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A CASE OF DISSECTING ANEURYSM.
810
specific
treatment should be
recovered
rapidly
and
given. completely.
The
resumption
in the functions of the of normal erythropoiesis.
patient improvement
A boy, aged 3, developed a boil on the left side of the neck. Three weeks later he had a coarse purpuric eruption, one or two of the patches breaking down and ulcerating, and his nose bled. The spleen was not palpable. The blood count was : red cells, 4,470,000 per c.mm. ; white cells, 8100 ; haemoglobin, 74 per cent. ; colour-index, 0-8 ; the differential count was normal ; platelets were reduced to 12,000 per c.mm. ; the bleeding time was much prolonged. The boil was incised, but there was no other treatment beyond ordinary nursing care. A week after admission the platelets had increased to 23,000 ; a month after admission they were 256,000 per c.mm., and the bleeding time was normal.
Few maladies can inspire us with a more urgent desire to institute active treatment than acute essential thrombopenia. Few are more liable to the fallacy of post hoc, propter hoc. It is undesirable that in so brief and so dangerous an illness the physician should rely on a therapeutic measure of unproved worth. It is clear that the value of liver is at any rate not proved in acute essential thrombopenia, while the following cases conclusively show that it has no action in chronic essential thrombopenia. CASE l.-A woman, aged 54, has suffered from recurrent attacks of purpura and epistaxis since she was 9 years old. She was admitted to hospital after an epistaxis lasting 12 hours. There were several purpuric spots, and she bruised very readily. The spleen was not palpable. The only abnormality in the blood count was a diminution of the platelets to 27,000 per c.mm. She was treated with I, liver extract for four months without any demonstrable -effect on the platelet count, and another severe epistaxis then occurred. No change occurred on omitting the liver ’treatment.
marrow on
the
REFERENCES.
1. Nittis, S.: Annals Int. Med., 1931, iv., 931. 2. Cramer, W. : THE LANCET, 1929, ii., 1332. 3. Cramer, and Drew, A. H.: Brit. Jour. Exp. 4. 5. 6. 7.
Path., 1923, iv., 271. Mondon, M. H.: Bull. et mém. de la Soc. Méd. des hôp. de Paris, 1928, lii., 1403. Holboll, S. A. : Hospitalstidende, 1929, lxxii., 841. Jacob, F. H., and Clapperton, T. : Brit. Med. Jour., 1930, i., 823. Box, C. R., and Massingham, R. : THE LANCET, Feb. 7th, p. 295.
A CASE OF DISSECTING ANEURYSM. BY J. L. LATE HOUSE
SWANSTON, M.B. EDIN.,
PETERBOROUGH AND DISTRICT MEMORIAL HOSPITAL.
SURGEON,
AN
engineer, a well-nourished and well-developed aged 54, was admitted to hospital with the following history. In the morning he was carrying a pail of coals when a sharp cutting pain in his man
stomach made him sink to his knees and then on the floor. The pain started in his back and went round his stomach. It was continuous and severe-he writhed in agony. He felt sick, but did not vomit. He had had a sharp pain in his stomach 14 days ago while working. He had always been active and healthy. He had no urinary or biliary symptoms. Appetite was good, no indigestion, bowels regular CASE 2.-A man, aged 50, has been attending Guy’s and opened that morning. Hospital with essential thrombopenia and secondary anaemia for 25 years. He is hardly ever free from slight Condition on admission.-Temp. 96.80 F., pulse-rate 66, epistaxis and melasna, but tolerates his disability very well respirations 28. Patient writhing in agony, groaning and -and steadfastly refuses splenectomy. The bleeding time is short of breath. Pain all over stomach. Abdominal much prolonged, and the spleen is easily palpable. At no excursion, with respiration ; large. umbilical reflex time have I been able to find more than 15,000 platelets per absent, slight hyperaesthesia all over. Percussion tympanitic ’c.mm. He was treated with liver extract and whole liver except in right flank, where dull. Liver dullness sixth for four months without improvement. CASE 3.-A man, aged 20, was one of
