No. 359.

LONDON, SATURDAY, JULY 17. [1829-30.

LECTURES ON SURGERY,

MEDICAL AND OPERATIVE,DELIVERED AT

St. Bartholomew’s Hospital;BY MR. LAWRENCE.

LECTURE LXV.

Mucous llTenabranes.-Ozcena; Treatment.Epistaxis ; Treatment.—Innocent Poly-pus; Treatment.—Malignant Polypus ;Treatment.—Inflammation itnd Abscess

of the Cavity of the -4ntrum.--IPlorbidGrowths of the Antrum ; Treatment.

Serous Membranes. -Wounds of SerousMembranes ; Treatment.—Empyema.—Hydrothorax.—Paracentesis Thoracis.—Air in the Pleuræ.—Inflammation of’,and Effusion into, tlae Pericardium.

Affections of Mucous Membranes.-I donot think it necessary to enter into anycnnsideration respecting the general affec-tions of the different classes of membranes,because the observations on the particularaffections of those membranes, and theirrariouscauses, will sufficiently elucidate thesubject; and, in comparing the number ofsubjects which still remain untouched of thecourse with those that have been discussed,I hnd it necessary to bring the observationsI have yet to make into the smallest possiblecompass. I shall, therefore, proceed to no.tice those affections of the membranes whichmore especially require attention.

Ozæna.—I had occasion, when speakingon the venereal disease, to mention ulcera- ’,tion of the mucous membrane of the nose,cams of the bones ofthat.cavity, and fœtidd,sebarge accompanyiug these states, as

consequences of syphilis. Such effects occur Ialso independently of syphilis, constituting Ithe disease called ozœna, which denote:; anaffection of the nose, accompanied by a

discharge. Syphilis, undoubtedly ismost commonly the cause of these affectionsof the Dose, but it is not so in all instances.There are cases iu which ulcerations, affec- a

tions of the bones, exfoliation of bone, anda most fcctid and offensive discharge, havetaken place from the nose, in individualswho have never suffered from syphilis inany shape, and, as appears rather extraor-dinary, you may have such symptoms evenin young’ subjects. I have seen them,—atleast I have known the fcetid discharge tolast tor several years in a child, which, al-though perhaps in some measure alleviatedby occasional remedies, yet has not beenperfectly removed, but ultimately, in conse-quence of the apparent inefficacy of the meansemployed, has been left pretty much to takeits own course.

Treatment.—In such a case one naturallyhas recourse to local remedies. Where youhave a serious local affection -of this kind,various astringent substances, in the formof lotions, are to be applied ; the sulphateofzinc, the nitrate of silver, the oxymuriateof mercury, may either be injected into the.nose by means of a syringe, or, putting asmall portion of either of such solutions onthe palm of the hand, it may be snuffed up,—inhaed into the nose. It is necessary, inthe first place, to cleanse the surface of thepart affected by means of tepid water, afterwhich the application I have mentionedmay be made use of; it is of course neces-sary to take care that the fluid does not passinto the pharynx through the nose and beswallowed. The adoption of such means asare proper to correct any deviation fromhealth will be proper, and where none exists,perhaps the alterative medicines, with sar-saparilla, may be of use.

Epistaxis.—N ot unfrequently hæmorrhagetakes place from the nose, and this is tech-nically called epistaxis. Young persons arevery subject to bleeding from the nose fromslight causes. In them the occurrence is ofa trifling nature ; certain quantities of bloodare lost, and then the bleeding stops. Ifthe bleeding should become formidable, rest,with aperient medicines and abstinence,soon put an end to it. But in the adult,and in persons advanced in years, hæmor-

rhage sometimes comes on to such ar. ex-

tent, and recurs so frequently, that it is

indeed alarming, even to the medical at.

tendant; at all events it is troublesome, as

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it is very difficult to be stopped. There areinstances, indeed, in which the quantity ofblood lost from the nose has been so consi-derable as to render the patient perfectlypale and very feeble, and even apparently toendanger life.

