3, I9I5] A-PRi1L 3X I9_ I_ TREATMENT OF DRY PLEURISY. [ UDCLJUNLM J(NAL5937 Xrepeating the manipulation, the cartilage cotuld apparently be opeln metlhod. The conjunctival reflex was briski tlhrouglh- felt, slipping in and out of position. out, and the was so For -a time the patient was much relieveed. At first there was anaestlhesia light that the patient was much fluid in the joint, but this disappeared under massage constanitly m]oviing lher head and fingers; nievertheless, the and passive muovement. She was able to walk, althougb there relaxatioln of the lower limbs was absolutely perfect, slhe was a little tenderness on pressure over the internal condyle. was receiving no painful stimuli whatsoever, as the nerve- The only movement that caused real pain was full flexion, blocking by the stovaine interrLupted them, and therefore which always gave rise to aching at the back of the joint. Full extension (which would tighten uip the posterior ligament of her pulse never exceeded 70, and slhock was- entirely the joint, and press uponi the cartilage if it were still displaced) absent. The combination of spinal analgesia with tlle could be quite painlessly performed. The pain persisted, and liglhtest possible general narcosis is the ideal anaesthesia- it was found that the knee was still an inch larger in diameter for these higih amputations. than the opposite one, even though no fluid could be demon- strated. Tuberculosis or osteo-arthritis was then suspected, annd a skiagrarn was taken. It showed a clear, well-defined cavity in the interior of the internal condyle of thefemur, which was somewhat expanded; the wall of the cavity was thinned TREATMENT OF DRY PLEURISY BY TEMIPORARY out and quite eveni in outline. There was no blurrinig of the 'lefinition of the parts around, nor any of the " fuzziness " that PARTIAL ARTIFICIAL PNEUMOTHORAX. is so characteristic of ttuberculosis. On careful examination By GEOFFREY LUCAS, the plate also showed a fracture of the internal condyle, involv- B.A.CANTAB., L.S.A.LOND., iig the knjee-joint, but this was missed by ever-body at the SENIORi ASSISTANT PHYSICIAN, NORDRACH-ON-DEE, DA.N-CHORY. time. Had it been observed, it might have led to a more detailed diagnosis beiing made before operationi. THE following case well illustrates thle benefit which may It wbs decided that the case was onie of eindosteal sarcoma following the injury of December, 1913. Mr. R. P. lIowlands, be derived frhiin temporary separation of tlle two inflamed wtho saw the patient in consultation, concurred in this sugges- surfaces of pleura in a case of long-stasiding dry pleurisy tion, and advised that the limb should be amputated, inasmuch by a layer of nitriogen, wlhich in tllis way acts as a pneu- as it was not possible to perform anly conservative operation matic splint, by mneans of wlicih the inflamed parietal and th?at would not entail much subsequent deformity and be at lisability. visceral pleura m-iay put comuplete rest, and concli- On May 2nd, the patient was anaestlhetized with Barker's tions arc produced under whichllrepair and rectuperatioi stovaine-glucose solution by spinal injection, and rendered jtust m-ay be brouglht about-a condition whlich ig not allo6wed unconscious with a minimal amount of ether, given by the drop them by Nature whilst they arc in, actual appositioni. Th-e miietho(l. She had also had morphine, gr. 1, and atropine sulph. lengtl of time for which the- so-called splint mnay be gr. - an hour previouslv. Axillary saline infusion was also be -the 6f adminiistered, and Dr. George, assisted by Dr. E. C. Andrews, applidl mrav regulated by req'uirements the case. amnputated the limilb through the thigh by means of unequal My object in publishing this case is not by any meanis atnterior and posterior flaps. At the conclusion of the operation to advocate this method of treatmeht for every case of dry the patienit's pulse was strong and regular (70), the colour was pleurisy, it is intended mnerely as a suggestion tlhat the good, and there were no signs of shock. Within half an hour method mighlt be well worth trying in similar cases of of leaving the theatre the patient was talking comfortablv to and her uaurse. The after-history