to costal margin. Abdominal musculature very rigid, despite deep breathing. Tongue dry and slightly a family of five furred. Pupils equal, reacting briskly to light; knee-jerks, children, three of whom have suffered from essential throm- left, + ; and right, + +. Respiratory system : slight bopenia. A sister died from haemorrhage at the age of 5. dullness right side ; vocal resonance +, vesicular breath He had suffered from epistaxis and melaena for 15 years. ; no accompaniments. Cardiac system : apex-beat, ’He had never had purpura, but bruised readily. The sounds sixth space, 4 in. out ; sounds closed. Urine : no sugar, was was not palpable, but the bleeding time "spleen pro- albumin, pus, or bile by ordinary tests. longed. His platelets were 30,000 per c.mm. He was It was decided to operate, but a mid-line incision failed 1treated with liver extract and whole liver by mouth for to reveal any abnormality and the abdomen was closed. tthree months. The platelets underwent no improvement, The patient’s condition remained unchanged and pain was and he had two severe epistaxes. He was readmitted to controlled by morphia. On the following afternoon he hospital for splenectomy, and died 36 hours after operation. " was feeling much better " but after a wash he suddenly CASE 4.-A boy, aged 7, brother of the above, has suffered became pale and dyspnceic and died. At autopsy the right thoracic cavity contained one gallon from bleeding from the gums and purpura since he was 4. His platelet count fluctuates between 10,000 and 90,000 of clotted blood which was displacing the lung and heart per c.mm. He has had rather irregular treatment with well over to the left side. The posterior mediastinum contained extravasated blood and the root of the lung Siver without improvement. showed a tear posteriorly and the pleural surface was CASE 5.-A man, aged 37, developed a severe secondary otherwise healthy. The alimentary system was healthy anaemia and thrombopenia, with purpura, haemorrhage and the stomach very large. The extravasation in the from the gums, and small cerebral haemorrhages, after posterior mediastinum was seen to extend down the spinal treatment of a chronic prostatitis. He was at first thought column along the aorta and common iliacs to their bifurca0 have septicaemia, but improved greatly with a series of tion. The aorta admitted no more than the tips of two ’transfusions. Thrombopenia and secondary anaemia per- fingers at any part. It had atheromatous changes most sisted. He was treated for two months with-liver and liver marked in the abdominal portion. At the junction of the - extract, but the platelet count was unchanged and small arch and thoracic portion was a T-shaped rupture of intima naemorrhages were continually present. I am unable to and media coat. About the middle of the abdominal decide whether he is suffering from essential thrombopenia portion was a second rupture ; it was 2-3 in. long and in or a chronic aplastic anaemia. the long axis of the aorta. The intima and media coats were separated from the tunica externa by clotted blood In all five cases the platelets fluctuated in numbers from a few inches below the lower rupture to the upper one. clotted blood was abundant around the aorta during the liver treatment, as they do in untreated Extravasated but the point through which it had passed the tunica little to rise after and a cases, tending haemorrhage
externa
was
not found.
below the critical level. The heart was enlarged and dilated. The pulmonary In no case was there any permanent increase in the and aortic valves were competent, with slight thickening number of platelets, and all bled during the liver of the mitral cusps. All the arteries had thickened walls. The kidneys showed a fine degree of chronic interstitial treatment. One must conclude that liver has no nephritis. Lungs and liver were congested. - specific power to increase the number of platelets, This case brings forward the difficulty in diagnosing .and that the rise in platelets which accompanies liver a treatment in pernicious anaemia is secondary to the dissecting aneurysm. The sequence of events can, sooner or
later
space
falling again
811 I A sudden slight increase blood, the sudden hsemothorax being the immediate in the blood pressure caused the aorta to stretch, I cause of death. but the inner walls being calcareous and less disThe interesting point is the resemblance the case tensible than the elastic outer wall, ruptured at the I had to a perforated gastric or duodenal ulcer. I consite of greatest strain-outside of the bend (arch) I sider the following points were of greatest diagnostic and the large area (abdominal portion), the pressurei value : (1) Site of origin of pain-viz., in the back and of the blood then tracking into and through the walls,I not epigastrium. (2) There was no period of reaction and eventually finding a spot to burst into the pleural idue to the dilating peritoneal fluids or shutting offby cavity at the root of the lung. The abdominal pain I omental adhesion, &c. (3) Respiration was of large and rigidity was referred from this area of extravasating excursion, and not short and jerky as in peritonitis.
however, be easily followed.
MEDICAL SOCIETIES DISCUSSION.
TUBERCULOSIS ASSOCIATION.