Treatment.-In the commencement of anaffection of this kind, you will find marks ofactive congestion about the head ; a sense

of increased determination of blood there,which seems to require the employmentof pretty active antiphlogistic means,-bleeding generally or locally, the applica-tion of leeches, abstinence, rest in thehorizontal position, and the application ofcold to the head. There are instances,however, in which this treatment does notarrest the particular symptoms, where

hæmorrhage recurs repeatedly, and whereit becomes necessary to adopt some localmeans. I have already bad occasion to

mention to you, that I consider a satu-

rated solution of alum to be one of thebest remedies of the styptic kind, and Imay now observe, that this may be employ-ed in the case of obstinate haemorrhagefrom the nose. A saturated solution may beapplied by means of lint, if we think we canreach the part whence the blood comes witha director or probe ; or the same fluid maybe thrown up into the nose by means of asvringe. We are, however, obliged, in someinstances, to proceed further than this, as i,when we have no other means of arrestingthe haemorrhage but that of plugging up thecavity of the nose. If we can stop up thefront aperture of the nose, which is easilyeffected, and also the posterior aperture,by which the nose communicates with thepharynx, the bleeding may be completelyarrested. We can introduce portions of lintthrough the nostril, carrying them up witha director, or a strong probe, and stuffing inportion after portion until the cavity is plug-ged. In this way we may thus, perhaps,stop the bleeding altogether; but after fill-

ing up the anterior part of the nose, wesometimes find that the blood passes overthe plug into the posterior opening and intothe pharynx, and that it becomes necessaryto plug the posterior opening also ; this canbe easily done from the front. An instru-ment has been invented for the purpose,which consists of a portion of watch-springat the end of a metallic stem, like a probe.This is contained in a tube, and passed withthe tube from the nostril anteriorly into thepharynx ; the instrument, which has gonestraight forwards in the tube, is then pushedout, and the spring occasions the end to curveforwards in the mouth towards the paiute.You can then fix to the end of this instru-ment a string with a plug of lint, and drawit in so as to plug up the posterior openingof the nose. You can thus easily stop the

posterior aperture, and effectually put an endto the loss of blood.

Innocent Polypus.-Tbe mucous mem-branes of the body generally, and that ofthe nose more particularly, are subject tomorbid growths on the surface, to which thename of polypi is g’iven. They consist oftumours, which adhere to the membrane bymeans of a comparatively narrow neck, orbasis. I now show you examples of polypiof the nose, which, as you observe, are variedin point of figure ; yet all of them agree inthe possession of a narrow pedicle, or neck,by which they adhere to the membrane.

Generally they are of a somewhat round orpyriform shape.The growths, which are thus produced

from the mucous membrane of the nose, arevarious in point of structure. The mostcommon are of a texture very much resem-bling the mucous membrane that producesthem, and such are called soft mucous orge-latinous polypi. There are others whichare of a firmer, a somewhat fibrous texture.These, however, are not very common inthe nose; they have been called sarcoma.tous, or fleshy, polypi. There are otherswhich are of a malignant character, and arepretty closely analogous to those growthswhich have already been described to youunder the name of fungus haematodes; theyare called malignant polypi.With respect to the more common kind,

the mild or mucous polypi, they grow fromthe exterior surface of the cavity of thenostril, that is, from the turbinated bones,or from the lower part of the a’thmoid bone.I do not know of any instances in which

polypi of this kind have been found to pro.ceed from the septum of the nose.They produce no inconvenience in their

early stage, and only become percpptible tothe patient in consequence of their increasein bulk, and the uneasiness which is thusproduced. They fill up the cavity of thenostril, they prevent the breath being drawnthrough the nose ; they produce uneasinessby the pressure which their bulk occasionsupon the membrane and the bony parts ofthe nose. The bulk of these mucous polypivaries according to the state of the atmo.

sphere. In moist and damp weather theyswell and become more considerable in size,and then the passage of air through thenostril is obstructed. In dry weather theyshrink again, and the patient is able to

breathe through the nostril more freely.When the patient complains of the inconve-nience arising from polypus, and we lookinto the nostrils, we observe the polypuspresenting itself towards the anterior partof the nostrils, and find it of a greyishor semi-transparent appearance, somethinglike a soft jelly. If we press ilpon themwith a probe, we find that they are hardly