was uneventful, and up to the obstinate long-standing dry pleurisy, where more presenlt time nio recurrence has taken place. recoagnizecl and better lnown means of treatmllelnt have On examination of the part removed, it was found thlat the failed. internal conldyle of the femur was occupied by a cyst conitaiining A lady, aged 50, was sent to this sanatoriunm. on May 7tl, fluid blood, iiot uinder pressure; the cyst-wall was composed 1914. The recent muedical history bearinig on her present of dark, soft, miiarooll-coloured membranie, which cotuld easily Le stripped off ancd showed, onl histological examiniation, the illniess was that tlle righlt kidney lhad been removed fot- characteristic structuLre of a spindle-celled sarcoma, intermixed tuberculous disease in 1911. She lhad a slharp attaclk of wvith a niumber of giant cells. The bonv wall was so thin that dry pleurisy in September, 1913, the pain from whiclh lhad it could easily be indented with the finger in several places, and continned ever since. there was a supracondylar fracture which had involved the In January, 1914, four small foi- klnee-joint. A thiii membrane stretched across the line of haemiioptyses occurred', fracture, showing that union was at anly rate tending to whlich the patient was confined to bed for a montlh. There occulr. The structures outside the internial condvle, in its im- was a furthelr small lhaemoptysis in the beginning of Marc]i, mllediate viciniity, were inlvolved in an extension of the growth, and since then the patient hadl becen living quietly at a as wvas demonstrated by the microscope as well as by the niaked- South Coast watering-place. eye appearan-ces, but there was no extensioai towards the Examinationi of the chest oni adm-uissioni revealed a Popliteal space, or up the thiglh. liealed tuberculous lesion at the left apex. Th-1ere weci- Looking back upoln tlle case, onie realizes that lmore signs of muleli dry pleurisy over the middle and lower imiiportance should have been attached to tlle persistence lobes on tlle riglht side, a coarse leathery rub being audible of localized tenderness upon pressure over the internal from the fourtlh rib in front and the sixth dorsal vertebra condyle-a very valuable sign of a fracture inl many cases. behind, downwards to the base of the lutng. AcLute pain Suclh tenderness, moreover, is often seen in cases of endos. was com-plained of over this site. Tlhe patient was kept teal sarcoma. Local tenderness betokens a local lesion. at rest in bed, anid tlhe usual palliative luetlhods of treat- If the case had been one of tuberculosis, it is extremely iment adopted, without bringing,f about any amelioration of improbable tlhat it would lhave remained localized to one the symptoms. ThroughouLtt this perio(d the temperatur-e part of tlle joint for any length of time; it would have and pulse-rate were normal. involved the whole cavity, and flexion, pain on movenment, After a lapse of ten weeks--nio improvement being or pyrexia would have ensued. Possibly, also, on very apparent-it was tlloughlt tllat gentle exercise might detailed exaimiination under tlle anaesthetic, the isolated prove benieficial, and walking exercise, in gradually in-- movement of the internal femuoral condyle might have been creasing distances, was commuenced uuntil a distance of observed, if tlle idea of fractture had occuLrred. A skiagranm two miles was reaclhed. Still the paini provedl most per- talken then would have led to an earlier diagnosis of the sistent, anld as it was m-iaterially interferina with the existence of the growth. For it seems probable that it patienlts rest at niigilt, she expressed le1 anxiety that was the initial inijLrv, the striking of the knee against the somethling "1radical" muiglht be done to improve matters stone step, that gave rise to the sarconma, and that tlhe for lher. Tile possibility of producinig a partial temuporary second trivial accident cauised a patlhological fracture. On artificial plneumotlhorax was suggested, and tho pros anld reflection, it seems lhardly possible that a muere step from CoIns were. puit impartially before 11re; after som1ie ConI- a stationary bus to the groiund could lhave caused such sideration