THORACENTESIS IN PHTHISIS.

727 A most unusual companion to me in health was the familia]. Had a loose stool in the morning ; no micturition since. " prickly heat." But after being conveyed on board a Roya]lr Has been taking wine and milk freely through the day. for passage to England, I then learned how 8th.-Pulse 116 ; respiration 48; temperature 98’5°. Has mail very near my case had been fatal, for the first evacuation by taken nourishment through the nigh ;is very weak, but stool evidenced " black vomit," or blood thrown out fromL perfectly easy. Evening : Much the same. 9th.-Died rather unexpectedly about 11 A.M. the colon, in appearance not unlike the confectio rosae Assisted by Dr. J. H. Moir, formerly of Crimond, I perca.nma3. Micturition was difficult, except in the erect posi tion. Had blood been thrown out on the mucous membrane formed a somewhat hurried necropsy five hours after death. of the small intestines, frem its proximity to the lactea]L Externally : The body was extremely emaciated ; face pale I fancy it would have been fatal. Had calomel bee]]land colourless, no puffing. The carbolic plaster was found given in ten-grain doses, the digestive tract would havebeenL in situ on the chest; no pus was on it. The wounds were almost closed ; the larger one was easily opened by manipuso weakened as to have precipitated a fatal result. the skin. Internally : The pericardium was unduly be lating (To continued.) distended with watery fluid. Fatty deposit had taken place at the base of the heart over the ventricles, as also on the auricle. All the cavities contained blood, more parright THORACENTESIS IN PHTHISIS. ticularly the right auricle. The wall of the right ventricle was perfectly friable; this degeneration in a more limited BY A. D. LEITH NAPIER, M.D., C.M. The size of the heart was way affected the left side. normal; the valves healthy; the musculi pectinati and WHILE the pathology of phthisis has advanced greatly oi chordae tendineæ hypertrophied. The left pleura was atlate years, comparatively little has been done in eiideavour- tached anteriorly to the chest-wall with comparatively recent adhesions; the lateral adhesions were less firm. Hard ingto innovate on the stereotyped treatment. As a step in nodes were plentifully scattered throughout the whole lung. this direction I desire to record the following :The right lung was wholly fibroid, except at the apex ; and Jane M-, aged eight and a half years, the child of pooi the pleural adhesions were so firm that it was found imposparents residing in Fraserburgh, took ill during the spring sible to remove the lung intact. A very large cavity, easily of 1877 with " a bad cold"; after some time she became so admitting a doubled fist, occupied the right apex, and in it we found recent thickened pus; very little fluid pus was ill that she was frequently confined to bed. I was asked tc’ found. There was no appearance of general pyothorax. see her in December, 1877, and then diagnosed pneumonic’ The necessity for relief, indicated by the urgent symptoms phthisis of the right lung, and also, to some extent, of the. present, as above related, demanded an operation. My left. I have no notes of these observations, but from memory principal object in bringing the case under the notice of the state that the right lung seemed almost wholly solidified, profession is to suggest inquiry as to-(a) Are we justified in cavities in phthisical lungs, as is mostly done, by nonexcept at the apex, where gurgling was heard. I saw hei treating interference ? or (b) Would it be wise to have more frequent again a day or two after my first visit, and, finding my resort to operative procedure ? The question is, as regards an services useless, as she persistently refused all medicine, allied condition, admirably discussed by West.’ In many, I requested the parents to let me know if she became worse. may say in most cases, in the third stage of phthisis, occurI was asked to visit her again on the evening of Feb. 3rd, ring in children, the existence of cavities is easily diagnosed.2 we to interfere as soon as a cavity could be discovered 1878, and did so about 9 o’clock. I found, in addition to Were means of operation, and the insertion of a drainage-tube, by greatly increased emaciation, and still further deterioration with due’ antiseptic precautions, is it unlikely that live. of the left lung, a large swelling, about the size of a big could be prolonged, or mayhap saied, .which otherwise orange, over the anterior right chest, the upper border arising would be inevitably doomed ? As to the means of operating, below the second rib. I was informed that "the lump" I conceive that with a large trocar and cannula, or even an ordinary straight bistoury, we are as efficiently armed, and began to form ten daysprevious to my visit, and had " in- more so than with any of the existing aspirators. The creased greatly in size the last day or two." Coughing gave to aspirators in empyema have been well weighed objections a marked impulse to the tumour; amphoric breathing was ere now, and in country practice the more simple and very loud in the right subclavian region; tinkling was not familiar the instruments, the more frequently will they be heard, but, owing to the extreme prostration of the child, used. No difficulty arises from antisepticism, as a small hand spray-producer, which can be easily managed by the only a cursory examination was made. The pulse was up- most inexperienced, is quite sufficient for the purpose. It wards of 140; respiration 60. I ordered wine and milk, as be that in most instances little permanent benefit may much as could be taken. would result, but if we should have as satisfactory a proFeb. 4th.-A very bad night had been passed, the attend- portion of cures as after tracheotomy in diphtheria (a modest ants having frequently looked for immediate death. About enough hypothesis) why countenance the one and condemn a cupful of milk and three ounces of sherry wine were given the other procedure ? The most probable secondary result and through the night. Very urgent dyspnoea and orthopnoea is emphysema, though this is not a necessary were the symptoms, and I determined to even were it so, it would be by no means a sufficient de’evacuate the swelling, which was clearly filled with pus. terrent. In an almost identically similar case which was Assisted by Mr. Mellis, the following procedure was carried lately under my observation, the emphysema was purely out. I introduced a large trocar and cannula into the tumour ; local. As this case is highly illustrative of my subject, I on withdrawing the trocar only two or three drops of pus may give it briefly :flowed, when the cannula became blocked up with thick Emily C-, the child of a staff sergeant of the Hadpus, which a probe could not break down. I then made a dington Artillery Militia, aged eight, came under my care valvular slit, fully half an inch in length, by means of on July 26th, 1878. The history was an ordinary one of a straight bistoury. A very large quantity of thick pus pneumonic phthisis ; both lungs were deeply involved ; the escaped. The wound was then covered with carbolic plaster, child was a perfect skeleton, and seemed in the very last which was fixed in position, and a pad and roller applied. stage of existence. Several cavities existed, more especially The whole operation was conducted under carbolic spray. on the right side, but my little patient was so very irritable Immediately after the escape of pus the patient was greatly that thorough examination was next to impossible, and, as relieved and the breathing decidedly easier. the breathing was easy, the question of operative interfer5th.—Pulse 130. Has had a much better night; is breath- ence was not raised. She lingered on till August 26th, when ing without difficulty, and has taken a fair quantity of gruel, a swelling on the right anterior chest, which appeared, milk, and wine since yesterday. Evening : Pulse 126. according to her mother, only a week or so before, and of 6th.—Pulse 120; respiration 48. Pus has escaped in very which I was not informed, burst, and discharged pus most large quantity from the wound, the bedclothes being actually freely. Large quantities of pus were discharged up to soaked. Evening: Pulse 120 ; respiration 50. twenty-four hours from her death ; the child was very 7th.-Pulse 140; respiration 60. Child looking emphysematous. When she moves the dyspnoea is apt to return, 1 Diseases of Infancy, pp. 366-7, fifth edition. but onlv then. Wound dressed under carbolic spray; open2 Maunsell and Evanson: Diseases of Children, p. 458, third edition. Churchill: Diseases of Children, p. 382, second edition. ing evidently closed. Evening : Pulse 120; respiration 56.