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sensible, unless the pressure is made uponthe hard parts. When we come to extractthem, they are very soft; they yield underthe forceps, a kind of serous fluid escapes,and thev become considerably reduced inbulk; they seem to consist of somethingvery similar in its nature to mucous mem-brane,Treatment.-Tlie only mode of effectu-

ally getting rid of these growths, is that ofremoval by a surgical operation. These, asI have already mentioned, are specimens ofvarious polypi taken out of nostrils; theywill give you an idea of the form and modeof attachment ; here is a specimen in whichthey are seen actually hanging from thebones; these are the mild gelatinous or

soft polypi. Various modes are describedin surgical writings, of getting rid of po-lypiofthe nose; such as by ligature, caustic,tearing and drawing out, or extraction, asit is more gently termed, by means of for-ceps. Now the latter, in point of fact, isthe only mode that is now used. Ligaturecannot be applied to a polypus of the nose;caustic can hardly be applied, or at leastthere is as much chance of your applying itto sound parts, as to the whole of the dis-eased growth only, and the actual cautery ismuch too violent a mode of proceeding. Theproceeding, then, which we adopt to get ridof a polypus of the nose, is to seize the

growth with a pair of forceps, to endeavourto take hold of it as near as possible to theroot, or pedicle, or neck, by which it is at-tached to the mucous membrane, and theneither to drag, or twist, or tear it out-amechanical proceeding, in fact, for extract-ing the growth. These which I now showyou, are the kind of forceps used; they area little curved at the end, and roughenedon the inside, so that they may obtainifirm hold of the growth, and enable youto apply an ample force to detach it fromits connexion. These other forceps, also,may be occasionally used,-made like dis-secting forceps, terminating in extremities,with a slide, so that when fixed on someobject that you wish to hold, and the slideis slipped down, the instrument retains itsgrasp without the necessity of continuingthe pressure. You may have them made

differently; so constructed at the ends as tokeep their hold according to the degree of Ifirmness which the occasion may require. !Sometimes you have a single growth in

the nose-one production, and no more. Thepatient is very fortunate in whom this is thecase. More commonly there are severalgrowths proceeding from various parts ofthe mucous surface, so that the repeated introduction of the forceps is necessary inorder to clear the nostril. Now when youconsider how imperfect a view you can ob-hia of the cavity of the nose from the an- ,

I

i terior aperture of the nares, you will beaware that the extraction of polypi is a veryblind sort of proceeding. When you havetaken away the one that has first pre-sented itself, and the nose becomes filledwith blood in consequence of the hæmor-

rhage that succeeds the extraction, all therest of your operation is in the dark. Youintroduce the forceps as widely opened asyou can, and seize any thing that comes incontact with them, and drag it out ; you mayeither do this, or twist it from side to side,carrying it backwards and forwards, so asto bring away the whole. You must repeatthese manoeuvres as well as the circumstanceswill permit, and you will then clear thenostril.

If these polypi have been neglected for along time, and have continued to increasein size, they ultimately become so consi"derable, as mechanically to distend the ca-vities of the nostrils, and produce very con"siderable inconvenience by pressure on thesurrounding parts. They may produce apressure that may interfere with the ductsof the nostrils, and consequently produce anobstruction to the passage of the tears. Theywill press down into the soft palate, passbackwards into the posterior nares, and intothe pharynx. Polypi may of course just aswell present themselves at the posterioropenings of the nose, as at the anterior.Thus, on depressing the tongue, and lookinginto the mouth, you will see a polvpous tumour, perhaps, descending into the throat.Not long ago a child, about ten years of

age, was sent to me to be examined, whichwas said to have polypus. On seeing theto child, I could hardly suppose such a thingexisted in her case, for the disease is scarcelyto be found in young subjects; but on intro-ducing the forceps, I discovered one. Themother said that the child did not swallowwell, and on looking into its mouth, I saw avery considerable polypus presenting fromthe posterior aperture. I introduced theforceps into the nose, carrying them as highup towards the neck of the tumour as Icould, hoping to surround the whole ofthe growth, so as to draw it out through theanterior opening of the nose, and I extracteda very large piece ; indeed I concluded that Ihad drawn out the whole; however, thechild said it still felt that something wasleft behind, and on looking into the mouth,I saw part of the polypus still ; I accord-

ingly pressed down the tongue, introducedthe forceps into the mouth, and drew outthe remainder from the throat. The piece Ithen took out was rather larger than thatwhich I had extracted in the first instance.I believe these were parts of one polypus;taking them both together, the growth wascertainly not less in size than the circumfe-rence of three of my fingers, while in length,

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the anterior part of the tumour presenteditself at the anterior nares, and the pos-terior part behind. There has been no

reproduction in this case. The removal of

polypi in the way I have mentioned, in

general produces only a temporary cure ;the growths are reproduced ; after a timethe nostrils become again obstructed, andwe find it necessary to recur again to

the same measures for relieving the pa-tient. In the case of a single polypoustumour which has been very effectuallyremoved, where we have been able to reachup to the neck of the tumour and carryit away completely, a very considerable

time- may elapse before reproduction takes

place. I removed a tumour of this kindfrom a gentleman a long time ago, and whenit came out, it was clearly brought away al-together. The case was one of single tu-mour. About four years afterwards, I think,he sent for me again ; the tumour had beenreproduced, and was again extracted in thesame manner. This was about three yearsago, so that I suppose he has not againexperienced inconvenience from the likecause.

