with the tincture of iodine” and his observation that “[the] best results are obtained, not from the use of supposed stimulants of the absorbents, but from means to promote the nutrition ... [such as] iodide of iron (sirup), cod-liver oil ... ” (page 374). But it was Dr. Hamilton’s idea that she blow up balloons — many balExperience