A BOROUGH COUNCIL COME TO JUDGMENT.
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1616 legislation. He then discussed the question of water- supply and pointed out the danger of thinking that legisla- tion which might undoubtedly be good for one part of the country was necessarily good for another part. He took as an example of this the well-known fact that the temper- ance question would never be solved until it was recognised that one kind of action was necessary in the country and another in the towns. The very varying requirements in different parts of the country had to be taken into considera- tion and he urged his hearers not to depend too much upon county councils placing themselves in the position of water companies. Mr. Wynter Blyth, in replying to the toast, congratulated the members on the fact that in a few months they would number 3000. The work of the institute had spread to the colonies and when branches were estab- lished in India and New Zealand the institution would become imperial and he would propose to alter the title to the Imperial Sanitary Institute. Special interest was attached to the speeches by the Director-General of the Royal Navy Medical Service and the Director-General of the Army Medical Service, both of whom referred to the enormous difficulty of enforcing sanitary principles during a big campaign such as that through which we had just passed. The education of the soldier and the blue-jacket was the only method which would effectually protect them. The dinner was well attended. ____ A BOROUGH COUNCIL COME TO JUDGMENT. THE Poplar Borough Council appears to be a body that not only enjoys strong opinions but also does not scruple overmuch in expressing them on occasion. We hasten to add that the particular opinions to which we refer are in the main sound and just, though in venting them too slight a consideration was shown for the difficulties and for the reputation of medical men whose actions had not been in accord with the views of the borough council. The Poplar Borough Council very laudably provides means for test- ing the diagnosis of, among other diseases, diph- theria. A practitioner, however, within the jurisdiction of the council notified a particular case as diphtheria without having availed himself of the tests supplied by z, that body. As it turned out, the patient, who was removed as infectious, was not suffering from diphtheria or from any notifiable disorder. In its perhaps righteous indignation the council, it seems to us, " doth protest too much. " To begin with, although everyone will admit the value of bacteriological aid in diagnosing diphtheria yet no one would be wise to maintain that there are not plenty of instances in which the diagnosis can be perfectly justifiably made upon clinical evidence alone. Such may have been the case on the occasion to which we refer. Moreover, feeling thus secure of his diagnosis without further help the practitioner may have thought it of great importance that no time should be lost in removing the patient. He may well have considered that it would be a greater advantage to gain time in isolating the case, supposing it to be infectious, than to establish the innocence of the complaint if it was not. Many circumstances may combine to. determine a correct line of conduct in cases like these, and while one set of effects of action appeals most strongly to the borough council another set may assume a more prominent position in the mind of a medical man. It is often hard for the layman to realise the difficulty that there may be .in dis- tinguishing between diseases that are essentially different in nature and vastly different in the gravity of their results. To the uninstructed it very likely seems, strange that there are many cases in which an "ordinary sore- throat" may be almost indistinguishable from so formidable and familiar a malady as diphtheria. Yet every medical man is aware that to make the distinction decisively and at a first examination may be difficult, if not impossible. Nevertheless, it is, of course, all-important to arrive at such a decision at once when there is involved the question of removing a patient who is in a position to infect a large number of other persons. Such a consideration may con- ceivably excuse even the neglect of precautions admirably provided by a well-advised and energetic borough council. ALBUMINOUS EXPECTORATION AFTER PARA- CENTESIS THORACIS. IN the -tnteriean Journal of the Medical Sciences for April Dr. David Riesman has recorded a case of a very rare com- plication of paracentesis thoracis-profuse albuminous expec- toration. The first case was published by Pinault in 1853. Subsequently