: Malignant Polypus.—The tumours of amalignant character that arise in the nose,take place under different - circumstances, Iand present themselves under symptoms al-together different from those which belongto the polypi I have just mentioned. The

malignant polypi form with great pain; themild or mucous polypi, form without anyuneasiness. The malignant polypi presentlivid, dirty, bleeding, surfaces. Slightpressure on them with the end of a probe ora director produces a copious flow of blood.The patient experiences very considerablepain, particularly in proportion as the poly-pus increases in size. After a certain pe.riod, these growths increase very rapidly ;they distend the cavity in which they aresituated ; they extend towards the roof ofthe nostril, and produce great pain by press-ing on the bone ; they depress the palate;they produce ulceration of the mucous mem-brane, and a carious state of the bones ; andfrom these various local effects, and the

great irritation and pain which the patientexperiences, they ultimately terminate fa-tally. In some instances they make theirway through the roof of the nostril into thecavity of the cranium, so that ultimately,symptoms of pressure on the brain are pro-duced, in addition to those which usuallybelong to the growth of the polypus. Hereis a specimen of this kind, which had ob-tained a most formidable magnitude in a veryyoung subject. It occurred in the case of apatient who died in this hospital. This isone of his eyes ; this is the nose, very muchenlarged ; and here is a section of the tu-mour, exhibiting a kind of cartilaginous and

medullary texture, filling up the whole ca.vity of the nose, and extending through thecribriform plate of the aethmoid bone mothe cavity of the cranium. Here a larsemass of it projects into the skull ; you willhardly recognise the eye and the nose. Hereis a portion of the opposite side of the sec-tion, presenting the anpearance of a tirm

cartilaginous growth ; this is the oppositenostril, with the optic nerve of that side ex-tending round the tumour.

Treatment.—I need not observe to you,that we have no means of removing by sur-gical operation, affections of this kind. Wecan only witness the progress of the com-

plaint, and perhaps adopt occasional meansfor palliating the sufferings of the patient.

Inflammation and Abscess of the cavity ofthe Antrum.—The cavity which occupiesthe body of the superior maxillary bone—theantrum-may be the seat of inflammation,and of a secretion of matter which becomescollected in that part, the natural openingby which the antrum communicates withthe nose being obstructed. Under thesecircumstances, it becomes occasionally ne.cessary to make an opening into the cavityof the antrum to let the matter out. Thisismost advantageously accomplished, by re-moving either the first or second molartooth. The sockets of those teeth are sepa-rated from the cavity of the antrum by avery thin plate of bone, so that when youhave removed either of them, you can, withthe sharp end of an ordinary probe, or anysmall-pointed instrument, make an open.ing into the cavity of the antrum, whichwill let out the matter, should there be anyaccumulated.Morbid Grouwths of the Antrum.—This

cavity is also occasionally the seat of mor.bid productions, of the polypous kind, orof a malignant nature, or perhaps of a sar- comatous- description, which arise withinthe cavity, and, slowly increasing in size,distend the bony parietes, enlarge thedimensions of the cavity, and encroach

upon the parts which are situated inthe neighbourhood. These growths will

press upwards the inferior portion of theorbit, and thus interfere with the parts con-tained within its cavity; they will depressthe anterior part of the roof of the mouth,causing a ptominence in that situation ; theywill enlarge the cheek externally, and, infact, by their continued progress, iiist dimi.nishing the thickness of the bony parietesthat constitute the sides of the cavity, ren-dering them very thin, and then distendingthem, they occasion a very great increase ofsize in those parts, and encroach apparentlyin a very serious manner, on aU the neigh-bouring organs. They frequently loosen theteeth and push them out, and they occa.sionally make their way out through the

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slceolar processes; presentiug themselves inthe cavity of the mouth.

