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HEPATIC PUS IN THE PERITONEUM.
DR. J. HILTON THOMPSON ON FACTITIOUS URTICARIA.
924
A CASE OF FACTITIOUS URTICARIA. BY J. HILTON
THOMPSON, M.D.VICT. &c.,
LATE SENIOR RESIDENT MEDICAL OFFICER TO THE HOSPITAL, PENDLEBURY.
by the removal of the exudated material that the blood return to the capillaries and the colour become normal.
can
Chorley Old-road, Bolton, Lancashire.
CHILDREN’S
HEPATIC PUS IN THE PERITONEUM. seventeen years of age, well nourished and healthy BY SURGEON-CAPTAIN T. SHAW, M.B., B.CH. DUB. looking, stated that since infancy any slight irritation of the skin had been followed in a short time by a wheal, even the WITH reference to the statement made by Kartulis that the friction of a towel used in the ordinary way producing large pus of hepatic abscesses following dysentery of hot countries cedematous patches. At school he escaped corporal punishis free from micro-organisms, and its escape into the peritoneal ment owing to the startling effects produced by smacks on the is, therefore, not likely to be followed by peritonitis,1 face and hands. When first seen by me the patient had a cavity the following summary of a case will be of some interest. wheal on the back of his neck corresponding to the upper On Nov. 10th I found a Hindoo beggar lying on the road edge of his collar. In a few seconds after having passed a in a terribly weak and emaciated condition ; he complained of blunt point over the skin of the face, using about the same intense pain in, and there were marks of the cautery over, the amount of force as in writing, a faint red line appeared, in He was sent to the hospital in Dooly. On about thirty seconds more the line became distinctly elevated, hepatic region. examination the following condition was revealed. and when the skin was stretched it appeared as a white streak. physical The upper line of the superficial liver dulness reached the This raised line became gradually anemic, and in about two border of the fifth rib and the lower border of the liver minutes appeared white, in marked contrast to the surrounding upper was 10 cm. below the edge of the costal arch (in sternoskin. For about ten minutes the wheal became gradually mammary line) ; there was slight bulging and the skin was broader until it was about a quarter of an inch in breadth. In freely movable and normal to look at ; crepitations were heard over the base of the lung. I thought that I detected friction sounds over the prominent liver area ; jaundice was marked. The patient complained of pain both on pressure and spontaneously, chronic bronchitis, headache and constipation. On the llth I explored with a needle below the eighth cartilage in various directions and finally struck some clear reddish serous-looking fluid beneath the right rectus. The needle was directed downwards and backwards. I made a perpendicular incision through the rectus, but found no. adhesions ; the liver was tense and very red. Pieces of aseptic muslin were packed round the edges of the wound and a trocar was inserted in the place of the needle, but I failed to get anything. Pushing the needle further in I felt a sudden diminution of resistance, which was followed by the appearance of pus in the needle-groove. I cut down along the needle until thin yellow pus and blood gushed out. Pressure from the outside stopped the bleeding. At this stage collapse and almost entire cessation of breathing ensued, the pulse,
A
YOUTH
The patient restored by artificial respiration, by the application of hot towels over the chest, and by ammonia. Meanwhile the muslin packing had become disturbed, and I saw some pus and blood trickling out of sight into the abdominal cavity. The abscess was about the size of a hen’s egg, the walls being smooth and soft. After irrigation of the cavity a large drainage-tube was inserted and four peritoneal and some superficial sutures were used to close the wound, which was then dusted with iodoform, the operation being completed by b the application of a bandage. I made no attempt to swab any part of the peritoneum, nor did I follow Mr. Treves’ method2 of drying the abscess cavity, the reason being that its walls were soft and smooth. Subsequent progress was very slow and difficult. The temperature, which had remained normal for some days, began to rise in the evening, and more pus began to discharge. I explored the cavity again with a probe and evacuated a second collection of pus, which lay behind the first, by pushing the probe through the very brittle liver tissue. There was no further trouble, except that some sutural abscesses formed, which were soon cured. The abscess was irrigated every day. The patient never once complained of anything pointing to peritoneal mischief. At present (March llth, 1893) he walks about a good deal and has become very stout, but still suffers from bronchitis. Slight bulging only is visible beside the incision, which may very probably be the starting point of an abdominal hernia. It is impossible to make him limit his diet (which includes g3zi, or clarified butter). The question of the presence of pus and blood in the peritoneal cavity is important, but the more facts that are known about it the less will one hesitate to open liver abscesses before an irreparable amount of liver tissue has been destroyed. In the present case the liver has returned to its normal dimensions.