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728 much easier after the abscess burst. Death occurred oj1 Sept. 4th. In further support of the advisability of such interference3 I will cite another case, which, though not of the same class , illustrates well the benefits of free openings. Alex. Gpost-runner, FraserburO’h, was under my treatment about two years ago. He had remittent typhoi(1 fever, pleurisy, and pleuro-pneumonia for upwards of fou:r He was then affected with profuse clammy months. sweatings; diarrhoea; very high temperature, at times 105°F ; pulse 140 ; hectic flush ; and complete dulness of the lett chest. He was seen by several of my medical friends during the course of his illness, and of seven of these all agreed h(3 On two occasions I aspirated him, but witli was doomed. only a slight improvement; he could not latterly allow of{L drainage-tube ; and, growing desperate, I made a fre( incision of three-quarters of an inch into the chest at th< lower border of the sixth rib. Shortly after pus was dis charged freely, and ran for some weeks. In about tw() months from the date of my last operation he resumed his, arduous duties. Inthe first case related the operation had, as was provecl post mortem, no blame in hastening the end ; the secondl case did not admit of interference; and the third was; happily terminated by the means employed. I do not advocate operation except it be certain that the cavity is sufficiently near the surface to ensure our reaching it. If the opening could be made posteriorly, so much the. better; but should an abscess point, or were a cavity neai the surface anteriorly, I would not hesitate to second the. efforts of nature. Taking three of our best works on modernL medicine,3 we find the operation theoretically approved of inL In practice no difference, except in degree, is empyema. appreciable between true empyema, false empyema, 01 abscess, and the caseated lung tissue in its ultimate stage oi degeneration ; the prognosis may be better in one than in another, but actually the treatment does not admit of great variety. A case suitable for the treatment counselled is unquestionably exceptional at present, but it is possible, with due skill, care, and precaution, that artificial aids to the emptying of phthisical cavities may yet be employed more frequently with success ; and with this hope I commit my experience to those who have the more fertile field of hospital practice at their command. Dunbar, N.B. -

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REMARKABLE OSCILLATIONS OF TEMPERATURE WITHOUT APPARENT CAUSE. BY WALTER

ILIFFE, F.R.C.S. ED.

