periosteal excoriations. In such cases nothing so tends towards recovery as the action of the muscles contiguous to such eccentric implantations.

The above enumeration includes all cases of the class previously specified for the nine years preceding November, 1877, but excludes the cases received since that date.

RECENT PROGRESS IN THE TREATMENT OF THORACIC DISEASES.

BY F. I. KNIGHT, M. D.

Bloody Fluid in the Right Pleura; Paracentesis; Recovery. Dr. Broadbent read notes of a case of unusually rapid effusion of bloody fluid into the right pleura, in a gentleman aged seventy-six,1 who recovered after paracentesis. The patient consulted Dr. Broadbent on the 16th of May, suffering from dyspnoea on exertion, which had been gradually increasing for ten days. There was evidence of right pleural effusion; dullness to nipple-level in front and mid-scapular region behind. The next day the dyspnoea had increased, and now there was dullness all over the right chest, except a small area below the clavicle. Respiratory murmur was absent, and there was tubular breathing between the scapula and the spine. On the 18th, the right pleura was obviously full of fluid, and it seemed that paracentesis was absolutely necessary. Accordingly, on the next day, two quarts of highly bloodtinged fluid were withdrawn by means of the bottle aspirator, a small canula being used, and only gentle suction employed. A considerable quantity was left behind, but it was thought prudent to stop. The heart, which had been displaced to the left, regained its normal position. The fluid was highly charged with blood, and the probability of the effusion depending on malignant disease was entertained. The next day the temperature was 102° F.; the fluid did not again increase, but gradually became absorbed. The patient left town at the end of June. Dr. Broadbent remarked on the advanced age at which the effusion had Occurred. He had always considered advanced age as a reason for early tapping, owing to the slowness of absorption and loss of elasticity of the costal and pulmonary structures, as well as the need to preserve the patient's strength. Another point was the rapidity of the effusion, which was unparalleled in his experience. This, added to the amount of blood it contained, all seemed in favor of malignant disease. There was still some impaired mobility of the right side of the thorax, and evidence of bronchial dilatation. The amount of blood present was explained in part by the rapidity of the effusion. Mr. Maunder, in the

1 Report of a meeting of the Clinical Society of London, Lancet, March 30, 1878.

discussion which followed the reading of the case, said that the only explanation offered of the origin of the blood was the possible presence of malignant disease. Probably this was not the cause, the patient being in good health, and twelve months having elapsed since the operation. He suggested that it might be accounted for as the result of congestion and oozing, from want of tone in an elderly person, and analogous to the accumulations of blood sometimes met with in the bladders of old men, and from which they often recover.

Pleuritic Effusion; Sudden Death without Paracentesis. - Dr. Broadbent also read the notes of this case at the meeting mentioned above. The patient was a young man, twenty-four years of age, with a phthisical family history, who was attacked with pleurisy in the right side at the end of August. For two weeks he suffered from shortness of breath. On September 28th he was seen by Dr. Broadbent; there was evidence of much effusion, and the heart was displaced. There was no paroxysm of dyspnoea, but it was decided to perform paracentesis the next day. The patient passed a good night, but was attacked by dyspnoea at six A. M., and shortly afterwards died. It must be noticed that there was not a single paroxysm of dyspnoea before the final attack. No post mortem was obtained, but the cause of death was probably thrombosis in the veins of the right lung extending to the heart. Dr. Whipham mentioned a similar case which occurred in St. George's Hospital two years ago. The patient was under the care of Dr. Barnes for ulceration of the os uteri, and had been in the hospital for a month. Ten days before her death she had a slight shivering, but nothing pointed to the pleuritic effusion until two hours before her death, when she was attacked with dyspnoea. Dr. Whipham was able to ascertain the presence of effusion into the left pleura, which was confirmed after death. No thrombi were found. [The amount of effusion is not stated.] Other cases of sudden death in patients with pleural effusion were alluded to by different gentlemen, but no particulars were given. [It is to be noted that sudden death in Dr. Broadbent's case occurred with an effusion in the right pleura. If we are not mistaken the effusion has been in the left in a large majority of such cases reported. Trousseau explained them as due to the dislocation of the heart, and the consequent torsion of the vessels, especially the aorta, inasmuch as it might easily happen that the circulation should be entirely cut off by a sudden movement of the body, violent cough, etc. Bartels 1 considers this explanation very improbable; he does not believe that the aorta could be so twisted by displacement of the heart that it would not be kept pervious by the force of the blood. Bartels thinks that fainting and occasional sudden death can be better explained by a compression and interruption of the circulation in the large venous

