us to the inevitable conclusion, that the lungs, so far from being cured, were too much injured to expand to their former dimensions." 207. The author gives two striking examples of the extent of mischief some. times done to the lungs of patients said to be cured of effusions into the chest by absorption. One was the case of a woman, aged 37, whose left side was much flattened, dull on percussion, and without even the feeblest sound of respiration. She had suffered some years before death from an attack of pleurisy, of which she had been cured. On examination of the body, the left lung was found considerably diminished in size, impervious to air, condensed into a dry homogeneous mass, and retained in contact with the ribs by a thickened and almost cartilaginous pleura: no tubercles were found in the lungs. In the other case, it does not appear that the patient was considered to have been cured of a pleuritic affection. The lower two-thirds, however, of the right lung were adherent to the ribs and condensed into a dry mass from the effects of this disease. The writer thinks that these cases are more common than is generally supposed, and that "they show that patients may be sent out of an hospital, apparently cured of empyema and hydrothorax, because the fluid has been absorbed, but who must suffer all their lives from the loss of one lung, and they prove most clearly that absorption of effused fluid is not necessarily a cure." After arguing the propriety of having recourse to paracentesis, when mercury carried to salivation has failed to cause the removal of the fluid, in order to prevent this serious injury to the lungs, Dr. Roe alludes to the opinion of Broussais and Dr. C. J. B. Williams," that retention of pus, possibly of serum, for a long time in the pleura, leads to the development of tubercles in the lung of the opposite, or even of the affected, side," as affording an additional argument in favour of an early operation. He combats the opinion entertained by some medical men that paracentesis, though necessary in empyema, is wholly unnecessary in hydrothorax, because those cases which cannot be cured by anti-phlogistic means may be cured by generous diet and tonics, by the fact that Dr. Boyd, in the space of three years, at the St. Marylebone Infirmary, opened the bodies of 24 persons who died of hydrothorax, without tapping having been employed. The objections to paracentesis are reduced to this-" that it inflicts a wound; whilst in favour of it, it may be said, that in empyema it at once removes a noxious fluid, and does far less injury to the constitution than the absorption of purulent matter; that in both empyema and hydrothorax, it immediately relieves the lungs from the effects of pressure, and accomplishes that which internal medicines cannot, in the majority of cases, effect in weeks; and by its early employment, those irremediable changes already noticed are anticipated, and every chance is afforded for the complete restoration of the lung; that it removes that distention of the pleura, which paralyses the absorbents, and if inflammation be overcome by suitable remedies, it will effectually cure these diseases, provided the lungs are sound, and that without inducing any evil consequences." The author mentions the mode which Nature often adopts for evacuating the fluid, by the pus making its way between the intercostal spaces and bursting externally, and also through the lung itself into a bronchial tube, No. 100. 28 and an interesting case is given in which a cure was spontaneously effected by the latter method. The cases in which it is considered that the operation should be performed, are serous effusions forming so rapidly as to endanger life; cases of empyema; serous effusions in persons of delicate health after the usual treatment has failed or been neglected; and mechanical hydrothorax, for the purpose of relieving the difficulty of breathing and prolonging life. The author details a case of the latter disease in which life was certainly prolonged seven months by the operation. We find the following excellent remarks on the conditions of success : "Whether the operation shall materially assist in curing cases of simple pleuritic effusion, or afford merely temporary relief, depends on the time at which it is performed. To be successful, it is indispensably necessary that it should be employed before either the constitutional powers of the patient are too much reduced, or the thoracic viscera have undergone irremediable organic changes: for in the former case the absorbents cease to perform their functions, and, therefore, cannot prevent the re-accumulation of fluid after it has been removed; in the latter, a perfect cure is impossible. It is only when the lung is in a condition to expand to its full size, according as the pressure upon it is withdrawn, that the cure is effected without any visible alteration of shape in the diseased side. But when the operation is delayed till the lung has become atrophied, condensed, bound down by adhesions, or in any other way prevented from at once expanding sufficiently to meet the ribs, the shoulder becomes depressed and the side contracted, in order to bring the pleuræ into contact with each other: the body is then deformed, and the original capacity of the lung is very much diminished. When the lung is so much reduced in size that the pleura investing it cannot be brought into contact with the costal pleura, a cure is impossible: for a space must intervene between them, into which pus or serum will continue to be secreted, and the operation will be required again and again, till the patient dies from exhaustion. Under such circumstances, paracentesis cannot be looked upon as a curative measure, and, therefore, should only be employed to relieve distress of breathing." 