however, remaining distinctly perceptible. was
more the anasmia was less marked and in about hour the appearance of the face was normal, and no irregularity could be felt by passing the finger over the skin. Wheals could be produced on any part of the body, the amount of force required varying with the thickness of the A zone of hypermmia-more or less well marked skin. according to the vascularity of the part-developed round the wheals. The most likely explanation in this case appears to be that a slight irritation of the skin disorganises the nervous mechanism of the capillaries, as a result of which there is intense vaso-dilatation round the point of injury, and probably there is also a dilatation of the capillaries immediately affected by the pressure and an escape of blood plasma through their wails into the surrounding extra-vascular spaces. Thus a local thickening of the skin is produced, and the local increase of pressure, by forcing the blood from the capillaries in the immediate vicinity, explains the anaemia of the affected area. The increase in the breadth of the wheals is probably due to the exudation going on for some time, and it is only when the exudation has ceased and the pressure has been diminished
ten minutes
half
an
Goona. 1
Vide my 2
in THE LANCET of Aug. 20th, 1893. THE LANCET, May 21st, 1892.
case
MR. CAMPBELL WILLIAMS ON TREATMENT OF TERTIARY SYPHILIS.
bodily exhaustion, and I recommend going to
THE TREATMENT OF TERTIARY SYPHILIS BY INUNCTION. BY CAMPBELL
WILLIAMS, F.R.C.S. ENG.
subject as the treatment of naturally feels diffident before rushing into print. The usual routine practice-namely, that of saturating the patient to varying degrees with the iodides of potash, soda and ammonia-is that most frequently adopted. In some cases this procedure not only fails to clear up the UPON such
a
tertiary syphilis
well-known
one
lesion or to arrest the progress of the disease, but may do absolute harm to the patient. Above and beyond the digestive impairment that may ensue and the ordinary well-known iodic symptoms, gangrene may even be induced by its abuse. It is not usual in England to resort to inunction as a method of treatment even in the early stages of the complaint, and much less so in the later. This is probably due to a variety of causes. Amongst others may be cited the difficulty in carrying it out, or the attendant expenses and loss of time may prohibit its use by the patient. By this it will be seen that the method advocated requires the assistance of a trained rubber, for patients cannot properly perform inunction upon themselves. In the private practice of the late Mr. Berkeley Hill it was my good fortune to see a great number of cases treated in this manner with the most successful results, after failure by iodides. It was his intention, had he lived, to have presented to the profession his views upon this method of treatment. He had no faith in iodides as curative agents, but regarded them more as palliative agents. The method enjoined is as follows : The patient is ordered one ounce of mercurial ointment with lanoline and one drachm of olive oil, to be divided into eight packets, one packet to be rubbed in after each bath. Lanoline is a better basis than lard, in that it is free from irritating fatty acids. Mercurial erythema or eczema seldom follows its use, but I have seen rather severe folliculitis. It requires the addition If of olive oil to render it less tenacious and to increase its power of penetration. Preparatory to the inunction the patient is made to sit in a hot bath for from ten to fifteen minutes. It is well to start at about 95° F. and to gradually raise the temperature to 100°, or more if it can be borne, until perspiration breaks out upon the forehead. The object is to clean the skin and open its pores. He is then dried and the ointment is thoroughly rubbed in all over the body. By distribution the friction and irritation are not localised. Such a procedure requires at least twenty minutes good work on the part of the rubber. With the exception of Sunday, a daily bath is given. The patient should always be seen after every fifth or sixth bath, for many are intolerant of one-drachm doses and the packets require reduction to 30 or 40 grains. The gums and the pharyngeal mucous membrane must be carefully watched and Too vigorous treatment in the patient’s weight recorded. debilitated subjects may cause increase of ulceration instead of promoting granulation; then theamount of the packet should be decreased. At the commencement of the baths the patients not unfrequently complain of languor and lassitude ; but this feeling soon wears off. Sometimes they have intestinal symptoms, but the griping is not as acute as in the mouth treatment. This may be due to absorption, but more frequently owing to errors of diet. Occasionally they become slightly anaemic and require tonics. Personally, if the stomach will bear it, 1 prescribe iron throughout the course of baths. Forty-two baths are reckoned as a
i
It is then frequently judicious to give the patient rest for a fortnight. Specific treatment is either entirely stopped or, should the exigencies of the case demand it, very mild remedies are given by the mouth. A second course of baths, making eighty in all, is then prescribed. In the bulk of cases this has been found to be sufficient. Whilst under inunction the following mouth wash is used : Five drachms of alum, two and a half drachms of acetate of lead, half a drachm of essence of peppermint, warm water to twenty-four ounces. The salts should be dissolved separately ; then mix and filter and add the essence to the clear filtrate. The mouth should be washed four or five times a day with this preparation. During the course of the baths the patient is to be ordered to clothe warmly, to be in-doors after seven o’clock and to always course.