Treatment.—In the books of surgery, youliatl various operations proposed for expos-ing the cavity of the antrum and clearingaway tile growths that are thus produced,bet you will, I believe, never have occasionto resort to them. I cannot say that I everfound it necessary to proceed to an opera. Ition of this kind, for although I have seenmaov instances of very serious growths,existing and producing the various incon-vegiences which I have (letaileti, the casesbave never proceeded so far that 1 have judg- ied it necessary to interfere with them byoperation; nor have 1 ever seen an operationof the sort performed by any one else. Icould not, therefore, state any thing on thesubject from my own experience, nor add towhat is already recorded by surgical writers.I do not, therefore, think it necessary toenter into details on the matter. I wouldonly notice here a proposal made by Profes-sor Pattison, of the London University, inan edition of Burns on the Anatomy of thellead and Neck. In very serious cases, hesuggests tying the carotid artery, in orderto cut off the supply of blood from thegrowth. The Professor gives some in-stances in which this operation was attendedwith such an effect that large portions ofthe growth sloughed away. I do not knowthat he mentions any case in which a com-plete cure was effected, though the evi-dence would show that considerable effectLad been produced, and we should probablydeem this proceeding preferable to trephin-ing and cutting away large portion’s of theupper jaw,-operations which are mention-ed by various surgical writers.

Serous Membranes.

Wounds of Serous Membranes.—Woundswhich penetrate into the cavities that arelined by the serous membranes of the bodyrequire great attention. A wound pene-tratiug into the chest or abdomen, is verylikely to produce general inflammation ofthe surface of the cavity thus exposed ; andMeh wounds are not uncommonly compli-cated with protrusion of some part of thecontents of those cav i ties.

Treatment.—In the latter case, that is,when there is a protrusion of any of the con-tents, whether the wound is in the chest orin the abdomen, we must first gently re-place the protruded part, and then approx-imate the edges of the wound, so as toretain them iu apposition ; we shall thus,most likely, prevent the occurrence of in-fiammatton within. In the case of a largewound, whtcltevermay be the cavity, we shallproliably find, that although we can replacetile protruded parts, we are unable to retainthem iu their situation without adopting

some very efficacious means of approximat-ing the edges of the wound. I should haveno hesitation under these circumstances,particularly in the case of a wound in theabdomen, in applying sutures, carrying themonly through the integuments, and taking,care that they do not involve the serousmembrane. The further treatment will con-sist in the employment of all the means cal-culated to prevent inflammation, and thesemust generally be of a very active iuhd, forinflammation is very likely to take place,and if it occur in any part of a cavity likethat of the peritoneum or pleura, it is imme-diately propagated over the surface. You canhardly be too active in your treatment, whichmust be continued until all risk of inflamma-tion is at an end.There are various circumstances under

which a surgical opening into the cavityof the thorax has been considered neces-sary. In penetrating wounds of the cavityof the chest, particularly those which aremade by gun-shots, the cause of the acci.dent, as for instance, the shot, sometimeslodges within, and there remains ; or por-

I tions of the clothing are carried in; some-times blood is effused from the woundinto the cavity; or the presence of the

foreign body may produce effusion cf blood,inflammation, and formation of matter within.

Empyema—is the consequence of inflam-mation of the pleura, arising from internalcauses, where the formation of matter takesplace within the chest. If for this therebe no ready outlet, it increases in quantity,and by interferingwith the surrfounding parts,the heart, the other lung, the neighbcuringviscera of the abdomen, and so forth, pro-duces effects that will be speedily fatal to

the individual.Hyd)-otho2-ax.-Again ; large effusions of

serum sometimes take place in the chest,constituting hydrothorax.

Further ; it occasionally happens that anabscess, whether the result of common in-flammation, or of tubercular disease of thelung, opens into thf cavity of the cliest,and from the opening thus made, whichmay communicate with some of the b(-on-cliial tubes, air escapes into one of the

pleurae, and you have one side of the chestdistended. Under these circumstances,-the existence of the presence of foreignbodies, effusion of blood, effusion of serum,abscess, or the entrance of air from the

bursting of an abscess,-it may become ne-cessary to make au opening into the chest,in order to give issue to the accumulationwithin ; it becomes necessary to perform theoperation of-

I-lay-aceittesiv Thoracis—tapping of thechest. The best situation for making auopening into the chest, provided you haveyour choice of the spot, is between the tifth