220. Dr. Roe attempts to fix the precise period after which the operation ought not to be delayed, which he makes about three weeks. We should have thought that the author's experience of this disease, and of its variable progress influenced by the state of the constitution and the action of remedies, would have shown him the futility of fixing upon any precise period for resorting to paracentesis. In several of the successful cases in the tables furnished by our author, the operation was delayed beyond three weeks. He states, however, that no case occurred in his own practice, in which, after a lapse of five or six weeks from the commencement of effusion, a patient was perfectly cured. The changes produced in the lung after this period, and sometimes before it, were irremediable. Dr. Roe gives the credit of the invention of the grooved exploring needle to Sir B. Brodie; but Dr. Watson ascribes it, and we believe justly, to the late Dr. T. Davies, of the London Hospital. The author advocates the plan of closing the wound after the operation, and repeating it if necessary, in preference to making a fistulous orifice by introducing a piece of elastic gum catheter, a point in which we decidedly concur with him. Dr. Roe mentions a diagnostic mark of this disease, which he believes has not been hitherto described. It consists, in a marked degree, of fulness or even protrusion of the infra-clavicular region on the affected side; this often exists to a remarkable degree, and it is generally associated with increased resonance of the voice in the same situation. Are we indebted to Dr. F. Bird, or to the author, for this diagnostic mark? the paper leaves us in doubt. He does not regard the bulging of the intercostal muscles as a constant or a frequent sign of the presence of fluid in the chest, and agrees with Dr. Stokes, who is of opinion that it only takes place in cases of purulent secretion. He believes that the protrusion does not depend on mechanical pressure, and is indicative of the quality, not of the quantity, of the effusion, but no attempt is made to explain its cause. Is not the bulging influenced a good deal by the thickness of the false membrane lining the costal pleura? when thin it must yield to pressure and when thick resist it. Dr. Roe very properly cautions the practitioner not to attach too much value to the side on which the patient lies as indicating the seat of effusion, and refers to a case in which death was produced by paracentesis having been performed on the healthy side from this cause. This ought not to happen, for no operation should be performed unless the other signs clearly indicated the seat and nature of the disease. The left side of the chest is more frequently affected than the right, in the proportion, as estimated from the cases in the paper, of seven to five. A table is given shewing the results of the operation in those cases in which it has been employed under the author's observation or that of his friends. Of these 24 cases, 18 recovered and six died. Nine of these were cases of empyema, of which S recovered and I died. Thirteen were cases of inflammatory hydrothorax, of which 9 recovered and 4 died. One was a case of mechanical hydrothorax and the patient was relieved. One was a case of pneumothorax and fatal. Dr. Roe also gives some notes of the result of this operation, collected by Mr. B. Phillips. Of 122 cases, 88 were cured: 31 were cases of pyothorax, of which 26 were cured, and 9 cases of hydrothorax, of which 6 were cured. The paper is followed by a long appendix containing the particulars of the 24 cases given in the table. Our analysis of this communication has been so full that we must refer those of our readers desirous of further information to the volume itself. It is remarked, in conclusion, that these cases "will show that the success of the operation was directly in proportion to the shortness of the time which intervened between the accumulation of the fluid and the per formance of the operation, and that when it was unsuccessful the chief cause of its failure was its being postponed until too late a period." Our author's experience of paracentesis thoracis, in cases of effusion into the chest appears to have been unusually large, and the results which he has here detailed cannot fail to be useful in determining the doubtful questions of treatment. The propriety of operating in cases of empyema as soon as the presence of pus is detected, is pretty generally admitted; and Dr. Roe's observations show that, even in cases of hydrothorax, delay may be injurious, and lessen the chances of perfect recovery. We think, however, that the valuable information which this paper contains might have been presented to the Society in a less diffuse form. There is a good deal of repetition, and even common place observations which add unnecessarily to the length of the paper. XIX. ACCOUNT OF A CASE OF EMPYEMA WHICH RECOVERED AFTER REPEATED PUNCTURES OF THE PLEURAL SAC. By Theophilus Thompson, M.D. The subject of this disease was a boy between five and six years of age, and Dr. Thompson was not consulted till the little patient had been ill two months, and had evident symptoms of considerable effusion in the right side of the chest. Mercurial ointment, quinine, and decoction of chimaphila were tried for a few days, but as the effusion appeared to increase, an exploratory needle was introduced into the side, and pus detected. The operation of paracentesis was at once performed with a