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A CASE OF CESAREAN SECTION FOR CYESIS COMPLICATED BY MALIGNANT DISEASE OF THE RECTUM.
’
CLINICAL NOTES.
600
tenderness and erythema over the sac, no articulation with the sternum could be made out. In August there were increasing asphyxia, loss of power, and pain in spite of pushed doses of opium, chloral, and bromide, as well as belladonna locally. For the last three days of life there were cedema of both hands and much sweating. His florid complexion was maintained till the morning of his death, for two hours before which there were marked pallor and complete unconsciousness. Necropsy.-The post-mortem examination was made on Aug. 12th, eleven hours after death. An examination of the chest only was allowed. The aneurysm was of the arch of the aorta, saccular, not diffuse, and there had been no rupture of it. The sac was the size of two fists and extended upwards to above the cricoid cartilage, and, having destroyed the right sterno-clavicular joint, depressed the clavicle and overlapped the right half of the sternum to below its junction with the second rib, the sternal end of the clavicle and the outer and posterior upper portion of the manubrium being completely eroded. The aneurysm commenced just internally to the origin of the innominate artery, which, beyond compression by the sac, was scarcely, if at all, implicated in it. Remarks.-The points of interest in this case are the sudden appearance of the aneurysm, its rapid growth, and peculiar distribution. The possibility of its being aortic was not lost sight of : but certainly at the time of diagnosis and, indeed, until the extension of the enlargement to the left, two months later, all the symptoms pointed to its having an innominate origin. The one point of consolation is that no operative interference was resorted to. New Cross, S.E. more
TWO CASES OF PHTHISIS IN WHICH KOCH’S NEW TUBERCULIN WAS TRIED. BY F. M.
SANDWITH, M.D. DURH., M.R.C.P. LOND.,
PHYSICIAN TO KASR-EL-AINI HOSPITAL, CAIRO.
always to be prepared culin itself is painless, a little stinging.
at the time it be used." The tuberbut the glycerine in the solution cause:;?
Cairo. __________________
A CASE OF CESAREAN SECTION FOR CYESIS COMPLICATED BY MALIGNANT DISEASE OF THE
RECTUM. BY ALBERT J. RIDDETT, M.R.C.S.ENG., LATE OBSTETRIC HOUSE
PHYSICIAN,
L.R.C.P.LOND.,
MIDDLESEX HOSPITAL.
ON Aug. 3rd, 1897,I was hastily summoned by a midwife to see a patient, aged thirty-seven years, who according to the account given me had been in labour twenty-four hours. I found the patient in a marked degree of prostration, the pulse 120 and occasionally intermittent; she had also vomited two or three times. On abdominal palpation I found the fcetus lying transversely with the cephalic extremity to the right side of the pelvis ; per vaginam the postarior vaginal wall was found to be pushed forwards, and a hard irregularmass could easily be made out blocking up the pelvic outlet. The true conjugate diameter only measured two and a half inches. Per rectum about four and a half inches from the anus a hard nodular swelling was felt, which bled even on careful manipulation. Uterine contractions were frequent and strong, so I at once gave a quarter of a grain of morphia hypodermically ; this was at 6 A.M. and effectually stopped the. contractions. From the cachectic appearance of the patient, the evident wasting, a history of occasional diarrhœa,. together with the presence of a tumour and the patient’s age,. I had no doubt that it was a case of malignant disease of the rectum, which had taken on a rapid growth during thelater weeks of pregnancy. This was, I learnt, the sixth confinement, the five previous ones having been quite normal. I put it to the patient’s friends that either craniotomy or Cæsarean section must be performed, strongly advocating the latter, inasmuch as I thought craniotomy would be dangerous, probably causing sloughing of some portion of the growth and consequently septic mischief. I saw the patient again; at 9 A.M., when, as the uterine contractions were recommencing, I gave another injection of morphia (quarter of a grain), and had her prepared for operation, the patient and her friends having given me permission to perform Cæsarean section. Ether having been administered I opened theabdomen by the ordinary laparotomy incision; then my friend, Dr. Owen Williams, who kindly assisted me at the operation, firmly compressed both broad ligaments, thus effectually controlling the blood-supply to the uterus ; the latter organ was quickly opened by a median longitudinal incision, sponges having been placed on either side to prevent escape of liquor amnii into the peritoneal cavity; the foetus was extracted, and the placenta (which was on the posterior uterine wall) with the membranes expressed. There was but an insignificant quantity of blood lost. The uterus contracted well under the stimuli of pressure and hot sponges. The muscular wall of the uterus was closed by twelve deep silk sutures, which did not include the mucous membrane ; superficial Lembert’s sutures were next inserted,. so that the peritoneal surfaces accurately approximated. The Fallopian tubes were next tied and divided. The uterus, which had been partly withdrawn from the abdominal cavity, was now replaced and the abdominal wall sutured in threelayers-(a) the peritoneum with catgut, (b) the sheath ofthe rectus with silk, and (e) the skin and superficial tissue with silkworm gut. I may say that the case resembles somewhat one Dr. Wm. Duncan had whilst I was his house physician at the Middlesex Hospital, and in the operation I have recorded F endea-.-oured to follow as closely as possible Dr. Duncan’s methods. The patient is now practically convalescent and has had an uninterrupted recovery save slight vomiting which commenced about twelve hours after the operation;, this was stopped by means of iced champagne. The child (a male) is alive and doing well.