cases have from time to titne been recorded by continental, British, and American writers. In Pinault’s case the patient was a man, aged 34 years, who had had for three months left pleural effusion. Three litres of fluid were removed and the dyspnoea was at once relieved. In the evening the dyspnoea recurred and about a pint of albu- minous fluid was expectorated. In 1873 Terillon in his These de Paris reviewed the whole subject and collected 21 cases, of which two were fatal. In the case now described by Dr. Riesman the patient was a woman, aged 48 years, whe- had suffered from cough and occasional attacks of dyspnoea for six months. For some time there had been slight dysphagia. On examination signs of right pleural effusion were found. The neck was enlarged and the natural depres- sions were obliterated. Above the inner end of the right clavicle was a hard gland. Paracentesis was performed in the seventh intercostal space and posterior axillary line. Three pints of somewhat turbid yellowish fluid were with- drawn. When a little less than a quart had been removed the patient began to cough. At first the cough was dry but towards the end of the paracentesis a little frothy fluid was brought up. As the face became blue and the cough more intense the paracentesis was stopped. During the following six hours about five ounces of turbid amber-coloured fh1id covered with a layer of froth half as thick as the fluid and contain- ing a few streaks of blood were expectorated. The patient then was much more comfortable than before the paracen- tesis. The expectoration, but not the cough, had diminished. Moist rales were heard over the whole of the right lung. 0 the following day there was a little cough, the dysphagia had ceased, and the right chest was resonant. A fortnight later paracentesis was again necessary and about a quart of fluid was removed. Severe cough again occurred but it was accompanied by only a little tenacious serum. A large hard gland was found above the left clavicle. Over the sternum there was dulness which extended about two inches beyond the left border. Tumour of the anterior mediastinum, prob- ably sarcoma, which was obstructing the veins returning blood from the right pleura, was diagnosed. 12 days later paracentesis yielded more than three pints of fluid. It was followed by severe spasmodic cough but there was no albuminous expectoration. A fortnight later the patient died. At the necropsy sarcoma of the anterior mediastinum was found. The albuminous fluid expec- torated was of specific gravity 1018 and coagulated on boiling into a solid mass. In the recorded cases the albu- minous expectoration seldom occurred during the para- centesis but generally after an interval varying from a few minutes to half an hour. In rare instances the interval was two hours ; in one case it was 18 hours. The symptoms are as follows. The feeling of relief following the paracentesis, is terminated by cough and dyspncea. The cough quickly becomes severe, expectoration increases, and theie is a terrible sense of oppression and orthopneea. Respiration is labourecl, the face is cyanosed, the skin is clammy, and the
Transcript of A BOROUGH COUNCIL COME TO JUDGMENT.
1616
legislation. He then discussed the question of water-
supply and pointed out the danger of thinking that legisla-tion which might undoubtedly be good for one part ofthe country was necessarily good for another part. He tookas an example of this the well-known fact that the temper-ance question would never be solved until it was recognisedthat one kind of action was necessary in the country andanother in the towns. The very varying requirements indifferent parts of the country had to be taken into considera-tion and he urged his hearers not to depend too much uponcounty councils placing themselves in the position of watercompanies. Mr. Wynter Blyth, in replying to the toast,congratulated the members on the fact that in a few
months they would number 3000. The work of the institutehad spread to the colonies and when branches were estab-lished in India and New Zealand the institution would
become imperial and he would propose to alter the title to
the Imperial Sanitary Institute. Special interest was attachedto the speeches by the Director-General of the Royal NavyMedical Service and the Director-General of the Army MedicalService, both of whom referred to the enormous difficultyof enforcing sanitary principles during a big campaign suchas that through which we had just passed. The educationof the soldier and the blue-jacket was the only methodwhich would effectually protect them. The dinner was well
attended. ____
A BOROUGH COUNCIL COME TO JUDGMENT.