1 Deutsches Archiv für klin. Med., iv. p. 265.

trunk; especially might the vena cava ascendens, as it passes through the diaphragm, when it is firmly adherent to the edges of the foramen quadrilaterum, suffer an almost right-angled twisting.]

Dyspnoea not an Habitual Symptom of Pleurisy with Effusion. - Dr. Dieulafoy says it is generally believed that dyspnoea is one of the most common symptoms observed in pleurisy with effusion; and certainly, at first sight, it seems quite natural, when two litres of liquid exist in the chest, when the lung is flattened and thrust back by the effusion, and when hæmatosis is only imperfect, that the breathing should be oppressed. Yet such oppression does not exist, or only to an insignificant extent. Effusion, when it amounts to a very large quantity, impedes respiration but slightly, so that dyspnoea is not to be regarded as an habitual symptom of pleurisy with effusion. This is a point of great practical interest in relation to the indications for thoracentesis.

At the commencement of a pleurisy, when the pain in the side is so acute, the patient may have short, interrupted, and jerking respiration, and he is said to have dyspnoea. His breathing is indeed difficult, but it is difficult and impeded only because it is painful, effusion having nothing to do with it, as it does not yet exist. The breathing becomes easier in proportion as the pain disappears, although the effusion is making incessant progress, and it is often when the effusion has reached its apogee, attaining two or three litres, that the patient believes himself cured, because he is then free of fever and of pain. During the acute stage of pleurisy, also, febrile action accelerates the respiration; for whatever may be the cause of fever, it renders combustion active, and consequently accelerates the respiratory rhythm. But fever is in general very moderate in pleurisy, and exerts but a slight effect on the respiration. Nevertheless, both pain and fever are two of the elements of pleurisy which, by a different mechanism, may engender disturbance of the respiration; but when these two elements have disappeared, or have not existed (as in certain subacute pleurisies termed latent), the patient has no dyspnoea, notwithstanding the large accumulation in his pleura. He certainly is not able to make the same exertions as a man in good health, but when he is in bed, and in the repose which any patient must be in to undergo a medical examination, the dyspnoea is so insignificant that it ought not to be regarded as an element of diag nosis, and should not be accepted as an indication in regard to paracen

tesis.

This association between a large effusion and an almost normal respiration, which at first seems so strange, is not difficult of explanation. In the physiological condition respiration is not exerted alike over the whole pulmonary surface, certain parts of the lung, especially the supe1 Gazette hebdom., September 27th; Medical Times and Gazette, October 12, 1878.

rior lobes, contributing but very little to the function. But in a pathological condition, when the play of the lung is impeded by the presence of an effusion, the healthy lung comes into action through its whole extent, and nearly reëstablishes the equilibrium in the phenomenon of hæmatosis.