CASE 1.—The first patient was a German who for four years has had tubercle of both lungs. Koch’s instructions were followed in all particulars, and the initial injection was 0milligramme, or two micro-milligrammes. The patient’s temperature taken at 7 A.M. and 7 P.M. ranged before treatment from 97.8 to 99’4°F., but the injection was invariably followed by a reaction, sending the evening temperature up to 1002° or 101°, and after three micro-milligrammes had been injected the evening thermometer showed 1014° and 101’6. But the morning temperature never rose above 97.80 , showing that the reaction only lasted a few hours. The injections were all made at 10.30 A.M. For the first two days the expectoration notably diminished, but then increased, especially at night. After three weeks the injections had to be discontinued because of slight pleurisy and haemoptysis. From the previous history of the patient I do not think that either of these complications were due to the tuberculin TR. The pulse and respiration rate hardly changed in spite of the temporary rise of temperature, being always 70 and 13 to 14 in the mornings and 97 and 20 to 22 in the evenings. CASE 2.-The second patient was a Greek, also suffering from chronic tuberculous lung disease. In his case there was also a temporary rise of 1° F. after injections of two, and again later after injections of three, micro-milligrammes. In his case there was also some local reaction, as shown by the appearance of pain and some diminution of swelling in a tuberculous epididymis. His lung symptoms seemed to improve under treatment. It is of course quite likely that Koch himself would have thought these two cases unsuitable for his new discovery. The tuberculin TR contains not the toxin but the components of the bacilli themselves, and will probably be found very useful for lupus without complications. If all lung cases react as easily as mine, the injections might be used as a method of diagnosis more delicate and less dangerous than Leicester. the old tuberculin. At present one is a little shy of a remedy which is to be increased in dosage from 1/500 milligramme UNIVERSITY OF DURHAM COLLEGE OF MEDICINE,. to 20 milligrammes-i.e., the minimum dose is 10,000 times smaller than the maximum. To become popular the new Newcastle-on-Tyne.-The prizes and scholarships will be remedy must be made easy to obtain, less costly, and mast presented at the opening of the Winter session by the Right. be diluted in a less cumbersome way, if " the dilution is Honourable Lord Barnard.
HOSPITAL MEDICINE AND SURGERY.
601
lurch, and
A Mirror OF
HOSPITAL BRITISH
PRACTICE,
AND
FOREIGN.
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.-MORGAGNI De Sed. et Caus. Morb" lib. iv. Procemium.
i
-
LONDON TEMPERANCE HOSPITAL. A CASE OF
PIROGOFF’S AMPUTATION.
(Under the care of Dr. W. J. COLLINS.) WHEN amputation at the ankle is required for disease of the foot there is a general consensus of opinion that Syme’s operation affords a better chance of the complete removal of the disease than Pirogoff’s, in which a portion of the os calcis is retained. This is especially the case in tuberculosis
I
of the tarsus, for it is rare to find such extensive disease of the tarsal bones as to require amputation without the calcaneum being affected. In the case of amputation for injury obviously this objection does not apply. Instrument makers assert that it is more difficult to adapt an artificial foot to a Pirogoff stump than to that resulting from a Syme’s amputation, but this is really an imaginary difficulty. The greater suitability of the stump for walking is the chief reason for preferring the Pirogoff operation to the other ; in the former it is practically the thick heel pad supported by a rounded bony surface which comes in contact with the ground, while in Syme’s the freshly sawn surfaces of the tibia and fibula press against the skin flap. A boy, aged thirteen years, whose family history was unimportant, was said to have injured his right foot when jumping some three weeks before his admission to the London Temperance Hospital on Nov. 3rd, 1896 ; an abscess formed and broke below the internal malleolus, leaving a
Sketch
showing relativ e lengths of stumps after Syme’s and
Pirogoff’s amputations.