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and sixth, or between the sixth and seventhribs, in a direction lying between the ante-rior and lateral parts of the chest. If youmake the opening on the left side, you will,at all events, take care to go far enoughback, to be completely clear of the situa-tion of the heart. In making an open-ing into the chest, it might appear advisableto let it be in the lowest or most dependingsituation. You will recollect, that the su-

perior surface of the diaphragm is in con-tact with the surface of the ribs to a con-siderable extent, so that if you make an

opening very low, you might cut againstthe surface of the diaphragm, and fail to

give issue to that which you wish to eva-cuate. Where, also, there has previouslybeen inflammation, the part at which thediaphragm and the ribs come in contact, issometimes occupied by adventitious sub-stances from the effusion of lymph; if,therefore, you were to make a puncture inthat part, the escape of matter could not beeffected ; consequently, the proper situationfor performing the operation of paracentesisof the chest is between the fifth and sixthribs.

Further ; it is advisable to make the open-ing on the upper margin of the lower ribs,in order to avoid wounding the intercostalartery.

In the case of empyema, that is, wherematter is contained within the cavity of thechest, you would of course take into consi-deration the previous symptoms; for thesewill enable you to decide whether it is pro.bable that matter has formed. You mustconsider also the actual state of the patientat the time you make the examination, and,if the symptoms have indicated inflamma-tion of the pleura-if there have been severepain on one side of the chest-if there havebeen that degree of difficulty of respirationwhich is produced by pleurisy-if after a cer-tain length of time rigours have come on, in-dicating the formation of matter-if at thetime you examine the patient, you find thatone side of the chest is swelled, is cedema-tous (for the formation of matter in the in-terior of the chest is so great, as to be at-tended with oedematous tumefaction of the Icellular membrane externally, similar to that ’’

which marks a phlegmonous abscess in anypart of the body)-if in addition to thesecircumstances you nnd that there is any ob-vious enlargement of one side of the chestas compared with the other, and that thereis a partial protrusion of some of the in-tercostal spaces indicating the presence ofmatter in some particular part-if you findon percussion that there is a dull or deadkind of sound on the side of the chest atwhich you make the trial, and that there isan absence of that resonance which indicatesthe healthy state of the lung,—and if you

also find (supposing the inflammation tohave taken place on the left side) that thepulsation of the heart is not perceptible inits proper place, but perhaps under thesternum, or middle of the chest-you maythen pretty safely conclude, that there is acollection of matter in the cavity of thepleura. This collection of matter becomesso considerable, that if it occur on the leftside, it will even push the heart over to theright side ; you will find an absence of thepulsation on the left side, the heart beatingon the right. If the collection of matterhave taken place on the right side, the dis-phragm will be pressed down, and the liverwill be pushed downwards also, so that itsedge can be felt below its natural situationin the abdomen. These are circumstancesby which you can estimate pretty accuratelythe existence of matter in the cavity of thechest, and which, when the symptoms areso well marked, would justify you in makingan opening through the parietes of the chestfor the discharge of such matter.You will ask, perhaps, Is it probable that

the patient will be saved by making such anopening 1 Why that is extremely doubtful;the circumstances are very serious; manydifficulties present themselves, when wecome to consider the question of recovery.However, the progress of the affection, ifleft to itself, is so necessarily fatal, and thecircumstances under which such a patient issituated are so desperate, that an attempt tosave him is rendered perfectly justifiable.Now, on examining the body after death,

we find the whole interior of the cavity con-taining the matter, lined by a thick stratumof what we should call coagulable lymph,-athick adventitious membrane, a quarter of aninch, or even more, in thickness. We findthe cavity converted into a state very simi.lar to that of the cyst of an abscess; we findthe lung condensed and reduced in size,perhaps to a fifth or a sixth of its naturaldimensions,-shrunk, and closely aggluti-nated to the side of the chest.We may immediately perceive, therefore,

by these circumstances, and by making a

comparison between the mode of recoveryhere, and that in which an abscess in othercases is to be healed, that there are greatdifficulties in the way of a cure. If youhave an abscess in any of the soft parts ofthe body, when you have evacuated the

matter, the parietes or sides can contract;they can approach, and gradually do ap-proach, so as to obliterate the cavity; buthere you have the walls of the cavity in agreat measure bony, and not admitting ofthat contraction ; the condensed lung can-not expand again, so as to fill up the placeit formerly occupied. We find, therefore,that after letting out the matter, the spacepreviously occupied becomes more or less

