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a matter on which we speak with great confidence from a large experience of the use of nux vomica. The official dose of strychnia is not quite so extravagantly wrong; yet grain is at least twice as high as the minimum dose should be fixed, and grain is a quantity far too large to be given in repeated doses (as strychnia usually is given) with advantage or even safety. So again with morphia: the acetate and hydrochlorate are recommended to be given in doses of from to grain; the former of which is excessive as a minimum dose even for adults, much more for children.
We could go on, for a considerable time, multiplying these examples of an insufficient and often mischievously misleading official posology: and we cannot but remark that the occurrence of such errors in works of official authority are exceedingly to be regretted, for more than one reason. That the result may be highly inconvenient in a practical point of view is shown by such an occurrence as that which led to the above-mentioned inquest at Ramsgate; but there is another point of view in which the official neglect of accurate attention to dosage is of even more unfortunate significance. We fear that it does but indicate an ignorance and a carelessness which are very widespread in the profession, and of which we are constantly encountering proofs in prescriptions which come under our notice. It is not too much to say that the majority of practitioners-consulting and general-seem to be almost wholly unaware of the important differences of effect which may be produced by extending the range of variations of doses, and especially by so breaking up one large dose into many small ones as to ensure its passage into the circulation without exciting inconvenient and unnecessary disturbance. We believe that no greater service could be performed by the colleges, or the great medical societies, than the formation of a committee of competent men for the special investigation of this question of dosage for it is a subject which is as yet only in its infancy, and the best knowledge which exists about it is undoubtedly confined to a very small section of the medical profession.
A CASE OF RHEUMATIC FEVER TREATED WITH A COLD BATH; DEATH OCCURRING IMMEDIATELY ON LEAVING THE BATH.
BY SYDNEY RINGER, M.D.
THESE short notes are published as this case will help to answer the following questions:-Can cold baths be administered in rheumatic fever without danger? and is it advisable before employing this treatment to wait for the onset of hyperpyrexia? or should we commence it when high fever, absence of jointpain, suppression of perspiration, and delirium show that there is danger that hyperpyrexia may occur? As hitherto all cases of rheumatic hyperpyrexia have proved fatal unless treated by cold baths, it is obvious that this case in no way contra-indicates that treatment on the occurrence of this dangerous condition.
A young woman, aged 24, was admitted into University College Hospital with rheumatic fever. Her father died suddenly from some unknown cause. Four years before the patient suffered from a severe attack of rheumatic fever. Her present illness begun about a week before her admission into hospital. On her admission she suffered from a sharp attack of rheumatic fever; her temperature rising daily to 103°. There was not, however, much joint affection, and at first she perspired freely, but latterly her skin grew dry. She rapidly got worse: thus during the nine days she was in hospital her temperature rose daily till it reached 105°, and her respirations rose from 32 to 60; her pulse remained about 120 per minute, and throughout was strong. Latterly she suffered from dyspnoea, and subsequently was propped up in bed with pillows. She wandered
a little at night, and on the day the bath was employed her intellect was a little obscured, and she passed her urine under her. At 7.42 P.M. of the ninth day of her admission she was placed in a general bath of 92°, her temperature in the axilla being 105° Fahr. In seven minutes, and before the temperature of the bath was reduced, her rectal temperature was 105°8; the temperature of the bath was then reduced. In eighteen minutes after the commencement of the bath her rectal temperature was 1054. After forty-four minutes her temperature had fallen to 103° 4, the temperature of the bath being 69°. Whilst in the bath she took 4 ozs. of brandy. She was removed because her breathing grew rather shallow. After being put to bed she merely gasped a few times for five minutes and died, notwithstanding the employment of artificial respiration, energetic friction to the surface of the body, and anal injections of brandy. At the post-mortem examination we found a few patches of recent lymph on both lungs, but not an unnatural quantity of serosity in the pleuræ. The heart was universally adherent to the pericardium, the adhesions being tough; the blood in the heart and great vessels was very dark-coloured fluid and free from clots. The left ventricle and auricle were dilated-especially the auricle. On the tricuspid, mitral, and aortic valves, numerous minute vegetations were seen at the usual places. The mitral, aortic, and pulmonary valves were a good deal thickened. The mitral valves admitted three fingers nearly to the knuckles; the two segments were united for a short distance; they permitted some regurgitation when tested at the tap. The heart's substance looked healthy, and was of fair consistence. On the surface, at places, there was a thin line of paler and rather opaque tissue. The walls of the left ventricle at the base. were inch thick, at the middle inch, and at the apex rather less than inch. The brain, liver, spleen, kidneys, stomach, and intestines were healthy. During life her urine contained a trace of albumen.