sinus which was discharging. A probe indicated carious bone. The patient was in much pain and was subject to starting at night ; the temperature in the evening ran up to about 101° F. A week later no improvement had resulted from rest; the boy looked worse, was losing weight, and was in much pain. On the llth, under chloroform, Dr. Collins performed Pirogoff’s amputation of the foot. The, sawn surfaces of the tibia and os calcis appeared to be: healthy to the naked eye, and were brought into accurate! apposition by silk sutures passed through foramina bored with a brad-awl. The wound healed well, though the temperature: ranged high for a week or two. On Jan. 2nd, 1897, he could walk without a boot and was gaining weight rapidly. When fitted with a dummy foot he walked without any ,
so well that some who saw him could not believe that the foot had been amputated. Remarks by Dr. COLLINs.-The Moscow meeting will, doubtless afford occasion for reviving the fame won by Nikolaus Pirogoff in many fields of human activity. As a profound anatomist, a military surgeon, a hospital organiser, and a university reformer he has impressed his rugged personality upon the history of his time. True, that to the ordinary English student his name is known almost exclusively by his osteoplastic modification of Syme’s amputation. of which an account with a diagram is to be found in his " Klinische Chirurgie," published at Leipzig in 1854. But this improvement in amputation of the foot, as he practised it, as also as more recently modified by Lefort and Gunther, I recently happened to was in itself a valuable reform. have in my wards two children of about the same age and height; in one case I performed Syme’s amputation as the caries was too extensive to save any of the tarsus, and in the other case (the notes of which are given above) I performed PirogofE’s modified operation. It occurred to me to photograph the patients side by side. The accompanying illustration (which I have reproduced faithfully from the photograph) shows the advantage in length in the case of the boy as against the shortening in that of the girl, in which Syme’s unmodified operation was done. The difference in the gait was not less noticeable even when the shortening in the latter case was corrected by a_cork sole.
ROYAL INFIRMARY, NEWCASTLE-UPONTYNE. A CASE OF RELAPSING PNEUMONIA.
(Under the care of Dr. THOMAS OLIVER.) A MAN, aged twenty-three years, was, on Nov. 26th, 1896, admitted into the Newcastle Royal Infirmary under the care of Dr. Oliver. As the patient was delirious no history of the illness was at this stage obtainable, except from the remark volunteered by a friend that he had been in bed for five days. Subsequently when he recovered it was ascertained from him that while at work on the 21st he had been suddenly seized with a violent shivering at 11 A.M., that do what he might he could not get himself warm, and that in the afternoon he felt so unwell he was obliged to go to bed. On the morning after his admission into the infirmary he had a flushed face and rapid breathing, his mind was still wandering, and he was the subject of short cough and rusty expectoration He was too ill for a careful examination to be made. All that could be done, therefore, was to make an examination of the front of the chest, by which was detected a limited area that was dull on percussion, commencing a few inches below the right clavicle, and over this area distinct tubular breathing could be heard. The left chest and heart were healthy. On the 28th, while there was evidence of the percussion note over the upper part of the right chest being less dull, there was detected a small area of dulness external to the right nipple and also that the base of the lung was dull. The area which gave this altered percussion note extended in an upward but slanting direction towards the axilla. On examining the chest posteriorly tubular breathing could be heard from the inferior angle of the right scapula downwards. Although the breathing was rapid (56 to the minute) there was no actual dyspnoea, the pulse was 110, and the temperature was 102° F., having fallen 2° since the previous night. Later in the course of the day there was a considerable degree of muscular twitching, but this disappeared on discontinuing the liquor strychninaa which for the past two days he had been taking. On the 30th he seemed to be rather better. His temperature on the previous afternoon was 1052°, but by midnight it had fallen to 98.4°, and with the fall of his temperature the delirium disappeared. For brevity’s sake, although the four hours’ chart is quoted from, it is not reproduced. For the next two days the patient seemed on the whole to be fairly well; but although his temperature had fallen he never exhibited that look of well-being which is discernible in any one who, having passed successfully through a sharp illness like pneumonia, may be said to have "turned the corner." He was heavy and listless, so much so that when, after remaining thus for a few days, and the temperature again began to rise, and the dulness at the right
CLINICAL NOTES.