Dr. T. CAMPBELL emphasised the possibility of primary infection in adult life, and regretted the AT a meeting of this society held at Oxford from concentration of attention on childhood infection.Thursday, March 26th, to Saturday, the 28th, the Dr. W. C. FOWLER regarded the regeneration of lung Thursday session was chiefly occupied with a dis- tissue as in the nature of a compensatory emphysema. cussion on Stereoscopic Radiography (see p. 822). - Dr. A. J. MORLAND pointed out the curious fact At the morning session on Friday a discussion on the that early cavities were absolutely spherical. He thought this was brought about by the retention of Natural Processes of Healing air under pressure owing to the valvular opening. When the air was liberated the cavity might collapse in pulmonary tuberculosis was introduced by Dr. JAQUEROD, of Leysin. Rest, hygiene, and diet as and practically disappear.-Dr. BURRELL thought methods of treating tuberculosis were now, he said, Dr. Morland’s suggestion might explain the existence being relegated to a secondary position. All treat- of pleural rings, which did not fill with lipiodol or ment tended towards collapse therapy, and those collapse with artificial pneumothorax.-Dr. G. 1B who believed in inducing an artificial pneumothorax HEBERT adverted to Mitchell’s theory of an air sac early were in the ascendant. Radiology had rendered as an explanation of pleural rings or annular shadow8 invaluable service to the study of the processes of - Dr. C. H. TOUSSAINT raised the administrative healing. Apart from certain acute and generalised i importance of the two factors, natural healing and. forms, pulmonary tuberculosis might be regarded as active intervention. Public cost had a bearing on A waiting-list meant the loss of important earlya chronic illness from the beginning, and this con- it. in treatment.-Dr. G. JESSEL spoke of thebe weeks the basis of of the should ception any description I Virchow’s of view was that all importance of relapses complicating the natural processes healing. lesions of pulmonary tuberculosis necessarily origin process of healing. He had noticed that cervical nated from miliary tubercles, but there were in thei glands, after apparent healing with artificial sunlight neighbourhood of chronic and fibrocaseous foci treatment, might again relapse.-Dr. R. R. TRAIL congested and simple inflammatory areas which said he had obtained help from the sedimentation nowadays were regarded as the antecedents of test in estimating resistance. Apart from pleurisy,. chronic lesions. This conception of the pneumonicI which always showed a high rate, chances were good nature of tuberculous lesions if a patient had a rate of from 9-20 per cent. Overor inflammatory in the minds of two English pathologists, 40 treatment was probably a waste of time.-Dr.originated Wilson Fox and Green, in 1873. Dr. Jaquerod F. R. WALTERS suggested the division of the waitingconsidered that in this stage of the disease the tubercle list into an urgent and a non-urgent category.bacilli remained on the surface of the mucous Dr. BASIL PRICE thought that while modern view membrane between the epithelial cells, in the alveolar had swung back to the aerogenous theory of origin, and intercellular spaces, and that their destruction the relation of this theory to lymphatic circulation and elimination was therefore rendered much easier. needed more consideration than it had obtained. It was only when these lesions did not heal that new In his experience the Ministry of Pensions cases of bronchitis and emphysema, which had been.. tissues were produced. ’ chronic The question, How recent is the disease " was watched ever since the war, not infrequently developedtherefore a matter of primary importance. It was pulmonary tuberculosis.-Dr. S. R. GLOYNE wa& necessary to distinguish the non-allergic type impressed with the different course that the process. found in childhood from the lesion of a patient of healing took in the different natural orders in the already sensitised by previous contact with tubercle animal kingdom. In man the processes of healing bacilli. In the former the pulmonary lesions might were nowadays largely studied by the radiologists,. regress and heal by resolution, or pass the non- who saw the patient long before the pathologist did". allergic phase and become serious. In the latter the and it was difficult to correlate the morbid anatomy inflammatory reaction was broncho-pneumonic, and with what was seen on the film. might end in cavity formation. This cavity was, In the afternoon Dr. L. T. S. BURRELL and Dr. N however, different from that of chronic disease ; its TATTERSALL introduced a discussion on the walls were not well-organised pyogenic membrane, but simple inflammatory tissue. It might heal by Future of Artificial Pneumothorax resolutio without leaving any apparent scar. A third form, chronic fibrocaseous tuberculosis, was a treatment. Dr. Burrell said that collapse therapy complicated process leading to fibrous transformation was the simplest method of applying the principle of the lung. The first two forms always existed of rest to the lung. All early cases of unilateral disease before the third, and it was in these that treatment I would, he thought, in the near future be so treated ! unless there was definite contra. indication ; more had its best chance of success.