and consultation 'with le1r relatives, sle severe symptoms as were present in this case, unless some requested that this treatment might be attenmpted. major injury lhad occurred, and perhaps tlle diagnosis of On October 11tlh, 1914, under the influence of 0.5 c.cnt. pathological fracture slhould at once lhave been discutssed. of omnloponi-scopolaminie, given lhalf ani hour previously, At any rate the case is very instructiv e, thotugll it is easy and a local injection of novocain, a Saugmiann's needle was to be wvise after the event. introdulced ilito thle sixthliglht intercostal space in the As regards the teclhnique of thle operation, it is only posterior axillary line. No difficuLlty was experienced ini necessary to comment upon the importance of the mea- linding the initerval betw-een tile parietal and visceral layers ures thLat were employed to Abolish s1ock. Anxiety- of tile pleura, and 200 c.cm. of niitrogen were introduliced. be)forehland, aucd pain- afiterwardls, weNere alikSe avoided by On the following day the patient still complained of pain, thle use. of mlorphline, andl unconsciounsless wsas inlduced anld and on- October 13tll a fui'ther injection of 300 c.cu. of maintained thlroughlout a fairly lenlgthy, operationl by thle nitrogen was giveln at tile same site. On tile day following, ulse of only tw-o ounlces of ether, even thoughl given by thle atusctltation show'ved tlhe' breath souLnd(Is ox-er the rialgt ba.o I 3, 59459__KI3ncAsJOMuIC)CAL OUPr-L .j3 11 ANG-1O-NEUROTIC OEDEMA. [ArRIL 1915 to be distant and no pleural rub was audible. Pain was abdolminal pain or volmlitinig, but the patient suffered fromii (listinectly relieved, tlhouglh still present at the end of a attacks of nausea at times, anid remained listless anid dis- inclined for physical exertioil. The lheart and other organs very deep inspiration. On October 18th a further qutantity appeared quite healthy. As the sodium sulphate mixture was (f 300 c.cm. of nitrogen was introduced, which had the oausing much relaxation of the bowels, I prescribed, after a effect of entirely abolishing the pain, even at the end of couple of days, a colchicum mixture and a tonic of iron and (leep inspiration. On November lst a final injection of quininie wvith a salinie aperient each morning. Onl September 400 .c.cm. of nitrogen was given, after whichi the imiano- 4th his condition was unaltered. He felt disinclined for exer- were 0 tion, though he slept well and( ate fairly well. Temiiperature mnetric readings of the intrapleutral presstures 100°F. I advised a return to his usual diet. At abont 3 a.mn. alnd -3 cm. of water. on Septemlber lOtlh the patienit awoke and fouind his tongue At no time during the periods of injectioii of nitrogen swolleni; I saw him at 8.30 a.m., and found the left half of the were there any signls of intrapleuiral fluid, nor was tler'e tolngue considerably enlarged, whilst the right half looked almost normal. The swelling, he said, hal already subside(d aniy disturbance of tlhe temperature or pulse-rate. very considerably, and by the eveninlg it was gone. On The after-hiistory of the case was -uneventful; there -vas September 14th the patienit left Belize for a sea voyage. On no retturni of paini, anid the patient was able to leave on October 3rd, 1914, Dr. J. Edward' AuLstin of Porto Cortez, February 8tlh, inore than three miontlis after the last Republic of Honduras, wrote saying that, " On Septemiiber 18th injection, entirely free from symptoms. The phvsical I was called to attencd X. He preseilted one of the most tvpical cases of Quineke's disease-angio-nieurotic oedema-that has signs at tliis time w-ere those of slig Itly tlhienei-ed pleura. ever come unlder m-iy observation, the gastr ic crises being espe- The breath- sounds were normal. The nitrogeln lhad cially seveie. I have alvays fouind that calcium lactate coI1- idvidently becomie absorbed and the pleur'al suLrfaces wcrc trolled the maniifestations better than- any otlher remedy." This presumably in apposition again. was the first anid sole occasion that the typical abdominal pains were experienced. In a later communication Dr. Austih, wlho had l)ractised for maniy years in Porto Cortez, stated, " I lhave