THE problems of medical science are undoubtedly great and various, and one of the most interesting, if not the most important, is to be found in studying the exact sources and modes of origin of animal heat. A definite knowledge regarding it would give us much valuable and needed information upon many points, and more particularly as to the exact signification of temperature alterations in specific and This other fevers, in lesions of the nervous system, &c. must be my apology for bringing the following interesting and exceptional case before the readers of THE LANCET. Early last spring I was called to see a young lady, Miss L. I-, aged eighteen, and found her suffering from measles, which at that time was epidemic in the school where she was. The attack was one of moderate severity, the maximum evening temperature 102.5°, and the rash well out; in about a week she was convalescent, the evening temperature normal, and all symptoms having disappeared, she had my permission to get up the following morning, but at an early hour I was sent for, and found her much worse. There was a high pulse (120), quick respiration, flushed face, a nervous fidgety manner, skin, the tongue thickly covered with a white fur, bowels constipated, no inclination for food, the thermometer registering 105’4°. I suspected some inflammatory condition, and made a careful examination of each organ, but could detect nothing abnormal. The patient was tall and slightly built, and may perhaps be described as belonging to the nervo-

dry

3 Flint’s Practice of Medicine, p. 164, third edition ; Aitken’s Science and Practice of Medicine, p. 867, sixth edition; Watson’s Lectures on the Principles and Practice of Physic, vol. ii., p. 15], fifth edition.

phlegmatic type of temperament. She was somewhat excitable and perhaps hysterical, limiting the meaning of that word to a condition of weakness of will with emotional sensibility and ready excitability. I was informed she had commenced menstruating at fifteen years, but after the first month the discharge had entirely ceased and had never returned even in the slightest degree. Her complexion had become dusky, the face covered with an acne rash, and the skin under the eyes ’especially dark; she had never suffered

from feverish illness of any moment, but she had been for some few months under my care with the object of bringing about the periods. I had tried various remedies, all ol which had been unsuccessful. During the following ten days the temperature (which with the greatest care both in the axilla and was in the mouth) underwent the most extraordinary and erratic changes, without my being able to find any specific cause. In the course of the twenty-four hours it would vary from the normal to 106°, and upon one occasion 107°; the period of the highest temperature being variable, sometimes at night, at other times in the morning or afternoon ; and not at all during the course of the illness did the temperature rise or fall at any uniform hour. With the increase of heat the pulse and respiration rose more or less. proportionally, the tongue became coated, the patient acquired a restless, fidgety manner, would answer questions in a short, abrupt tone, finger the bedclothes, and wander with her hands about the wall close to the bed. As the temperature fell these phenqmena would subside, and it was truly marvellous to notice how, in some instances, the tongue, quite foul with the high temperature, would become perfectly clean in even so short a time as half an hour, as the latter approached its normal character. I subjoin a few temperature readings, which will serve as an illustration so, far as the temperature, pulse, and respiration are concerned :

taken

The treatment comprised cold-packing (this was always adopted when the temperature rose to 106°), and the administration of such drugs as aconite, digitalis, and bromide of potassium. At the end of ten days the elevation of temperature began to abate, and in a few more it became normal and remained so, the patient recovering her health gradually; and now, speaking generally of her condition, she is much better than she had been for many months previous to this illness. Amenorrhoea still persists, but the complexion is clearer, the lethargy and tiredness are much diminished, and the acnerash is gone. I will not offer comments upon this case further than to point out the probable connexion with the hysterical temperament and the condition of amenorrhoea. I may mention that Dr. Hamilton, of Windermere, saw the case with me, and failed to find any cause to which we could refer the peculiar features characterising it. Kendal.

ON ELASTIC PRESSURE IN THE TREATMENT OF INFLAMMATION OF THE JOINTS, AND ON A MODE OF ACCURATELY MEASURING THE FORCE EMPLOYED.

BY C. B.

KEETLEY, F.R.C.S.,

ASSISTANT-SURGEON TO THE WEST LONDON HOSPITAL, ASSISTANT-DEMONSTRATOR OF ANATOMY AT ST. BARTHOLOMEW’S HOSPITAL.

AND

LATE

THE object of this paper is to call attention to the proved, but neglected, powers of elastic pressure in the treatment of chronic inflammation and of " dropsy " of the joints. There will also be described in it a new method of applyingthis elastic pressure, by which new method the amount of pressure can be measured, regulated, and recorded to a nicety, and to which the author proposes to apply the name of "hydraulo-elastic pressure," because its nature is partly