I
M.
i
I
il
i
‘
specific
treatment should be
recovered
rapidly
and
given. completely.
The
resumption
in the functions of the of normal erythropoiesis.
patient improvement
A boy, aged 3, developed a boil on the left side of the neck. Three weeks later he had a coarse purpuric eruption, one or two of the patches breaking down and ulcerating, and his nose bled. The spleen was not palpable. The blood count was : red cells, 4,470,000 per c.mm. ; white cells, 8100 ; haemoglobin, 74 per cent. ; colour-index, 0-8 ; the differential count was normal ; platelets were reduced to 12,000 per c.mm. ; the bleeding time was much prolonged. The boil was incised, but there was no other treatment beyond ordinary nursing care. A week after admission the platelets had increased to 23,000 ; a month after admission they were 256,000 per c.mm., and the bleeding time was normal.
Few maladies can inspire us with a more urgent desire to institute active treatment than acute essential thrombopenia. Few are more liable to the fallacy of post hoc, propter hoc. It is undesirable that in so brief and so dangerous an illness the physician should rely on a therapeutic measure of unproved worth. It is clear that the value of liver is at any rate not proved in acute essential thrombopenia, while the following cases conclusively show that it has no action in chronic essential thrombopenia. CASE l.-A woman, aged 54, has suffered from recurrent attacks of purpura and epistaxis since she was 9 years old. She was admitted to hospital after an epistaxis lasting 12 hours. There were several purpuric spots, and she bruised very readily. The spleen was not palpable. The only abnormality in the blood count was a diminution of the platelets to 27,000 per c.mm. She was treated with I, liver extract for four months without any demonstrable -effect on the platelet count, and another severe epistaxis then occurred. No change occurred on omitting the liver ’treatment.
marrow on
the
REFERENCES.
1. Nittis, S.: Annals Int. Med., 1931, iv., 931. 2. Cramer, W. : THE LANCET, 1929, ii., 1332. 3. Cramer, and Drew, A. H.: Brit. Jour. Exp. 4. 5. 6. 7.
Path., 1923, iv., 271. Mondon, M. H.: Bull. et mém. de la Soc. Méd. des hôp. de Paris, 1928, lii., 1403. Holboll, S. A. : Hospitalstidende, 1929, lxxii., 841. Jacob, F. H., and Clapperton, T. : Brit. Med. Jour., 1930, i., 823. Box, C. R., and Massingham, R. : THE LANCET, Feb. 7th, p. 295.
A CASE OF DISSECTING ANEURYSM. BY J. L. LATE HOUSE
SWANSTON, M.B. EDIN.,
PETERBOROUGH AND DISTRICT MEMORIAL HOSPITAL.
SURGEON,
AN
engineer, a well-nourished and well-developed aged 54, was admitted to hospital with the following history. In the morning he was carrying a pail of coals when a sharp cutting pain in his man
stomach made him sink to his knees and then on the floor. The pain started in his back and went round his stomach. It was continuous and severe-he writhed in agony. He felt sick, but did not vomit. He had had a sharp pain in his stomach 14 days ago while working. He had always been active and healthy. He had no urinary or biliary symptoms. Appetite was good, no indigestion, bowels regular CASE 2.-A man, aged 50, has been attending Guy’s and opened that morning. Hospital with essential thrombopenia and secondary anaemia for 25 years. He is hardly ever free from slight Condition on admission.-Temp. 96.80 F., pulse-rate 66, epistaxis and melasna, but tolerates his disability very well respirations 28. Patient writhing in agony, groaning and -and steadfastly refuses splenectomy. The bleeding time is short of breath. Pain all over stomach. Abdominal much prolonged, and the spleen is easily palpable. At no excursion, with respiration ; large. umbilical reflex time have I been able to find more than 15,000 platelets per absent, slight hyperaesthesia all over. Percussion tympanitic ’c.mm. He was treated with liver extract and whole liver except in right flank, where dull. Liver dullness sixth for four months without improvement. CASE 3.-A man, aged 20, was one of