600
tenderness and erythema over the sac, no articulation with the sternum could be made out. In August there were increasing asphyxia, loss of power, and pain in spite of pushed doses of opium, chloral, and bromide, as well as belladonna locally. For the last three days of life there were cedema of both hands and much sweating. His florid complexion was maintained till the morning of his death, for two hours before which there were marked pallor and complete unconsciousness. Necropsy.-The post-mortem examination was made on Aug. 12th, eleven hours after death. An examination of the chest only was allowed. The aneurysm was of the arch of the aorta, saccular, not diffuse, and there had been no rupture of it. The sac was the size of two fists and extended upwards to above the cricoid cartilage, and, having destroyed the right sterno-clavicular joint, depressed the clavicle and overlapped the right half of the sternum to below its junction with the second rib, the sternal end of the clavicle and the outer and posterior upper portion of the manubrium being completely eroded. The aneurysm commenced just internally to the origin of the innominate artery, which, beyond compression by the sac, was scarcely, if at all, implicated in it. Remarks.-The points of interest in this case are the sudden appearance of the aneurysm, its rapid growth, and peculiar distribution. The possibility of its being aortic was not lost sight of : but certainly at the time of diagnosis and, indeed, until the extension of the enlargement to the left, two months later, all the symptoms pointed to its having an innominate origin. The one point of consolation is that no operative interference was resorted to. New Cross, S.E. more
TWO CASES OF PHTHISIS IN WHICH KOCH’S NEW TUBERCULIN WAS TRIED. BY F. M.
SANDWITH, M.D. DURH., M.R.C.P. LOND.,
PHYSICIAN TO KASR-EL-AINI HOSPITAL, CAIRO.
always to be prepared culin itself is painless, a little stinging.
at the time it be used." The tuberbut the glycerine in the solution cause:;?
Cairo. __________________
A CASE OF CESAREAN SECTION FOR CYESIS COMPLICATED BY MALIGNANT DISEASE OF THE
RECTUM. BY ALBERT J. RIDDETT, M.R.C.S.ENG., LATE OBSTETRIC HOUSE
PHYSICIAN,
L.R.C.P.LOND.,
MIDDLESEX HOSPITAL.
ON Aug. 3rd, 1897,I was hastily summoned by a midwife to see a patient, aged thirty-seven years, who according to the account given me had been in labour twenty-four hours. I found the patient in a marked degree of prostration, the pulse 120 and occasionally intermittent; she had also vomited two or three times. On abdominal palpation I found the fcetus lying transversely with the cephalic extremity to the right side of the pelvis ; per vaginam the postarior vaginal wall was found to be pushed forwards, and a hard irregularmass could easily be made out blocking up the pelvic outlet. The true conjugate diameter only measured two and a half inches. Per rectum about four and a half inches from the anus a hard nodular swelling was felt, which bled even on careful manipulation. Uterine contractions were frequent and strong, so I at once gave a quarter of a grain of morphia hypodermically ; this was at 6 A.M. and effectually stopped the. contractions. From the cachectic appearance of the patient, the evident wasting, a history of occasional diarrhœa,. together with the presence of a tumour and the patient’s age,. I had no doubt that it was a case of malignant disease of the rectum, which had taken on a rapid growth during thelater weeks of pregnancy. This was, I learnt, the sixth confinement, the five previous ones having been quite normal. I put it to the patient’s friends that either craniotomy or Cæsarean section must be performed, strongly advocating the latter, inasmuch as I thought craniotomy would be dangerous, probably causing sloughing of some portion of the growth and consequently septic mischief. I saw the patient again; at 9 A.M., when, as the uterine contractions were recommencing, I gave another injection of morphia (quarter of a grain), and had her prepared for operation, the patient and her friends having given me permission to perform Cæsarean section. Ether having been administered I opened theabdomen by the ordinary laparotomy incision; then my friend, Dr. Owen Williams, who kindly assisted me at the operation, firmly compressed both broad ligaments, thus effectually controlling the blood-supply to the uterus ; the latter organ was quickly opened by a median longitudinal incision, sponges having been placed on either side to prevent escape of liquor amnii into the peritoneal cavity; the foetus was extracted, and the placenta (which was on the posterior uterine wall) with the membranes expressed. There was but an insignificant quantity of blood lost. The uterus contracted well under the stimuli of pressure and hot sponges. The muscular wall of the uterus was closed by twelve deep silk sutures, which did not include the mucous membrane ; superficial Lembert’s sutures were next inserted,. so that the peritoneal surfaces accurately approximated. The Fallopian tubes were next tied and divided. The uterus, which had been partly withdrawn from the abdominal cavity, was now replaced and the abdominal wall sutured in threelayers-(a) the peritoneum with catgut, (b) the sheath ofthe rectus with silk, and (e) the skin and superficial tissue with silkworm gut. I may say that the case resembles somewhat one Dr. Wm. Duncan had whilst I was his house physician at the Middlesex Hospital, and in the operation I have recorded F endea-.-oured to follow as closely as possible Dr. Duncan’s methods. The patient is now practically convalescent and has had an uninterrupted recovery save slight vomiting which commenced about twelve hours after the operation;, this was stopped by means of iced champagne. The child (a male) is alive and doing well.