ON A CASE OF PERICARDIAL EFFUSION, IN WHICH PARACENTESIS WAS PERFORMED.
BY THOMAS BARLOW. B.SC., M.R.C.S.
THE following case presents several points of interest. Twice the pericardium was tapped by the aspirator, and twice the abdomen, with marked relief, and without any bad effects from the operation. The child was feverish throughout, and neither the fever nor the considerable ascites could be satisfactorily explained during life, but after death these were found to be due to tubercular peritonitis. There was a considerable amount of recent and old tubercle in the abdominal cavity; whilst only a small patch, with scattered recent grey granulations, and situated in the lower lobe of the right lung, was discovered in the chest. The visceral and parietal pericardium was enormously thickened, and yet the two surfaces were not at all united, the heart hanging free in its thickened envelope.
H. V., aged 6 years, was admitted into University College Hospital, February 7th, 1873, under Sir William Jenner. He was afterwards under the care of Dr. Ringer. The boy's mother gave the following history:-At the end of November 1872 he complained one night of pain in the left knee. His mother states that there was neither redness nor swelling, that he was not feverish, did not sweat, and that his urine was not highcoloured. The pain in the knee continued for a week, but was not so bad as to prevent his moving about. In three weeks the child seemed all right again, but fourteen days ago, i.e. six weeks after the onset of the knee trouble, the mother noticed
that he was losing flesh, that his breath was short, his abdomen increasing in size, and that there was slight puffiness below the eyes. During the last week the child had wheezed and coughed, and his urine had contained a red deposit. Previous historyNever had scarlet fever nor rheumatism, so far as mother knows.
STATE ON ADMISSION. — The boy walked into the ward without showing any distress. When he sits up in bed he raises his shoulders and bends his head forwards. When he lies down he lies on the left side: says he has no pain. He has an occasional short catching cough. No expectoration. A little wheezing is audible close to the bed, and there is slight dilatation of the alæ nasi. Pulse, 152; respiration, 40; temperature, 1016; skin dry; tongue very red. He is very pale; skin transparent. Is slightly puffy beneath the eyes.
Chest shows ricketty enlargement of the ends of the ribs at junction of the cartilages. Elevation in excess. There is recession of intercostal spaces in both inframammary and lower axillary regions. A little oedema of chest walls. Rhonchal fremitus to be felt over both fronts. There is some bulging in cardiac region. Apex beat cannot be seen nor felt. Absolute cardiac dulness begins in second space; its right margin extends to in. to the right of the sternum. Double grating friction is heard over the sternum, and in. to the right of the sternum, from the junction of the xiphoid to the junction of the third costal cartilages; loudest at the junction of the xiphoid. Neither heart sounds nor friction can be heard at or below the nipple. Right front resonant. Both backs a little deficient at bases. Vocal fremitus to be felt down to extreme bases. Pectoriloquy over both backs. Sibilant and subcrepitant râles over whole front and back.
Abdomen.-There is a small umbilical protrusion, which his mother affirms has come on during the last week. Flanks bulged, but tympanitic. There is oedema of the abdominal walls. No oedema of ankles.
Urine scanty; acid; specific gravity 1034; large deposit of lithates; no albumen, no sugar.
One week after admission the boy was seen by Sir William Jenner, who gave the following note:-"There is some fluid in the peritoneal cavity. Liver dulness begins at fifth space.