a
put on an overcoat after the bath. He should avoid mental and
925
take exercise daily short of fatigue. bed early and rising late. The teeth should be cleaned twice daily with precipitated chalk and soap. As regards diet, malt liquors, effervescing wines, acid drinks, coffee, raw fruit, salads, and pickles should be avoided ; green vegetables and cooked fruit may be indulged in sparingly ; the patient may eat freely of butcher’s meat, eggs, fish, game, poultry and light paddings, and drink one or two pints of fresh milk daily. Before beginning inunction I always examine the patient’s mouth. Much of the so-called ptyalism can be avoided if the teeth are scaled, should the gums be spongy owing to the presence of tartar. It is well in these cases to get the patient to rub powdered alum into the gums twice daily, in order to harden them. Cases of serpiginous ulceration, necrosis, visceral and other gummatous lesions which had resisted other modes of treatment, when treated in the foregoing manner improved most rapidly. The patients were treated either in their own houses, nursing homes, or at the medical baths of University College Hospital. To the latter any practitioner may send his patient. There is a special class of case that does better at Aachen or some other quiet resort, where he is removed from the temptations of London life This is not so much due to the action of the local waters or to superior rubbing, but rather to the circumstance that the patient is made to lead a regular life, to feed plainly, and to keep early hours. Welbeck-street, W. ________________
A CASE OF EMPYEMA. WALTERS, L.R.C.P. LOND., M.R.C.S.
BY A. P.
THE following case is recorded in the columns of THE LANCET chiefly to add another successful one to the list of those which may be included under the term of "cottage surgery," showing that with ordinary precautions and daily attention a favourable result may ensue. On Nov. 17th, 1892, I was called to a cottage in the country to see a boy aged eleven. He was in a febrile condition, with a peculiar erratic erysipélatous eruption on the face, arms and trunk, being unequal in distribution. The right pleura was found to be inflamed, and upon physical examination fluid was suspected to be present. On the day following I withdrew serous fluid with a hypodermic On the 20th the right’ side was found flat syringe. An on percussion and the breath sounds were inaudible. aspirator fitted only with fine needles was employed, and the right pleural cavity was punctured in two or three spaces, but no fluid could be withdrawn on account of the bore of the needle becoming choked. The following day the right pleural cavity was aspirated and ten ounces of laudable pus The patient developed a hacking cough, were withdrawn. probably from puncture of the visceral pleura on the 20th. The temperature rose to 103°, and the pulse was 180 per -minute. From the 23rd to the 25th the pulse and temperature were about the same as on the 21st, but with a slight increase of pulse-rate ; respirations 37 per minute. The patient’s, general condition was’ nevertheless fairly satisfactory, except for a hecticcondition and a hacking cough which prevented him from sleeping at night. On the 26th, the patient being slightly anaesthetised, the pleural’’ cavity was opened in the sixth space, in the mid-axillary line, and two pints and a half of purulent non-odorousfluid were withdrawn. The wound was well washed with hot carbolic lotion and a drainage-tube five inches in length, with a bore of a quarter of an inch, was inserted into the cavity and the wound dressed with absorbent wool. Onthe 27th the wound, which discharged freely, was well washed with hot lotion, and a piece of wool soaked in carbolic lotion was always kept over the aperture as soon as the dressing was removed. (This was done at all subsequent dressings, for with each inspiration there was always suction of air through the drainage-tube for at least three weeks after the operation.) On Nov. 28th, 29th, 30th and Dec. 1st the wound was dressed, but the patient’s general condition was unsatisfactory. The drainage-tube was withdrawn at each dressing and washed in carbolic lotion. The patient was still hectic, there was an abundant discharge from the wound, but, with the exception of an acrid odour owing to the retention of the discharge during the twenty-four hours, it was inodorous. From Nov. 27th to Dec. lst there
924
A CASE OF FACTITIOUS URTICARIA. BY J. HILTON
THOMPSON, M.D.VICT. &c.,
LATE SENIOR RESIDENT MEDICAL OFFICER TO THE HOSPITAL, PENDLEBURY.
by the removal of the exudated material that the blood return to the capillaries and the colour become normal.
can
Chorley Old-road, Bolton, Lancashire.