CASE 1.—The first patient was a German who for four years has had tubercle of both lungs. Koch’s instructions were followed in all particulars, and the initial injection was 0milligramme, or two micro-milligrammes. The patient’s temperature taken at 7 A.M. and 7 P.M. ranged before treatment from 97.8 to 99’4°F., but the injection was invariably followed by a reaction, sending the evening temperature up to 1002° or 101°, and after three micro-milligrammes had been injected the evening thermometer showed 1014° and 101’6. But the morning temperature never rose above 97.80 , showing that the reaction only lasted a few hours. The injections were all made at 10.30 A.M. For the first two days the expectoration notably diminished, but then increased, especially at night. After three weeks the injections had to be discontinued because of slight pleurisy and haemoptysis. From the previous history of the patient I do not think that either of these complications were due to the tuberculin TR. The pulse and respiration rate hardly changed in spite of the temporary rise of temperature, being always 70 and 13 to 14 in the mornings and 97 and 20 to 22 in the evenings. CASE 2.-The second patient was a Greek, also suffering from chronic tuberculous lung disease. In his case there was also a temporary rise of 1° F. after injections of two, and again later after injections of three, micro-milligrammes. In his case there was also some local reaction, as shown by the appearance of pain and some diminution of swelling in a tuberculous epididymis. His lung symptoms seemed to improve under treatment. It is of course quite likely that Koch himself would have thought these two cases unsuitable for his new discovery. The tuberculin TR contains not the toxin but the components of the bacilli themselves, and will probably be found very useful for lupus without complications. If all lung cases react as easily as mine, the injections might be used as a method of diagnosis more delicate and less dangerous than Leicester. the old tuberculin. At present one is a little shy of a remedy which is to be increased in dosage from 1/500 milligramme UNIVERSITY OF DURHAM COLLEGE OF MEDICINE,. to 20 milligrammes-i.e., the minimum dose is 10,000 times smaller than the maximum. To become popular the new Newcastle-on-Tyne.-The prizes and scholarships will be remedy must be made easy to obtain, less costly, and mast presented at the opening of the Winter session by the Right. be diluted in a less cumbersome way, if " the dilution is Honourable Lord Barnard.
HOSPITAL MEDICINE AND SURGERY.
601
lurch, and
A Mirror OF
HOSPITAL BRITISH
PRACTICE,
AND
FOREIGN.
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.-MORGAGNI De Sed. et Caus. Morb" lib. iv. Procemium.
i
-
LONDON TEMPERANCE HOSPITAL. A CASE OF
PIROGOFF’S AMPUTATION.
(Under the care of Dr. W. J. COLLINS.) WHEN amputation at the ankle is required for disease of the foot there is a general consensus of opinion that Syme’s operation affords a better chance of the complete removal of the disease than Pirogoff’s, in which a portion of the os calcis is retained. This is especially the case in tuberculosis
I
of the tarsus, for it is rare to find such extensive disease of the tarsal bones as to require amputation without the calcaneum being affected. In the case of amputation for injury obviously this objection does not apply. Instrument makers assert that it is more difficult to adapt an artificial foot to a Pirogoff stump than to that resulting from a Syme’s amputation, but this is really an imaginary difficulty. The greater suitability of the stump for walking is the chief reason for preferring the Pirogoff operation to the other ; in the former it is practically the thick heel pad supported by a rounded bony surface which comes in contact with the ground, while in Syme’s the freshly sawn surfaces of the tibia and fibula press against the skin flap. A boy, aged thirteen years, whose family history was unimportant, was said to have injured his right foot when jumping some three weeks before his admission to the London Temperance Hospital on Nov. 3rd, 1896 ; an abscess formed and broke below the internal malleolus, leaving a
Sketch
showing relativ e lengths of stumps after Syme’s and
Pirogoff’s amputations.