to costal margin. Abdominal musculature very rigid, despite deep breathing. Tongue dry and slightly a family of five furred. Pupils equal, reacting briskly to light; knee-jerks, children, three of whom have suffered from essential throm- left, + ; and right, + +. Respiratory system : slight bopenia. A sister died from haemorrhage at the age of 5. dullness right side ; vocal resonance +, vesicular breath He had suffered from epistaxis and melaena for 15 years. ; no accompaniments. Cardiac system : apex-beat, ’He had never had purpura, but bruised readily. The sounds sixth space, 4 in. out ; sounds closed. Urine : no sugar, was was not palpable, but the bleeding time "spleen pro- albumin, pus, or bile by ordinary tests. longed. His platelets were 30,000 per c.mm. He was It was decided to operate, but a mid-line incision failed 1treated with liver extract and whole liver by mouth for to reveal any abnormality and the abdomen was closed. tthree months. The platelets underwent no improvement, The patient’s condition remained unchanged and pain was and he had two severe epistaxes. He was readmitted to controlled by morphia. On the following afternoon he hospital for splenectomy, and died 36 hours after operation. " was feeling much better " but after a wash he suddenly CASE 4.-A boy, aged 7, brother of the above, has suffered became pale and dyspnceic and died. At autopsy the right thoracic cavity contained one gallon from bleeding from the gums and purpura since he was 4. His platelet count fluctuates between 10,000 and 90,000 of clotted blood which was displacing the lung and heart per c.mm. He has had rather irregular treatment with well over to the left side. The posterior mediastinum contained extravasated blood and the root of the lung Siver without improvement. showed a tear posteriorly and the pleural surface was CASE 5.-A man, aged 37, developed a severe secondary otherwise healthy. The alimentary system was healthy anaemia and thrombopenia, with purpura, haemorrhage and the stomach very large. The extravasation in the from the gums, and small cerebral haemorrhages, after posterior mediastinum was seen to extend down the spinal treatment of a chronic prostatitis. He was at first thought column along the aorta and common iliacs to their bifurca0 have septicaemia, but improved greatly with a series of tion. The aorta admitted no more than the tips of two ’transfusions. Thrombopenia and secondary anaemia per- fingers at any part. It had atheromatous changes most sisted. He was treated for two months with-liver and liver marked in the abdominal portion. At the junction of the - extract, but the platelet count was unchanged and small arch and thoracic portion was a T-shaped rupture of intima naemorrhages were continually present. I am unable to and media coat. About the middle of the abdominal decide whether he is suffering from essential thrombopenia portion was a second rupture ; it was 2-3 in. long and in or a chronic aplastic anaemia. the long axis of the aorta. The intima and media coats were separated from the tunica externa by clotted blood In all five cases the platelets fluctuated in numbers from a few inches below the lower rupture to the upper one. clotted blood was abundant around the aorta during the liver treatment, as they do in untreated Extravasated but the point through which it had passed the tunica little to rise after and a cases, tending haemorrhage
externa
was
not found.
below the critical level. The heart was enlarged and dilated. The pulmonary In no case was there any permanent increase in the and aortic valves were competent, with slight thickening number of platelets, and all bled during the liver of the mitral cusps. All the arteries had thickened walls. The kidneys showed a fine degree of chronic interstitial treatment. One must conclude that liver has no nephritis. Lungs and liver were congested. - specific power to increase the number of platelets, This case brings forward the difficulty in diagnosing .and that the rise in platelets which accompanies liver a treatment in pernicious anaemia is secondary to the dissecting aneurysm. The sequence of events can, sooner or
later
space
falling again
811 I A sudden slight increase blood, the sudden hsemothorax being the immediate in the blood pressure caused the aorta to stretch, I cause of death. but the inner walls being calcareous and less disThe interesting point is the resemblance the case tensible than the elastic outer wall, ruptured at the I had to a perforated gastric or duodenal ulcer. I consite of greatest strain-outside of the bend (arch) I sider the following points were of greatest diagnostic and the large area (abdominal portion), the pressurei value : (1) Site of origin of pain-viz., in the back and of the blood then tracking into and through the walls,I not epigastrium. (2) There was no period of reaction and eventually finding a spot to burst into the pleural idue to the dilating peritoneal fluids or shutting offby cavity at the root of the lung. The abdominal pain I omental adhesion, &c. (3) Respiration was of large and rigidity was referred from this area of extravasating excursion, and not short and jerky as in peritonitis.
however, be easily followed.
MEDICAL SOCIETIES DISCUSSION.
TUBERCULOSIS ASSOCIATION.
