Lower border sharp and well defined-can be felt half-way between ensiform cartilage and umbilicus, and 2 in. below the margin of the thorax in the nipple line. The cardiac dulness now extends to within one finger's breadth of the right nipple. There is relative dulness from the junction of the first costal cartilage with the sternum, nearly as far as the angle of the left scapula. Friction heard as high as the second space. No heart sound to be heard in the position of the apex, but very obscure friction. Rhonchus as before; the boy expectorates a little aërated mucus." During the remainder of February and March the boy's physical signs changed little. The friction became almost inaudible, except at the ensiform cartilage, where it was very distant. Bronchitis became more pronounced, gurgling râles being heard down both backs. The ascites was unaltered. His dyspnoea became more decided, so that he was always obliged to be propped up. The jugulars became distended, although they did not fill from below.

His temperature during February and March was about 99° in the morning and 100° to 101° in the evening. He had emaciated considerably. There was no albumen in the urine, except on one day a trace: the quantity of urine in twenty-four hours was about 10 oz. His cardiac dulness (absolute) was now bounded by a line taken from a point 1 in. to the left of the right nipple, up to the junction of the second right costal cartilage with the sternum, thence to a point in. to the left of the left nipple.

When patient leans forward the apex can be felt very obscurely in the nipple line in the fifth space; cannot be felt when he leans back. There is still a little obscure friction at the ensiform cartilage. The first sound just audible in position of apex, but exceedingly distant.

Dr. Ringer, who had now charge of the case, being of opinion that there was no reason to expect that anything would cause the absorption of the fluid, considered that paracentesis of the pericardium was the right thing to be done. This was performed by Mr. Christopher Heath, on the 18th of April, Dr. Anstie being present, as well as Dr. Ringer.

The skin was punctured by the smallest aspirator trocar, 1 in. below and in. inside the left nipple.

The trocar was

pushed up and out. It entered the pericardium above the fourth rib: 33 oz. of fluid were withdrawn, and then it ceased to flow; the trocar was pulled out, and the point where it had been introduced was covered with collodion. The fluid was slightly turbid, brownish in colour; sp. gr. 1025; showed nothing under the microscope except a few blood-corpuscles and large epithelium scales, and coagulated en masse on boiling. There were no signs of collapse during the operation; the pulse was unaffected. Although the quantity of fluid removed was so small, the symptoms were decidedly relieved. He lay with his head on the pillow, which he had been unable to do for weeks, and his respirations were reduced from 56 to 48 in the minute. With respect to physical signs: immediately after the operation there seemed a little improvement in the note under the left clavicle, but when examined later in the evening by Dr. Ringer, not a fingerbreadth's difference in dulness could be detected in any direction. The apex beat was certainly more distinct, being felt in the nipple line 1 in. below the nipple; also in. outside and below the nipple.

Next day a little superficial rhonchus was heard, along with gurgling and subcrepitant rhonchus over the left front. It simulated pleuritic friction, but altered slightly on coughing. From the time of his entering to that of leaving the hospital there was no sign of effusion into the pleura.

The boy's improvement did not last more than two or three days, and on the 26th April it was decided to do paracentesis pericardii again. It seemed probable that the small quantity of fluid removed on the first operation was due to the trocar needle having been introduced too high and directed upwards. Mr. Heath therefore on this occasion punctured directly through the skin into the pericardium at the upper border of the fifth rib instead of the fourth. The canula was pushed in two inches deep 6 ozs. of reddish brown fluid were withdrawn; sp. gr. 1024, neutral; coagulated en masse on boiling.


After the operation the resonance was decidedly improved on the right of the sternum. The position of the heart's apex was unchanged, but it was felt more distinctly both in the nipple line and to the left of the nipple.

The boy's symptoms were again relieved. He was able to lie

down, and slept that evening. There was less jugular pulsation: the pulse and respirations did not change; they averaged about 150 to 50 respectively.

His temperature in the evening now ranged from 101° to 103°, in the morning from 100° to 101°.