seen in practice probably niine or ten cases, most of wlich were adult meni." The patienit returnied to Belize on October 25tl, NOTES ON TWO CA.SES OF ANGIO-INEUROTIC anid I sav hiim the niext day. Dr. Austini adh-inistered calciunii lactate with soene benefit, althotuglh the swellings still appeared OEDEMA. on the tonigue at intervals of a few days. On the day he lande(d in Belize he had a similar attack affecting the tongue only. BY F. L. DAVIS, J.P., MI..C.S., L.R.C.P.LoN-D., Wlhen he reached Bluefields, Nicaragua, as there was no calcium B3ELIZE, BRITISH HONDURAS. lactate in the town., a doctor pit up a minxture conitaining calciuim glycero-phosphate, and as the patient thought that this prepara- O-N the miorningti of AuiguLst 21st, 1914, I was called to see tion ha(l more effect iln controlling the symptoms I advised hiim X., a clergymani, aged 49. to keep onivith it. Two weeks )efore the present illness, wlen in Corozal, a small coast town in the northi of the colony, lie lie told me that htis tlhroat had (given hiim trouible during awoke at 4 a.m. to find llis tonguie so swolleni as to malke it the night. The righit tonsil and adjacenit parts were sonmewhat imnpossible for hiim to speak or to swallow. The -previouis swollen anid congested. I prescribedl a gargle of tannic acid evening he had gone to bed feeling perfectly well. He got and aluim, advising him to rest hiis voice and to remain indoors. some lotion from a chemist an(d by noon the swelling had suib- -He then drew my attention to his hands and fingers, wvhich, he sided. About two montlhs previous to tlle attack att Corozal said, were burning and pricking, and felt stiff anid swvollen. the toncgue was affected in precisely a similar way. The Some of the fingers certainly appeared a little swolleni and red- patienit was born in British Guiana. Fronm the age of 18 to 23 dlenied, but I suspected that the Ipatient ha(l probalfly scratched lie remained in. England, and after that, unitil tiie presenit themll in the endeavour to allay the itching, and I ordered an illness, he lhad lived in the WVest Indies, but lhad miiadle periodical Ointment of lhazeline. Next morning I fouind the patient in hiis visits to England, the time so spenit aniountiiig in all to about bedroom niot feeling Nvell enough to get up. Thie thtroat ap- seven years. There is no history of aniy illness at all resem- pearances wvere quite normal, bout hie had passed a wretche( blinig this comi-plainit in aniy member of hiis family, eitlher onl iight owing to intense irritation of the handls and feet. Al1l the tlle maternal or paternial side; neither lha(d the patielnt himiiself lingers and both hand(s as far as tlhe wrists, and a!l the toes and ever had an attack previous to hiis arrival in this coloniy sonic both feet as far as tlhe ankles, were conisidierably swollen, red- two -ears ago. He tells imie that lie has always been of at dened, and oedematous, especially over the dorsal surfaces. nervous anid senisitive niatture, but in general appearanle is Trhe patient coIld nIot refrain from. ru[bbinigl tand sc'ratching strong alid lhealthy. His daughter, aged 23 years, hlas suffere( tihemi. I now recognlized the niature of the affection. For local for manay years frome very severe asthlmatic attacks. The oilY ap)plication I ordere(d a calamine aind( zinie lotion. Internially I illnless lhe himiiself rememnbers to lhave hla(l was ani attack of gave an aperient and a nmixture of sodiumiii bicarlbonate anid dysentery in 1883, wvhichi beca-ie clhronic anid conitinued for rhubarb. By tle next miiorniinlg, the swellinig and irritation of ab)out one year. Four years ago, x%lien boarding a steamer ill thie lhanids and feet lhad v-ery considerably subsided, but a stormii, lie received a severe blow oni his back, followed by the penis and scrottum- wer-e eiormously swollen aildoedie lamiieness anid slirinkingc of the mluscles of the rigit leg. Thlis iiatous, the skin and subc-utaneous tissue being so pale conditioni lasted for abouit one year, dturing whichl period lie and translticent as to look like a bladder. Tile patient saidl that was niot conifined to be(l. The leg is nlow strol'g and wvell. the swelling hiad beeni even greater. I