The first consequence which results from this absence of dyspnoea in pleuritic effusion is that dyspnoea furnishes only insufficient or unsafe indications when an operation has to be decided upon. To delay evacuating the pleura until the patient is attacked by dyspnoea is to wait until the effusion has attained proportions so considerable that the life of the patient has already been long in danger by the time the decision is arrived at. All the cases in which sudden or rapid death has occurred during the course of a pleurisy with effusion are neither known nor published, but those which have been published show us that the patients generally die on account of cardiac coagula, coagula of the pulmonary arteries, and thrombosis favored by the entirely mechanical conditions of displacement, torsion, and flattening of vessels, and of the obstructed circulation due to the effusion. Another consequence arising from this absence of dyspnoea is that when it is present in pleurisy it is a sign of complication; so that whenever a patient, the subject of pleurisy with effusion, presents more than from twenty-eight to thirty respirations per minute, we know that we have something besides a pleurisy to deal with. If careful examination be made, it will be found that the pleurisy is secondary, developed in the course of Bright's disease, or of a cardiac affection with congestion of the lung; or the pleurisy is associated with other diseases, as double pleurisy, bronchitis, pneumonia, pericarditis, fluxion of the chest, or pulmonary congestion.

To sum up: (1.) Dyspnoea is not one of the habitual symptoms of pleurisy with effusion. Pleural effusions, even when they reach eighteen hundred grammes or two litres, only accelerate the respiratory rhythm by four or five respirations per minute. I am not speaking, be it well understood, of the painful period which is often accompanied by false dyspnoea, and I make reserves in the cases in which fever is still vivid. But under all other circumstances, in the apyretic phase of pleurisy, and in subacute, latent, and chronic pleurisy, dyspnoea is a symptom so anodin that it does not merit being taken into consideration in reference to diagnosis, prognosis, or treatment. (2.) On the other hand, when a true dyspnoea is proved to exist during the course of a pleurisy, we must always be on our guard against a complication, whether the pleurisy be secondary (as in Bright's disease or affection of the heart), or whether it be associated with other phlegmasiæ or pulmonary congestion.

Auscultation of the Arteries. - Matterstock, who was excited to the 1 Deutsches Archiv für klinische Medicin, November 29, 1878.

study by the work of Weil, gives the following as a summary of his

observations:

(1.) In mitral disease there exists in the majority of cases a diastolic murmur, that is, with arterial expansion, in the carotid and subclavian arteries, usually of a soft, blowing character. This may be due to an irregular movement of the blood in consequence of diminished filling of the artery, or may be produced in the neighboring distended vein by the intermittent pressure of arterial expansion.

(2.) The systolic murmur heard in the pulmonary area in various diseases (pulmonary stenosis, mitral affections, pulmonary emphysema and cirrhosis, anæmia, etc.) is often propagated with striking intensity into the left subclavian, and even into the axillary artery. The same is true of the pulmonic second tone.

In like manner, the auscultatory phenomena of the aortic orifice stand in intimate relation to the arteries of the right side.

(3.) A murmur may be produced simply by pressure [of the stethoscope] in all accessible arteries under the most different conditions; this has no semeiotic significance.

(4.) A tone also may be produced artificially by pressure [of the stethoscope] in all the large compressible arteries into which a small quantity of blood is thrown by quick ventricular contraction.

(5.) This pressure tone is due to the vibrations both of the arterial wall and the fluid.

(6.) The double murmur is also artificial [that is, produced by pressure]. Its occurrence is associated with no particular valvular affection. All that is necessary for its production is a moderately large quantity of blood thrown into the arterial system, not too slowly, and that the arterial wall shall have retained its contractility, or at least shall not have lost very much of it. The most necessary condition for its production is suitable pressure.

(7.) In most cases the second half of the double murmur is due to centripetal movement of the blood. In rarer cases it may correspond to anadicrotism of the pulse; then it is probably due to a double contraction of the heart, and is nothing more than a reduplicated tone transformed into a murmur by pressure.

(8.) The reduplicated diastolic arterial tone is for the most part produced by a double contraction of the ventricle. It has no pathognomonic significance.

(9.) The double tone may be found in all possible conditions, and is, at least in most cases, to be considered merely as a consequence of the katadicrotism of the pulse.

(10.) Cases of considerable aortic stenosis are distinguished above all other valvular affections by a want of the double murmur and pressure

tone.