In two days after the operation the cardiac dulness was as great as before; and now the abdomen, which had hitherto been excessively distended but had always been resonant in the flanks, became quite suddenly dull throughout, and so prominent in the umbilical region that it seemed likely to burst if not tapped. Now also there was considerable cedema of the legs and thighs.

Paracentesis abdominis was performed by Mr. Heath on the 2nd May, and 35 ozs. of clear slightly green fluid withdrawn, which coagulated spontaneously after standing a few minutes. Five days after this a decided diminution in cardiac dulness was noticed. The absolute dulness no longer extended beyond the right margin of the sternum, but was not otherwise affected.

The apex beat, however, was felt for a distance of an inch inwards from the nipple line in the fifth space, and well marked; a rubbing sound was to be heard both below the nipple and at the ensiform cartilage.

The lung signs remained as before. The ascites soon reaccumulated, and the tricuspid regurgitation became more marked. Not only in the jugulars, but also in the veins on the back of the hand, pulsation of respiratory rhythm was to be seen; and on one occasion Sir William Jenner believed there was a finer pulsation to be seen in the veins which corresponded with the heart's beats.

The boy was passing at this time not more than 12 ozs. of urine in twenty-four hours. He now began to get paroxysmal attacks of dyspnoea, during which he became quite purple; and the ascites having reaccumulated, paracentesis abdominis was repeated.

On May 23rd 36 ozs. were withdrawn, of the same character as before. This relieved his dyspnoea considerably. His temperature at this time was lower than it had been before, namely, 101° in the evening, and 99°6 in the morning. On one occasion the morning and evening temperature was 97°8.

On the 2nd of June the boy's mother, being afraid of his

dying in the hospital, took him out. I saw him at his home two or three times a week until he died. The general dema increased immensely. The right thigh, in spite of punctures, sloughed in two places (which were not the seat of punctures). One of these sloughs separated down quite close to the bone.

The boy died on the 3rd of July, i.e. seven months after the commencement of his illness.

POST-MORTEM EXAMINATION.-The pericardium contained half a pint of straw-coloured fluid. The parietal and visceral layers were covered with lymph inch thick. This lymph posteriorly presented quite a honeycombed appearance. Heart substance normal to naked eye inspection. Orifices normal except the tricuspid, which was dilated. There was about an ounce of fluid in the right pleura. In the upper part of the lower lobe of the right lung a mass of racemose tubercle, becoming cheesy, but not yet softened; in the lower part, grey granulations diffused throughout. No cavities. The upper lobe healthy. No granulations on the pleura. Bronchi full of mucus; walls injected. Left lung was pushed back, but not collapsed, and was to naked eye appearances healthy. No fluid in the left pleura. Mediastinal glands enlarged and matted together, firm and spotted on section, like those commonly described as tuberculous glands. Abdominal cavity showed abundant grey granulations in the mesentery and on the parietal peritoneum. Liver partly adherent, markedly nutmeg. A large blood cyst composed of semi-decolorised clot was seen between the liver and the stomach. No explanation of this could be offered, except that it occurred on one or other of the occasions when paracentesis of the abdomen was performed. Spleen healthy. Kidneys healthy with the exception of two little tuberculous (?) spots just under the capsule. No ulceration of intestines, and nothing abnormal about mesenteric glands, except that a few were soft and swollen. Permission not granted to open the head.



(Second Paper.)


Fellow of the Obstetrical Society, Surgeon-Accoucheur to the Royal
Maternity Charity, &c.

IN a former paper on this subject it was said that 1,000 drops. of absolute alcohol would dissolve ten grains of phosphorus. This is not quite correct, the fact being that it takes 242 grains of alcohol to dissolve one grain of phosphorus. The tincture with which most of the former series of cases were treated was made in these proportions. A watery mixture made with this tincture, although far less disgusting than an emulsion of oil of phosphorus, is still disagreeable enough to cause many patients to refuse it; it produces a very objectionable though diminished amount of eructation; and, lastly, it is very unstable. Although these objections are perhaps to be surmounted by the use of pills or capsules, the greatly superior result, which I believe I have seen to follow the use of a solution of the pure drug in a condition which admits of more easy absorption than those forms, rendered it necessary to discover some other medium of administration; and I have found that the following prescription answers all requirements:

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