ordered tile samile lotioin anid continued the niledicinle. Oin the miior1iiig of Auigust 24thi The special features in the case -were: (1) The rapid the hands, feet, penis, anid scrottim appeared practically onset of the swellings, the speedl with wlhichi they attained niormial, though there still reiliilled a feeling of tightiness in thleir miiaximumln developm-lenit, and their rapid subsidence. the fingersand toes Oil movemient. But the, lower lip had nOw The duration of these swellings in the case b)ecomie enormously swolleni; it was very tense and hard, alnd unlder review the patient said that it felt as if it were going to burst. I nlow was from six to ten lhours. (2) The tiiiie of appearanice of ordered calcium chloride, gr. xv, t.d.s., andt aspirini, gr. v, the swellings, alimiost invariably during the small hours, of every four hours. By the eN e.-:ing the lit) had returnied aInlost tllc morning. (3) The orderly progress of the swellinas. to its normal condition. On Auguist 25th and( 26th the patienit The rialgt tonsil anid side of the tlhroat were first affected, coniplaiiied of some sliglht seiisatioli of irritationl abotit the feet till the general marhell of tlle swellings was stund kniiees. I detected, however, a distinict putffy swelliiig on fronsi the feet the right side of the neck, abouit 3 in. long aid 2 in. wi(le, upwards, the last part affected beingy tlle touane. (4) Tlhe commnencilg at the lobuile of the ear and extending vertically muscular weakniess wlhichl the patient experielnced, lnot lownvardls. 'Tllis swelling vas niot the seat of aniv painl or only during, the attack, but after tlhe acute symptoms liad irritation, so that the l)atient had been uniiaNvare of its existence. passed off. (5) Those parts wlliclh had been tlle seat of OIn tihe morning of Au'guist 27th tihe iupper lip commence(d to swellings were nlever attacked a second swell and in a few hours reachie(d a condition ex-acikh similar to time, witlh the that of the lower lit Oil August 24tlh, yct by the evening the li1 sinigle exception of the toague, anid it would seem tljat hiad almost regainiedI its ncramal appearance. 'Tlie swellimf this organ is peculiarly liable to suffed, i viewo of the fact iioticed in the ileck the previous day lhadl entirely (lisappealed. that on two previous separate and distiniet occasions it .L ordered a diet of iiiilk, farinaceoas foods, mand Nvluite 'was affected and dturing the present illness it was attacked mileats, and a(lvised Ihim to avoid tea, coffee, aiid eg{vts. over anld over At 6.30 a.m. Oni Auguist 28th I received ani uirgent miessagie againi. anld- asked Dr. Harrisoni, the prinicipal imledical ofhice, and The above is an alilnost exact clinical picture of the l)r. Cassel, the assistanlt colonial surgeoil, to aecompany me. disease as it affected tlle writer of this article in Septeimber .\t 8.30 a.m. we found tlhe p)atienlt witli a gelleral eliargement anid October, 1913, oil his retuurn to Belize after tlhrce 01 the tongue, wvhich couldl Nvitli diffictilty h)e protruded. It weeks' camping out in tlle forest. JIlad beguni about 2 a.m., and( there was for a time the greatest I dlifficulty in swallowving, wliile speechi was impossible. Never- was engaged in entomological researchl in thlec extremlle tieless, the swellingd lhad subside(d considerably, although we south of the Coloniy on tllc banks of the SarstoonlRivel, uotice(l that speeclh was indistinict and( lheavy. Menitlhol, gr. , and experienced, as was to be expected, miany discomforts. in pill t.d.s., and sodiuim sulphate aud sodium suilpliocarbolIate Thle wreather wvas very bad, torrents of rain fell every day, ill m-ixtixtre were prescribed. During the wvliole illness the makinga thle forest tracts almost imlpassable; thle shlelter I ten)peratilre varied from 990 F. to 1001 F., and tile pulse fronm leaked 90 to 100. Tlhe uriine was examined several times aind always occupiedl badlly thrlough, roof ande sides,- anld of found to be normal. Dr. Cassel very kin(dly examinied a blood cour'se mBosqulitos playedl thirl p)art anda bit viciously by slide aind found nlothlilng ab)normal. Trhlere was never aniv day gs we7ll as by nlighlt. '1'he foodcl onlsisted of tinnl:ed