trocar, and fourteen ounces of greenish yellow pus were withdrawn. The wound was afterwards closed. The boy was relieved for a time, but in three days it became necessary to repeat the operation, when a pint of matter was discharged. Ten days afterwards twenty more ounces were removed, and again on the 21st of July, at the end of eleven days, a fourth operation was performed, and twenty-two ounces of thick matter were rapidly withdrawn. He improved in strength, and on the 28th the wound re-opened and gave exit to about four ounces of pus. A discharge continued to take place from one or other of the orifices made in the operations for several months. In December, the discharge, which had previously averaged two ounces in twenty-four hours, was reduced to an ounce, and after the application of ung. hydr. nitr. ox. to the opening for a few days, ceased altogether, but returned on the discontinuance of the ointment. "It was obvious, on the one hand, that any attempt to close the orifice would lead to injurious results, and on the other, that the fistulous opening might remain for life, unless some measure could be adopted to effect the gradual but complete emptying of the sac, and the approximation of its sides. We therefore determined cautiously to dilate the opening, and with this view Mr. Robarts prepared a plug, consisting of a piece of sponge, which had previously been firmly tied round with packthread, and saturated with wax. "This plug was introduced at night, on the 31st of December, and when removed on the 2nd of January, was followed by a copious discharge of pus. In a few days, the aperture having again contracted, another plug was introduced, and the next day withdrawn, when about six ounces of pus were discharged in a jet. "As the results of this plan proved so encouraging, the plug was again introduced on the 22nd of January, and removed the next day, when half an ounce of matter, still inoffensive, was removed." 278. After this period there was no fresh discharge, the orifice permanently healed, and the boy has remained perfectly well. The author, in his observations on this case, takes the same view of the inutility of remedies and the necessity for a prompt operation in cases of empyema, as that advocated by the writer of the preceding paper,—a view which is sanctioned by our best practical physicians. He adopted also the same practice as that pursued by Dr. Roe, of repeating the operation in preference to leaving a canula in the wound. We are at a loss. indeed, to find sufficient novelty in the case to account for a place being allotted to the paper in these Transactions. The chief point of interest, was the successful attempt to promote the gradual con traction of the suppurating cavity by dilating the fistulous opening, so as to permit a free discharge of the pus, the credit of which practice the author justly gives to Mr. Robarts, who originally requested Dr. Thompson's assistance in the case. XX. OBSERVATIONS ON THE The author remarks that in an operation for strangulated hernia, the intestine is not unfrequently found surrounded by omentum, which appears to form a second sac; but, with a little care it may be unfolded, and the intestine thus easily laid bare. But cases in which the intestine is contained in a complete sac, formed by the omentum, which it is absolutely necessary to divide, to reach the gut, have been rarely met with. After alluding to the imperfect notices of this subject to be met with in authors, he mentions that complete omental sacs were found in four cases out of thirty-four operations for strangulated hernia, performed at St. George's Hospital, in 1842-43; of these four cases, two were femoral, one inguinal, and one umbilical: "The formation of these sacs is attributed, by Richter, to the firm agglutination of the margins of the omentum, which has surrounded the bowel. To this explanation of Richter's, which does not appear to be applicable to the majority of cases, the two following explanations of the manner in which these sacs are, in some cases, formed, have been added. "1st. The gut, completely enveloped by the omentum, passes through the ring, and the omentum thus disposed round the intestine, becomes attached to the circumference of the neck of the hernial sac; this omental pouch is subsequently distended by the intestine, and thus forms a complete lining to the hernial sac. "2nd. An epiplocele takes place, and the portion of omentum which is protruded becomes altered in structure, and its folds firmly united to each other by the effusion of lymph; but within the abdominal cavity, in the neighborhood of the ring, the folds into which the omentum has been drawn may not be agglutinated; they will thus leave spaces into which a knuckle of intestine may insinuate itself, pass through the ring, and form for itself a bed in the altered mass of omentum which is in the hernial sac. It may happen, that two or three portions of gut may slip into the different spaces left between the folds of the omentum, and subsequently form for themselves separate pouches. Several separate sacs, with narrow necks, may be thus found in the omental mass which is in the hernial sac." 285. Once formed, these sacs may attain an immense size. In one case, the sac measured six inches in length, and eleven inches in circumference, at its broadest part. "The omentum in which a sac has been formed may, in the course of time, especially if it is irreducible, become altered in structure, either by the effusion of lymph, or by a deposition of fat which takes place in the walls of the sac. "By this alteration of structure the thickened sac may, in an operation, be |