CHILDREN’S
HEPATIC PUS IN THE PERITONEUM. seventeen years of age, well nourished and healthy BY SURGEON-CAPTAIN T. SHAW, M.B., B.CH. DUB. looking, stated that since infancy any slight irritation of the skin had been followed in a short time by a wheal, even the WITH reference to the statement made by Kartulis that the friction of a towel used in the ordinary way producing large pus of hepatic abscesses following dysentery of hot countries cedematous patches. At school he escaped corporal punishis free from micro-organisms, and its escape into the peritoneal ment owing to the startling effects produced by smacks on the is, therefore, not likely to be followed by peritonitis,1 face and hands. When first seen by me the patient had a cavity the following summary of a case will be of some interest. wheal on the back of his neck corresponding to the upper On Nov. 10th I found a Hindoo beggar lying on the road edge of his collar. In a few seconds after having passed a in a terribly weak and emaciated condition ; he complained of blunt point over the skin of the face, using about the same intense pain in, and there were marks of the cautery over, the amount of force as in writing, a faint red line appeared, in He was sent to the hospital in Dooly. On about thirty seconds more the line became distinctly elevated, hepatic region. examination the following condition was revealed. and when the skin was stretched it appeared as a white streak. physical The upper line of the superficial liver dulness reached the This raised line became gradually anemic, and in about two border of the fifth rib and the lower border of the liver minutes appeared white, in marked contrast to the surrounding upper was 10 cm. below the edge of the costal arch (in sternoskin. For about ten minutes the wheal became gradually mammary line) ; there was slight bulging and the skin was broader until it was about a quarter of an inch in breadth. In freely movable and normal to look at ; crepitations were heard over the base of the lung. I thought that I detected friction sounds over the prominent liver area ; jaundice was marked. The patient complained of pain both on pressure and spontaneously, chronic bronchitis, headache and constipation. On the llth I explored with a needle below the eighth cartilage in various directions and finally struck some clear reddish serous-looking fluid beneath the right rectus. The needle was directed downwards and backwards. I made a perpendicular incision through the rectus, but found no. adhesions ; the liver was tense and very red. Pieces of aseptic muslin were packed round the edges of the wound and a trocar was inserted in the place of the needle, but I failed to get anything. Pushing the needle further in I felt a sudden diminution of resistance, which was followed by the appearance of pus in the needle-groove. I cut down along the needle until thin yellow pus and blood gushed out. Pressure from the outside stopped the bleeding. At this stage collapse and almost entire cessation of breathing ensued, the pulse,
A
YOUTH
The patient restored by artificial respiration, by the application of hot towels over the chest, and by ammonia. Meanwhile the muslin packing had become disturbed, and I saw some pus and blood trickling out of sight into the abdominal cavity. The abscess was about the size of a hen’s egg, the walls being smooth and soft. After irrigation of the cavity a large drainage-tube was inserted and four peritoneal and some superficial sutures were used to close the wound, which was then dusted with iodoform, the operation being completed by b the application of a bandage. I made no attempt to swab any part of the peritoneum, nor did I follow Mr. Treves’ method2 of drying the abscess cavity, the reason being that its walls were soft and smooth. Subsequent progress was very slow and difficult. The temperature, which had remained normal for some days, began to rise in the evening, and more pus began to discharge. I explored the cavity again with a probe and evacuated a second collection of pus, which lay behind the first, by pushing the probe through the very brittle liver tissue. There was no further trouble, except that some sutural abscesses formed, which were soon cured. The abscess was irrigated every day. The patient never once complained of anything pointing to peritoneal mischief. At present (March llth, 1893) he walks about a good deal and has become very stout, but still suffers from bronchitis. Slight bulging only is visible beside the incision, which may very probably be the starting point of an abdominal hernia. It is impossible to make him limit his diet (which includes g3zi, or clarified butter). The question of the presence of pus and blood in the peritoneal cavity is important, but the more facts that are known about it the less will one hesitate to open liver abscesses before an irreparable amount of liver tissue has been destroyed. In the present case the liver has returned to its normal dimensions.
