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Ìnvolveù the whole abdomen. The swelling then remainedstationary for a little while, and increased very rapidly a shorttime before admission. The patient has repeatedly soughtprofessional advice, but counter-irritation and various meclicinesdid not procure any relief. The poor woman now began toexperience much inconvenience from the bulk of the tumour,and was therefore tapped three days befQre applying here.From some cause or other, no fluid but a little pus wasevacuated.

State on admission.-The patient has now much difficultyof breathing; she cannot lie down, and gets no rest at night.The abdomen presents an enormous size; the protruding massis very hard, and does not distinctly yield the sensation ofeffiised fluid.Mr. Stocker, the resident medical officer, ordered half a grain

of elaterium, to be repeated if necessary.On the third day after admission, the patient was tapped

by Mr. Hilton, but the withdrawal of the trocar was notfollowed by the escape of fluid. The symptoms for the nexttwo days became extremely distressing, when, on the secondmorning after the first operation, paracentesis abdominis wasagain performed, Mr. Callaway being the operator. The in-strument was introduced just above the umbilicus, about sixinches higher than the spot where Mr. Hilton had perforatedthe abdomen. Nearly a bucketful of fluid was evacuatedwith great relief to the patient, but directly afterwards shefell into a very low state, the pulse was hardly to be felt fora long time, and she complained of being very cold. Large Iquantities of wine and brandy were administered, warm waterwas applied to her feet, and blankets placed over them; thesemeasures soon restored her, and the flannel roller was put on.In the evening the patient complained of the tightness of

the roller, which was accordingly slackened. Bowels openedtwice on the day of the tapping.

Jan. 23rd, the day after the second operation.—The patienthas had a bad night; she was repeatedly sick, and brought upeverything she swallowed; she has severe pain in her legs,great difficulty of breathing, and has passed but very littleurine; tongue furred and dry; pulse weak. She has beentaking beef-tea through the night.The poor woman died the next day at four o’clock, and had

not passed urine for the last twelve hours.Post-rnootem examination, twenty-two hours cfter death.-

Legs dropsical; the abdomen contained a large quantity ofascitic fluid, in which were shreds of lymph, the result ofrecent peritonitis. Extending upwards, above the umbilicus,was a large tumour, quite detached, and springing from apeduncle by the side of the uterus, being, in fact, the leftovary enormously enlarged. The tumour was made up of

cysts, the upper one having been tapped before death; itscavity was now filled by a quantity of coagulated blood, whichhad poured out after the operation. The other cysts containedthe peculiar gelatinous fluid generally found in cystiformdisease of the ovary, and their walls consisted of hard tissue,which was thought to be malignant, but that point was notsatisfactorily determined. The left kidney was distended by awhite fibrous mass, the right was quite healthy, and the otherorgans were in a normal condition.

ST. GEORGE’S HOSPITAL.

Empyema; Thoracentesis repeated several times; PartialRecovery; Spontaneous Discharge of Pus through theParietes of the Chest.

(Under the care of Dr. BENCE JONES.)THE subject of the present case is now in the hospital, and

affords a most striking example of the very severe thoracicderangement and pleuritic effusion from which a patient mayrecover. It is principally in cases like this that the advan-tages of decisive measures are clearly seen, and it thenbecomes strikingly apparent how beneficial an operation istapping of the chest. It must be confessed, however, that thecases which are likely to embarrass the physician are not thosein which impending suffocation points distinctly "’o the necessityof the operation, but rather those in which the disease hasbecome chronic, where the symptoms are not clearly defined,and there is no impending danger. "BVe have seen several ofthis latter kind of cases within the last twelvemonth, andcould not help noticing that thoracentesis is now a morecommon operation than it was in former times. And it mayWell be looked upon with less dread at the present period,as the manner of performing it has been so iLDroved as to

expose the patient to very little danger as regards the opera-tion itself. We now no longer make a large gaping opening

to be subsequently distended with tents and pledgets; but thewound is small, and every precaution is taken to prevent theaccess of air and the renewed inflammation of the pleura.Very valuable hints have been given as to this operation by

M. Trousseau, up to a recent period physician to the Children’sHospital in Paris; and it is not a little strange to Englishpractitioners to hear of an hospital physician not only prac-tising thoracentesis, but also giving rules respecting it, andrecording numerous cases wherein he had met with consider-able success by following them. We find that M. Trousseaucombined in his operation the steps advised by Recamier, andmodified pretty recently by Reybard. M. Trousseau, whohas performed upon a great many children, not only thoracen-tesis, but also tracheotomy, divides his operation into twoparts. The first consists in making in the skin an openingwith a lancet, just large enough to allow of the passage of thetrocar, the incision to be in the eighth intercostal space, andin a line parallel with the rib. Before introducing the trocar,an assistant should cause the skin to glide upwards on the ribs,so that the aperture made with the lancet may correspondwith the seventh instead of the eighth intercostal space. The

trocar should then be thrust in, and made to run close to theupper border of the lower rib. The instrument must be verysharp, and pushed in with a certain amount of force, until theresistance is overcome. As soon as it is removed, the liquidflows out, and the valve begins to act. This valve should becomposed of some membrane which may be easily drivenby the pressure of the atmosphere upon the external openingof the canula. The valve, which may consist of several layersof the membrane, is to be fastened around the head of thecanula in the form of a tube, reaching a good distance furtherthan the handle of the trocar. Thus, when the latter is drawnout, the valve is seen at each act of inspiration to becometightly pressed by the atmosphere against the external openingof the canula. The use of this valve entirely precludes thenecessity of placing the tube, or a bag attached to it, underwater.As to the circumstances in which the operation is advisable,

and likely to be useful, it is generally admitted that two greatdivisions should be made-viz., cases in which the patient isbeing suffocated by excessive effusion of liquid (serous or puru-lent) into the pleura, and cases where there is no immediatedanger, though the quantity of fluid effused is considerable.