THE Poplar Borough Council appears to be a body thatnot only enjoys strong opinions but also does not scrupleovermuch in expressing them on occasion. We hasten toadd that the particular opinions to which we refer are in themain sound and just, though in venting them too slight aconsideration was shown for the difficulties and for the
reputation of medical men whose actions had not been inaccord with the views of the borough council. The PoplarBorough Council very laudably provides means for test-
ing the diagnosis of, among other diseases, diph-theria. A practitioner, however, within the jurisdictionof the council notified a particular case as diphtheriawithout having availed himself of the tests supplied by z,
that body. As it turned out, the patient, who was removedas infectious, was not suffering from diphtheria or from
any notifiable disorder. In its perhaps righteous indignationthe council, it seems to us, " doth protest too much. " To beginwith, although everyone will admit the value of bacteriologicalaid in diagnosing diphtheria yet no one would be wise tomaintain that there are not plenty of instances in whichthe diagnosis can be perfectly justifiably made uponclinical evidence alone. Such may have been the case
on the occasion to which we refer. Moreover, feelingthus secure of his diagnosis without further help thepractitioner may have thought it of great importancethat no time should be lost in removing the patient.He may well have considered that it would be a
greater advantage to gain time in isolating the case,
supposing it to be infectious, than to establish the innocenceof the complaint if it was not. Many circumstances maycombine to. determine a correct line of conduct in
cases like these, and while one set of effects of action
appeals most strongly to the borough council another
set may assume a more prominent position in themind of a medical man. It is often hard for the
layman to realise the difficulty that there may be .in dis-tinguishing between diseases that are essentially differentin nature and vastly different in the gravity of theirresults. To the uninstructed it very likely seems, strangethat there are many cases in which an "ordinary sore-
throat" may be almost indistinguishable from so formidableand familiar a malady as diphtheria. Yet every medical
man is aware that to make the distinction decisivelyand at a first examination may be difficult, if not impossible.Nevertheless, it is, of course, all-important to arrive atsuch a decision at once when there is involved the questionof removing a patient who is in a position to infect a largenumber of other persons. Such a consideration may con-
ceivably excuse even the neglect of precautions admirablyprovided by a well-advised and energetic borough council.
ALBUMINOUS EXPECTORATION AFTER PARA-CENTESIS THORACIS.
IN the -tnteriean Journal of the Medical Sciences for AprilDr. David Riesman has recorded a case of a very rare com-
plication of paracentesis thoracis-profuse albuminous expec-toration. The first case was published by Pinault in 1853.
Subsequently cases have from time to titne been recorded bycontinental, British, and American writers. In Pinault’s casethe patient was a man, aged 34 years, who had had for threemonths left pleural effusion. Three litres of fluid wereremoved and the dyspnoea was at once relieved. In the
evening the dyspnoea recurred and about a pint of albu-
minous fluid was expectorated. In 1873 Terillon in hisThese de Paris reviewed the whole subject and collected 21cases, of which two were fatal. In the case now described
by Dr. Riesman the patient was a woman, aged 48 years, whe-had suffered from cough and occasional attacks of dyspnoeafor six months. For some time there had been slightdysphagia. On examination signs of right pleural effusionwere found. The neck was enlarged and the natural depres-sions were obliterated. Above the inner end of the rightclavicle was a hard gland. Paracentesis was performed inthe seventh intercostal space and posterior axillary line.Three pints of somewhat turbid yellowish fluid were with-
drawn. When a little less than a quart had been removedthe patient began to cough. At first the cough was dry buttowards the end of the paracentesis a little frothy fluid wasbrought up. As the face became blue and the cough moreintense the paracentesis was stopped. During the following sixhours about five ounces of turbid amber-coloured fh1id coveredwith a layer of froth half as thick as the fluid and contain-ing a few streaks of blood were expectorated. The patientthen was much more comfortable than before the paracen-tesis. The expectoration, but not the cough, had diminished.Moist rales were heard over the whole of the right lung. 0the following day there was a little cough, the dysphagia hadceased, and the right chest was resonant. A fortnight laterparacentesis was again necessary and about a quart of fluidwas removed. Severe cough again occurred but it was
accompanied by only a little tenacious serum. A large hardgland was found above the left clavicle. Over the sternum
there was dulness which extended about two inches beyondthe left border. Tumour of the anterior mediastinum, prob-ably sarcoma, which was obstructing the veins returningblood from the right pleura, was diagnosed. 12 days laterparacentesis yielded more than three pints of fluid. It
was followed by severe spasmodic cough but there was
no albuminous expectoration. A fortnight later the
patient died. At the necropsy sarcoma of the anteriormediastinum was found. The albuminous fluid expec-torated was of specific gravity 1018 and coagulated on
boiling into a solid mass. In the recorded cases the albu-minous expectoration seldom occurred during the para-centesis but generally after an interval varying from a fewminutes to half an hour. In rare instances the interval wastwo hours ; in one case it was 18 hours. The symptoms areas follows. The feeling of relief following the paracentesis,is terminated by cough and dyspncea. The cough quicklybecomes severe, expectoration increases, and theie is a
terrible sense of oppression and orthopneea. Respiration islabourecl, the face is cyanosed, the skin is clammy, and the