however, remaining distinctly perceptible. was
more the anasmia was less marked and in about hour the appearance of the face was normal, and no irregularity could be felt by passing the finger over the skin. Wheals could be produced on any part of the body, the amount of force required varying with the thickness of the A zone of hypermmia-more or less well marked skin. according to the vascularity of the part-developed round the wheals. The most likely explanation in this case appears to be that a slight irritation of the skin disorganises the nervous mechanism of the capillaries, as a result of which there is intense vaso-dilatation round the point of injury, and probably there is also a dilatation of the capillaries immediately affected by the pressure and an escape of blood plasma through their wails into the surrounding extra-vascular spaces. Thus a local thickening of the skin is produced, and the local increase of pressure, by forcing the blood from the capillaries in the immediate vicinity, explains the anaemia of the affected area. The increase in the breadth of the wheals is probably due to the exudation going on for some time, and it is only when the exudation has ceased and the pressure has been diminished
ten minutes
half
an
Goona. 1
Vide my 2
in THE LANCET of Aug. 20th, 1893. THE LANCET, May 21st, 1892.
case
MR. CAMPBELL WILLIAMS ON TREATMENT OF TERTIARY SYPHILIS.
bodily exhaustion, and I recommend going to
THE TREATMENT OF TERTIARY SYPHILIS BY INUNCTION. BY CAMPBELL
WILLIAMS, F.R.C.S. ENG.
subject as the treatment of naturally feels diffident before rushing into print. The usual routine practice-namely, that of saturating the patient to varying degrees with the iodides of potash, soda and ammonia-is that most frequently adopted. In some cases this procedure not only fails to clear up the UPON such
a
tertiary syphilis
well-known
one
lesion or to arrest the progress of the disease, but may do absolute harm to the patient. Above and beyond the digestive impairment that may ensue and the ordinary well-known iodic symptoms, gangrene may even be induced by its abuse. It is not usual in England to resort to inunction as a method of treatment even in the early stages of the complaint, and much less so in the later. This is probably due to a variety of causes. Amongst others may be cited the difficulty in carrying it out, or the attendant expenses and loss of time may prohibit its use by the patient. By this it will be seen that the method advocated requires the assistance of a trained rubber, for patients cannot properly perform inunction upon themselves. In the private practice of the late Mr. Berkeley Hill it was my good fortune to see a great number of cases treated in this manner with the most successful results, after failure by iodides. It was his intention, had he lived, to have presented to the profession his views upon this method of treatment. He had no faith in iodides as curative agents, but regarded them more as palliative agents. The method enjoined is as follows : The patient is ordered one ounce of mercurial ointment with lanoline and one drachm of olive oil, to be divided into eight packets, one packet to be rubbed in after each bath. Lanoline is a better basis than lard, in that it is free from irritating fatty acids. Mercurial erythema or eczema seldom follows its use, but I have seen rather severe folliculitis. It requires the addition If of olive oil to render it less tenacious and to increase its power of penetration. Preparatory to the inunction the patient is made to sit in a hot bath for from ten to fifteen minutes. It is well to start at about 95° F. and to gradually raise the temperature to 100°, or more if it can be borne, until perspiration breaks out upon the forehead. The object is to clean the skin and open its pores. He is then dried and the ointment is thoroughly rubbed in all over the body. By distribution the friction and irritation are not localised. Such a procedure requires at least twenty minutes good work on the part of the rubber. With the exception of Sunday, a daily bath is given. The patient should always be seen after every fifth or sixth bath, for many are intolerant of one-drachm doses and the packets require reduction to 30 or 40 grains. The gums and the pharyngeal mucous membrane must be carefully watched and Too vigorous treatment in the patient’s weight recorded. debilitated subjects may cause increase of ulceration instead of promoting granulation; then theamount of the packet should be decreased. At the commencement of the baths the patients not unfrequently complain of languor and lassitude ; but this feeling soon wears off. Sometimes they have intestinal symptoms, but the griping is not as acute as in the mouth treatment. This may be due to absorption, but more frequently owing to errors of diet. Occasionally they become slightly anaemic and require tonics. Personally, if the stomach will bear it, 1 prescribe iron throughout the course of baths. Forty-two baths are reckoned as a
i
It is then frequently judicious to give the patient rest for a fortnight. Specific treatment is either entirely stopped or, should the exigencies of the case demand it, very mild remedies are given by the mouth. A second course of baths, making eighty in all, is then prescribed. In the bulk of cases this has been found to be sufficient. Whilst under inunction the following mouth wash is used : Five drachms of alum, two and a half drachms of acetate of lead, half a drachm of essence of peppermint, warm water to twenty-four ounces. The salts should be dissolved separately ; then mix and filter and add the essence to the clear filtrate. The mouth should be washed four or five times a day with this preparation. During the course of the baths the patient is to be ordered to clothe warmly, to be in-doors after seven o’clock and to always course.