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filled by air that passes in at ’the openingthrough which the evacuation has been pro-duced; that this air occasions decomposi-tion of the remaining matter, and becomesvery fetid ; this change is almost enough ofitself to cause death ; but certainly in thefeverish state of the patient, and underall the circumstances attending the affec-tion, it adds considerably to the danger.In certain cases, however, the patient11i11 surmount them all ; perhaps the lungbecomes partially expanded, the side of thechest gradually contracts, and after a con-siderable time (more particularly if a com-plete cure take place) the affected side un-dergoes a remarkable diminution in sizewhen compared with the other side, so thatthe intercostal spaces are almost oblite-rated ; and in old cases the contrast be-tween the sound and morbid sides is veryconsiderable. A case of empyema, then, isof course to be regarded as one of a veryserious kind; the prospect of the patient isvery unfavourable, whatever course we maypursue; but, under certain circumstances,the operation for evacuating the pus, affordsthe only prospect of preserving life, and is,therefore, to be undertaken in such cases.Hydrothorax.—With respect to the effu-

sion of water into the chest—hydrothorax—the case is less favourable for operation.This, of course, can only be undertakenwhen the effusion exists on one side.If it have taken place in both, we cannot fora moment entertain the idea of making anopening into the cavity. There are, per-haps, very few instances in which the effu-sion of fluid into the chest (or hydrothorax)is an idiopathic affection; that is, arisingfrom disease occurring in, and confined to,the serous membrane. Writers on the sub-

ject acknowledge that simple idiopathic hy-drothorax is very rare. In general, it is

merely a symptom of organic disease of theheart, lung, or some other part of the body, Jand, of course, the removal of the water insuch a case could be of no benefit to the pa-tient. I have never seen a case where itwas at all desirable for even temporary re-lief, and therefore I suppose a case indi-cating the necessity for it, is very un-

common.

Air in the Chest.—With respect to theadmission of air into the chest, I have hadoccasion to mention to you that in woundsof the lung, from which air escapes into thecavity of the chest, where collapse of the’lung is the consequence, and where the in-troduction of air into one side of the chestproduces a difficulty of breathing, in conse-4,jeDce of the mediastinum being pushed tothe other side, it may become necessary tomake an opening to let out the air on thatside. The same observation applies to acase which would be caUed by the French

pneumothorax, that is, where an abscess ofthe lung bursts into the chest, and some ofthe bronchial tubes still remaining open,the air taken into the lung by those tubespasses out of it into the cavity of the pleura.I saw a case of this kind in a medical mansome time ago, where subsequent to symp-toms of active inflammation of the lung, in-dicating that degree of inflammation whichwould have preceded the formation of an ab-scess, the symptom, indicating admissionof air into the chest, supervened, viz. theproduction of a tympanitic or hollow soundon percussion of the side into which theair had escaped. On tapping with thehand the side of the chest into which theair has been introduced, you obtain a si-milar sound, noise, and sensation, to thatproduced on patting the abdomen with thehand, when the intestines are distendedwith air. There is, moreover, in such a

case a very peculiar sound communicated tothe ear. If you put the ear in contact withthe chest, the passage of air into the chestpoduces what Laenl1ec has called the me-tallic tinkling, that is, the sound which is

produced by the dropping of shot into aporcelain or earthen vessel. Indeed, I donot know anything that could more accu-rately represent it. The existence thereforeof this metallic tinkling, combined witha tympanitic sound on percussion, of pre-vious symptoms indicating the existenceof inflammation and formation of matter,and the further combination with those

symptoms of great difficulty and distressin breathing, arising, in the first instance,from the collapse of the lung on the sidewhere the air has been introduced, and,secondly, from the pressure of the mediasti-num, when the air has been received, againstthe other side, sufficiently point out the na-ture of the affection.The reasons for making an opening into

the chest under these circumstances, are,the great distress of breathing which is im-mediately produced, and the necessity ofgiving to the patient some relief from thevery urgent symptoms under which he is la-bouring. The great probability, or rather thecertainty, we may say, is, that the patientwill perish. The only question is, whether,as far as the operation goes, we can givetemporary ease-whether we can lessen the

great difficulty of breathing. In the in-stance to which I have just alluded, on mak-

ing an opening into the chest, there was a

great rush of air from within, and the pa-tient subsequently became easy. From the

progress of the complaint, however, he died,though he was completely relieved at themoment, which is all that could be accom-

; plished, though this seems to me to be asufficient reason for having recourse to the

t operatton.

