such cases. But we must bear in mind that the conditions are such as to present obstacles in many cases to successful treatment, and empyema must therefore always be liable to prove disappointing. If we have to deal with an abscess in most other parts the pus can be entirely evacuated, and the walls of the cavity can be adapted to each other and kept in position. In the chest it is not so; we are dependent upon contraction of the chest-wall, ascent of the diaphragm, granulation from the pleura, and expansion of the lung; and it is hardly to be expected that repair conducted under such adverse circumstances should present no difficulties; we should the rather expect that the cavity is more likely to be diminished in some directions, obliterated in some, and so cut up irregularly as to render complete drainage a matter of great difficulty; and so it too frequently is. But, nevertheless, it can be said that, recognized early and treated secundum artem, the treatment of empyema, from being one of the most disheartening, has become one of the most successful and gratifying of surgical operations.

Of late, finding that the results of the treatment of empyema have not quite come up to their expectations, some have advocated the excision of a portion of one or more ribs, with the object of facilitating the falling in of the chest and of obtaining more free drainage. Applied to the majority of cases the practice is unnecessary, and therefore bad. The treatment of empyema by incision, as I have just said, is as successful as it can reasonably be expected to be, if the cases are taken in good time; and in cases which have been long overlooked, or which have been long discharging, whatever we may do is, in the majority of instances, unavailing. The large aperture that is made by the removal of the rib quickly closes up, and we are no better off than before.

CHAPTER XXV.

ACUTE TUBERCULOSIS.

Acute Tuberculosis has of necessity been several times touched upon in connection with the different viscera which the disease more particulary affects; nevertheless, it is such a distinct disease, and has so definite a clinical position, that a few words may be devoted to its more general bearings. It is a disease confined to no age, but is particularly one of childhood.

Pathology. But little is known of its nature at present, although of late years several very interesting observations have been made, which, if they ultimately take rank as assured facts, are of the greatest importance. First of these may be mentioned the discovery of the bacillus tuberculosis. This small body is supposed to be the virus which, introduced from without, forms a nidus in some of the lymphatic structures, provokes caseation, and thence, by fertilizing, becomes disseminated in all parts of the body. Certain experiments, too, have of late been carried out, which go to show that tubercle is propagated by inoculation only when the bacillus forms part of the virus which is introduced, in contradiction to previous less rigid experiments, which pointed to the probability of any suppurative focus being sufficient for the purpose. Next, there is a disease well known amongst cattle, which, having much of the anatomical distribution and histological structure of tubercle, is capable of transmission from the diseased animal to the healthy by means of the milk from diseased cows. Other

observations are accumulating, which go to show that, possibly under favoring circumstances, tubercular diseases may be transmitted from man to man; and, lastly, we have the features of the disease itself, which are, in many respects, those of a specific fever. The subject is hardly one for discussion here, it is so much a question of general pathology; nor do I mean in any way to indicate a leaning in either direction. Hereditary tendency, the infrequency of any proved contagion, the history of the disease as we see it going slowly on over ten, fifteen, twenty years in the lungs of adults—not to mention the doubt which must long weigh heavily against establishing such an important position for such minute organisms as these-must make any one hesitate to accept the doctrines of tubercle as at present stated; none the less, they are well worth consideration when we think over a disease so obscure as is acute tuberculosis.

It is supposed, however, by many who adopt the infective theory in its entirety, that whenever acute tuberculosis occurs there is some local focus or caseating centre from which the disease has become disseminated. And, no doubt, in many cases this is so; a cheesy bronchial gland, some chronic otorrhoea, some scrofulous disease of the kidney or Fallopian tubes-something of this kind exists somewhere, and from hence the disease infects the glands or lymphatic tissues, and thus spreads by continuity of tissue, or from gland to gland, to produce the infiltrations and nodular growths with which we are all but too familiar. But this certainly is not always so; miliary tuberculosis is, at any rate occasionally, found where, even after the most careful search, no caseous centre can be discovered. It is a disease, however, which seems particularly prone to outbreak in cases of this kind; and chronic otorrhoea, with disease of the temporal bone, epiphysial and joint diseases in young people, cheesy disease of the bronchial glands, and scrofu

lous disease of the genito-urinary tract, are some of its more common precursors or sources of infection.

Symptoms. In its earliest stages, it is one of the most insidious and most difficult to be sure of in the whole range of the diseases of childhood. General malaise, pallor, wasting, fatigue, want of appetite, irritability of temper, slight fever, these are the indefinite symptoms which herald its onset, as they do that of many other far less serious maladies. The symptoms are not uncommonly so slight as to be attributed to worms or some trivial ailment by the mother or nurse. To the medical man the appearance, perhaps, betokens more than this, but he is at a loss between acute tuberculosis and typhoid fever, or some other debilitated state which tonics will restore. Often he can only wait and watch, uncertain until the progressive emaciation and fever, perhaps enlargement of the liver and spleen, or more likely some few indications of disease in the lungs, compel him to relinquish hope. Sometimes he has hardly come to any conclusion, when intolerance of light, drowsiness, squint, are noticed; quickly followed by convulsions, coma, and death.

It is astonishing sometimes how much disease is found after death where there has been but little evidence during life. A boy of six years was lately admitted to the Evelina Hospital for slight jaundice. He had the appearance of being considerably emaciated; his temperature was 99.6°; his tongue red and dry, his lips over-red; he breathed peculiarly deeply, 32 per minute, there was undoubted loss of resonance below the right clavicle, and bronchial breathing was heard in the inter-scapular region behind. The pulmonary symptoms, however, were not marked, and by these alone the nature of the case must have been at best doubtful; but the spleen and liver were enlarged, and, with the jaundice, turned the scale decidedly in favor of acute tuber

culosis, for jaundice is not common at this age. It, and the enlargement of the liver and spleen, with evidences of emaciation and disturbed respiration, suggested tubercular disease of the liver and general tuberculosis. Even now the opinion was not altogether an unwavering one, for the jaundice disappeared and the child improved and left his bed for a day or two. Then he had a relapse, and his temperature ran up to 104°, and he died seven weeks after admission. The most that his chest had revealed was a good deal of dry crackling, chiefly below the nipples and in the scapular region, and occasional moist sounds in other parts. Dulness also came and went in an irregular fashion. At the autopsy, however, the lungs were stuffed with tubercle, and the bronchial glands were caseous and softening. In the liver were many small nodules of bile-stained tubercle, such as have been ascribed to tuberculosis of the ducts. The spleen also contained many tubercles.

Diagnosis. As I have already said, this is often difficult or impossible; but inasmuch as it is a general disease, affecting all the viscera and serous membranes, some help may sometimes be gained by detecting a slight pleuritic rub here or there, or any evidence of consolidation about the roots of the lungs. Hyperæsthesia of the skin and muscular twitchings not uncommonly indicate tubercular formation. in the spinal membranes, and any intolerance of light should be carefully considered. Any tubercle in the choroid or changes in the fundus oculi would make things certain. It may be added, that a hard enlargement of the spleen may give occasional help, but we must remember that the enlarged spleen of typhoid fever is sometimes, in childhood, an unusually resistant one, and the disease is most likely to be overlooked or to be mistaken for typhoid fever.

Prognosis. It runs a somewhat variable course, from three to six weeks; but, so far as is known, is always fatal.