a
put on an overcoat after the bath. He should avoid mental and
925
take exercise daily short of fatigue. bed early and rising late. The teeth should be cleaned twice daily with precipitated chalk and soap. As regards diet, malt liquors, effervescing wines, acid drinks, coffee, raw fruit, salads, and pickles should be avoided ; green vegetables and cooked fruit may be indulged in sparingly ; the patient may eat freely of butcher’s meat, eggs, fish, game, poultry and light paddings, and drink one or two pints of fresh milk daily. Before beginning inunction I always examine the patient’s mouth. Much of the so-called ptyalism can be avoided if the teeth are scaled, should the gums be spongy owing to the presence of tartar. It is well in these cases to get the patient to rub powdered alum into the gums twice daily, in order to harden them. Cases of serpiginous ulceration, necrosis, visceral and other gummatous lesions which had resisted other modes of treatment, when treated in the foregoing manner improved most rapidly. The patients were treated either in their own houses, nursing homes, or at the medical baths of University College Hospital. To the latter any practitioner may send his patient. There is a special class of case that does better at Aachen or some other quiet resort, where he is removed from the temptations of London life This is not so much due to the action of the local waters or to superior rubbing, but rather to the circumstance that the patient is made to lead a regular life, to feed plainly, and to keep early hours. Welbeck-street, W. ________________
A CASE OF EMPYEMA. WALTERS, L.R.C.P. LOND., M.R.C.S.
BY A. P.
THE following case is recorded in the columns of THE LANCET chiefly to add another successful one to the list of those which may be included under the term of "cottage surgery," showing that with ordinary precautions and daily attention a favourable result may ensue. On Nov. 17th, 1892, I was called to a cottage in the country to see a boy aged eleven. He was in a febrile condition, with a peculiar erratic erysipélatous eruption on the face, arms and trunk, being unequal in distribution. The right pleura was found to be inflamed, and upon physical examination fluid was suspected to be present. On the day following I withdrew serous fluid with a hypodermic On the 20th the right’ side was found flat syringe. An on percussion and the breath sounds were inaudible. aspirator fitted only with fine needles was employed, and the right pleural cavity was punctured in two or three spaces, but no fluid could be withdrawn on account of the bore of the needle becoming choked. The following day the right pleural cavity was aspirated and ten ounces of laudable pus The patient developed a hacking cough, were withdrawn. probably from puncture of the visceral pleura on the 20th. The temperature rose to 103°, and the pulse was 180 per -minute. From the 23rd to the 25th the pulse and temperature were about the same as on the 21st, but with a slight increase of pulse-rate ; respirations 37 per minute. The patient’s, general condition was’ nevertheless fairly satisfactory, except for a hecticcondition and a hacking cough which prevented him from sleeping at night. On the 26th, the patient being slightly anaesthetised, the pleural’’ cavity was opened in the sixth space, in the mid-axillary line, and two pints and a half of purulent non-odorousfluid were withdrawn. The wound was well washed with hot carbolic lotion and a drainage-tube five inches in length, with a bore of a quarter of an inch, was inserted into the cavity and the wound dressed with absorbent wool. Onthe 27th the wound, which discharged freely, was well washed with hot lotion, and a piece of wool soaked in carbolic lotion was always kept over the aperture as soon as the dressing was removed. (This was done at all subsequent dressings, for with each inspiration there was always suction of air through the drainage-tube for at least three weeks after the operation.) On Nov. 28th, 29th, 30th and Dec. 1st the wound was dressed, but the patient’s general condition was unsatisfactory. The drainage-tube was withdrawn at each dressing and washed in carbolic lotion. The patient was still hectic, there was an abundant discharge from the wound, but, with the exception of an acrid odour owing to the retention of the discharge during the twenty-four hours, it was inodorous. From Nov. 27th to Dec. lst there