600

Inflammation of, and Effusion into, thePericardium.—Respecting inflammation ofthe pericardium, and the effusion offiuid intoit, mention has sometimes been made of anoperation for removing the fluid, though I ibelieve there is no instance on record inwhich any such operation has been per.formed.’* I can hardly, for my own part, andjudging from my own experience, considerit possible that any combination of symp-toms could arise to justify such an operation ;I have, therefore, nothing to say to you re-specting tiie tapping of the pericardium.

ON THE

EPIDEMIC FEVER OF IRELAND;

By D. J. CORRIGAN, M.D.

(Concluded from p. 575).CLIMATE or season, absence of cleanliness

and crowded apartments, intemperance, con-tagion, all these have, severally, or toge-ther, been put down as principal causes offever.To climate or season being a cause of

fever, the answer is given in the facts

already ,stated, each epidemic having ragedthrough heat and cold, through summer andwinter, spring and autumn. The vulgaropinion that cold has power in checking epi-demic fever, is totaliy without foundation.In the two last visitations of 1817 and 18,and 1826 and 27, the epidemics were at

their height in the middle of winter, andbegan to decline in warm weather.As to absence of cleanliness, want of ven-

tilation, with crowded apartments, or intem-perance, being causes of consequence in theproduction of epidemic fever, it is obviousthat there can, among the lower orders, beno change in these particulars sufficient to I,account for the effect attributed to them.Were absence of cleanliness, ventilation,

&c., causes of any importance, there shouldbe some relation between changes in theseparticulars, and the extent of the epidemic ;but it has never been proved that with therise of any epidemic there had been increaseof filth or slovenliness, at all correspondingwith the increase of disease.When the epidemic of 1826 appeared, an

act of parliament was put in force, suggestedby the Board of Health, which obliged eachparish to appoint persons denominated offi-cers of health. Their duties were to see thatall nuisances, as collections of manure, &c.,

* It has been performed by Larrey, and(four years ago) by Mr. Jowett, ofNotting-ham. Vide LANCET, vol. xi., p. 712.

were removed, and that the habitations ofthe poor were whitewashed. Much mone eywas expended in this way ; in cleaning outdepots of filth for those who were too indo-lent to do it for themselves, and in white-wasliino- rooms for poor creatures who thenhad not the price of fuel to dry their wetwalls.

These measures of cleansing coming froma board of health, and enforced hv an act ofparliament, had an imposing effect; but alittle reflection would have convinced anyone who had had independence enough tothink for himself, that it was very improbablethat a dunghill or slaughter-yard which hadlain for years quiescent, should have sud-denly taken on and retained the new powerof elaborating fever, or that the walls of aweaver’s apartment, in which for successivesummers one or more families had lived ingood health, should have acquired in the

midst of winter the power of vomiting forthcontagion.

I would be far from undervaluing the ad-vantages of cleanliness ; but it is plain, thatall those matters over which the officers ofhealth were given control, had equally exist-ed, for an indefinite period of time,and with-out being accompanied by an epidemic, andthat spending time and money in theirre-moval, was bad in two ways. It was a use-less expenditure, and, presenting an appear-ance of active exertion, drew away attentionfrom the real cause. The act of parliamenttook away all discretionary power from theparishes; they might spend as much moneyas they pleased in the idle measure ofwhitewashing rooms and staircases, but

they could not layout one penny to save afellow-creature from starvation.

Contagion has been advanced as the sole,the indispensably exciting cause of the epi-demic fever of this country.That it is not the sole or original cause,

may at once be established by asking, Howdid the first case of typhus (for instance)originate ? Not from contagion, for conta-gion must first have been generated by abody labouring under the disease; it beinggranted by the contagionist that even onecase could arise without the application ofcontagion, it follows that any number mightarise in the same way. Contagion, then,cannot be the sole cause. It may be said

nothwithstanding, that contagion, generatedno matter how, in the first instance, is thecause of the rise and spreading of our epide-mics. The most sanguine supporters of

contagion allow that it becomes inert at thedistance of even a few paces from the bodygenerating it. This being admitted, it is

totally impossible, on the principle of con-tagion, to account for the rise of an epidemic.The epidemic of 1817 broke out in themonths of June and July in Clonmel and