sinus which was discharging. A probe indicated carious bone. The patient was in much pain and was subject to starting at night ; the temperature in the evening ran up to about 101° F. A week later no improvement had resulted from rest; the boy looked worse, was losing weight, and was in much pain. On the llth, under chloroform, Dr. Collins performed Pirogoff’s amputation of the foot. The, sawn surfaces of the tibia and os calcis appeared to be: healthy to the naked eye, and were brought into accurate! apposition by silk sutures passed through foramina bored with a brad-awl. The wound healed well, though the temperature: ranged high for a week or two. On Jan. 2nd, 1897, he could walk without a boot and was gaining weight rapidly. When fitted with a dummy foot he walked without any ,
so well that some who saw him could not believe that the foot had been amputated. Remarks by Dr. COLLINs.-The Moscow meeting will, doubtless afford occasion for reviving the fame won by Nikolaus Pirogoff in many fields of human activity. As a profound anatomist, a military surgeon, a hospital organiser, and a university reformer he has impressed his rugged personality upon the history of his time. True, that to the ordinary English student his name is known almost exclusively by his osteoplastic modification of Syme’s amputation. of which an account with a diagram is to be found in his " Klinische Chirurgie," published at Leipzig in 1854. But this improvement in amputation of the foot, as he practised it, as also as more recently modified by Lefort and Gunther, I recently happened to was in itself a valuable reform. have in my wards two children of about the same age and height; in one case I performed Syme’s amputation as the caries was too extensive to save any of the tarsus, and in the other case (the notes of which are given above) I performed PirogofE’s modified operation. It occurred to me to photograph the patients side by side. The accompanying illustration (which I have reproduced faithfully from the photograph) shows the advantage in length in the case of the boy as against the shortening in that of the girl, in which Syme’s unmodified operation was done. The difference in the gait was not less noticeable even when the shortening in the latter case was corrected by a_cork sole.
ROYAL INFIRMARY, NEWCASTLE-UPONTYNE. A CASE OF RELAPSING PNEUMONIA.
(Under the care of Dr. THOMAS OLIVER.) A MAN, aged twenty-three years, was, on Nov. 26th, 1896, admitted into the Newcastle Royal Infirmary under the care of Dr. Oliver. As the patient was delirious no history of the illness was at this stage obtainable, except from the remark volunteered by a friend that he had been in bed for five days. Subsequently when he recovered it was ascertained from him that while at work on the 21st he had been suddenly seized with a violent shivering at 11 A.M., that do what he might he could not get himself warm, and that in the afternoon he felt so unwell he was obliged to go to bed. On the morning after his admission into the infirmary he had a flushed face and rapid breathing, his mind was still wandering, and he was the subject of short cough and rusty expectoration He was too ill for a careful examination to be made. All that could be done, therefore, was to make an examination of the front of the chest, by which was detected a limited area that was dull on percussion, commencing a few inches below the right clavicle, and over this area distinct tubular breathing could be heard. The left chest and heart were healthy. On the 28th, while there was evidence of the percussion note over the upper part of the right chest being less dull, there was detected a small area of dulness external to the right nipple and also that the base of the lung was dull. The area which gave this altered percussion note extended in an upward but slanting direction towards the axilla. On examining the chest posteriorly tubular breathing could be heard from the inferior angle of the right scapula downwards. Although the breathing was rapid (56 to the minute) there was no actual dyspnoea, the pulse was 110, and the temperature was 102° F., having fallen 2° since the previous night. Later in the course of the day there was a considerable degree of muscular twitching, but this disappeared on discontinuing the liquor strychninaa which for the past two days he had been taking. On the 30th he seemed to be rather better. His temperature on the previous afternoon was 1052°, but by midnight it had fallen to 98.4°, and with the fall of his temperature the delirium disappeared. For brevity’s sake, although the four hours’ chart is quoted from, it is not reproduced. For the next two days the patient seemed on the whole to be fairly well; but although his temperature had fallen he never exhibited that look of well-being which is discernible in any one who, having passed successfully through a sharp illness like pneumonia, may be said to have "turned the corner." He was heavy and listless, so much so that when, after remaining thus for a few days, and the temperature again began to rise, and the dulness at the right