Dr. T. CAMPBELL emphasised the possibility of primary infection in adult life, and regretted the AT a meeting of this society held at Oxford from concentration of attention on childhood infection.Thursday, March 26th, to Saturday, the 28th, the Dr. W. C. FOWLER regarded the regeneration of lung Thursday session was chiefly occupied with a dis- tissue as in the nature of a compensatory emphysema. cussion on Stereoscopic Radiography (see p. 822). - Dr. A. J. MORLAND pointed out the curious fact At the morning session on Friday a discussion on the that early cavities were absolutely spherical. He thought this was brought about by the retention of Natural Processes of Healing air under pressure owing to the valvular opening. When the air was liberated the cavity might collapse in pulmonary tuberculosis was introduced by Dr. JAQUEROD, of Leysin. Rest, hygiene, and diet as and practically disappear.-Dr. BURRELL thought methods of treating tuberculosis were now, he said, Dr. Morland’s suggestion might explain the existence being relegated to a secondary position. All treat- of pleural rings, which did not fill with lipiodol or ment tended towards collapse therapy, and those collapse with artificial pneumothorax.-Dr. G. 1B who believed in inducing an artificial pneumothorax HEBERT adverted to Mitchell’s theory of an air sac early were in the ascendant. Radiology had rendered as an explanation of pleural rings or annular shadow8 invaluable service to the study of the processes of - Dr. C. H. TOUSSAINT raised the administrative healing. Apart from certain acute and generalised i importance of the two factors, natural healing and. forms, pulmonary tuberculosis might be regarded as active intervention. Public cost had a bearing on A waiting-list meant the loss of important earlya chronic illness from the beginning, and this con- it. in treatment.-Dr. G. JESSEL spoke of thebe weeks the basis of of the should ception any description I Virchow’s of view was that all importance of relapses complicating the natural processes healing. lesions of pulmonary tuberculosis necessarily origin process of healing. He had noticed that cervical nated from miliary tubercles, but there were in thei glands, after apparent healing with artificial sunlight neighbourhood of chronic and fibrocaseous foci treatment, might again relapse.-Dr. R. R. TRAIL congested and simple inflammatory areas which said he had obtained help from the sedimentation nowadays were regarded as the antecedents of test in estimating resistance. Apart from pleurisy,. chronic lesions. This conception of the pneumonicI which always showed a high rate, chances were good nature of tuberculous lesions if a patient had a rate of from 9-20 per cent. Overor inflammatory in the minds of two English pathologists, 40 treatment was probably a waste of time.-Dr.originated Wilson Fox and Green, in 1873. Dr. Jaquerod F. R. WALTERS suggested the division of the waitingconsidered that in this stage of the disease the tubercle list into an urgent and a non-urgent category.bacilli remained on the surface of the mucous Dr. BASIL PRICE thought that while modern view membrane between the epithelial cells, in the alveolar had swung back to the aerogenous theory of origin, and intercellular spaces, and that their destruction the relation of this theory to lymphatic circulation and elimination was therefore rendered much easier. needed more consideration than it had obtained. It was only when these lesions did not heal that new In his experience the Ministry of Pensions cases of bronchitis and emphysema, which had been.. tissues were produced. ’ chronic The question, How recent is the disease " was watched ever since the war, not infrequently developedtherefore a matter of primary importance. It was pulmonary tuberculosis.-Dr. S. R. GLOYNE wa& necessary to distinguish the non-allergic type impressed with the different course that the process. found in childhood from the lesion of a patient of healing took in the different natural orders in the already sensitised by previous contact with tubercle animal kingdom. In man the processes of healing bacilli. In the former the pulmonary lesions might were nowadays largely studied by the radiologists,. regress and heal by resolution, or pass the non- who saw the patient long before the pathologist did". allergic phase and become serious. In the latter the and it was difficult to correlate the morbid anatomy inflammatory reaction was broncho-pneumonic, and with what was seen on the film. might end in cavity formation. This cavity was, In the afternoon Dr. L. T. S. BURRELL and Dr. N however, different from that of chronic disease ; its TATTERSALL introduced a discussion on the walls were not well-organised pyogenic membrane, but simple inflammatory tissue. It might heal by Future of Artificial Pneumothorax resolutio without leaving any apparent scar. A third form, chronic fibrocaseous tuberculosis, was a treatment. Dr. Burrell said that collapse therapy complicated process leading to fibrous transformation was the simplest method of applying the principle of the lung. The first two forms always existed of rest to the lung. All early cases of unilateral disease before the third, and it was in these that treatment I would, he thought, in the near future be so treated ! unless there was definite contra. indication ; more had its best chance of success.
I
M.
i
I
il
i
‘