In the first division the operation is almost always called for,except there be, as remarked by]B,1(. Trousseau, some organiclesion which is likely in a short time to destroy the patient. Inthe second division may be noted acute hydrothorax; here theoperation should not be delayed, as patients have been knownto die in a few days by the rapid increase of the fluid, and thecomplete abeyance of the function of absorption. In thesecases the dulness reached to above the clavicle; the whole sideof the chest was raised; the intercostal spaces bulged out, andthe thoracic organs, especially the heart, were displaced.There are, however, chronic effusions which do not evince atendency to sudden and dangerous increase; but here the com-pression of the lung against the spinal column should betaken into consideration, and the organ not be allowed tobecome glued and permanently confined by fibrinous layers.In two of the cases of M. Trousseau the effusion had existed twomonths, but the fluid was found quite clear, and the lung ex-panded again upon the evacuation of the serum. This was alsothe case with a patient of Dr. Risdon Bennett at St. Thomas’sHospital, whose chest we saw tapped by Mr. Simon. Andit is very probable that such is also the state of things ina patient of Dr. Wilson, at this hospital, who has now beentapped five or six times, and is able, between the operations,to engage in very toilsome labour. This man was dischargedfrom the army when still very young, for chronic effusion in thechest. In fact, we well remember hearing Dr. Wilson mentionthat he has resorted pretty largely to thoracentesis in theselater times, and generally with favourable results.As to empyema, it is not an easy matter to say, in a given

case, whether the effused fluid is still serous, or whether the

purulent transformation has taken place. No doubt that pusfrequently forms after the accession of air when the opera-tion of tapping the chest has been performed; but it is notquite certain, so far as we have seen, whether pus may beprimarily secreted by the pleura. There is another serous

cavity, if we mistake not, which never secretes pus-viz., thetunica vaginalis testis.

It is in the meanwhile interesting to notice what a largeproportion of recoveries take place after tapping for empyema.Dr. Thomas Davies, quoted by Dr. Watson, gives a table,from which it appears that out of 16 cases of empyema in

which thoracentesis was performed, there were 12 recoveries.

494

This is certainly a very encouraging result, says Dr. Watson,and we are happy to put on record the following case, whichwell desers-es to be added to the list :-John ;’1--, aged forty years, was originally admitted,

under the care of Dr. Bence Jones, May 8th, 1853, with all thesymptoms of considerable effusion into the left side of thechest. He stated, on his admission, that he had been ill sixweeks, during which time the cough had been very severe.At that period he had one day fallen down suddenly, pantingfor breath, -whilst engaged at work as an agricultural labourer;but this accident will not appear when we recollectthat the left lung was at that time rapidly becoming useless.The patient was treated in the country, the usual range oftherapeutical means being used- -viz., bleeding, blistering, &c.On his admission, the symptoms of effusion were so marked,

and the distress so great, that Dr. Bence Jones had him

tapped on the following day. Mr. Henry Charles Johnsonperformed the operation, and we shall never forget the unbear-able fcctor which was exhaled by the pus which escaped uponthe perforation of the chest. The usual stimulating and ex-pectorating remedies were used; but the patient became soonmuch oppressed by reacenmulations, and it was found necessaryfor the next three weeks to re-open the aperture made in thethorax. Mr. Johnson subsequently made a large opening,which was covered with linseed poultices ; but the fcetor con-tinued to be almost intolerable. ’

The patient, though still weak, insisted, about three monthsafter admission, on being discharged, when he returned toWindsor, where he was admitted into the Union Infirmary.Here he was affected with occasional severe dyspucea, and

the accumulation of pus (which turned out as foetid as it hadbeen before) became so great, that the parietes of the chestgave way in iive different places at very short intervals. Thescars left after this spontaneous escape of purulent matter arenow visible. These repeated attacks brought him so low thathe was one day looked upon as dead; the shell was preparedfor him, but before he was put into it, the master of the work-house (certainly a very prudent and sensible man) put a looking-glass before the patient’s mouth, and as the glass becamemoistened, means of revival were used, and the poor maneventually recovered. It is needless to say that in the unionand at St. George’s, the man was kept up by medicine, food,and stimulants. When a little better, he tried to work in thefields, but could not accomplish this task, and eventually wasre-admitted into this hospital on the 8th of March, 1854.He looked, on this second admission, considerably better

than when he left, and the intensity of the cough had consider-ably diminished. He complained of some weakness in thelegs; the whole of the left side of the chest was quite dull onpercussion, and yielded no sort of respiratory murmur onauscultation, though the heart was not so forcibly pushed tothe right side. The patient has progressed pretty well sincehis second admission, and we hope that he will graduallyregain that amount of health which is compatible with hispresent state.

Medical Societies.

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, APRIL 25, 1854.—JAMES COPLAND, M.D., F.R.S.,PRESIDENT.

ADDITIONAL REMARKS ON THE STATISTICS AND MORBIDAPPEARANCES OF MENTAL DISEASES. By JOHN WEBSTER,Esq., M.D., F.R.S., &c.

This communication consisted of a synopsis of 115 dissections Iof patients dying in Bethlem Hospital, and was accompaniedalso by a careful analysis of the morbid appearances observedboth in the brain and the organs of the body. A paper pub-lished in the Society’s T1"CinsactÎolls for the year 1845 con-tained the post-mortem records of 175 insane patients; andthe 115 cases supplied by the present paper gave 290 dissec-

tions, an epitome of which gave the following result: In 226cases the pia mater was infiltrated; in 207, effusion had takenplace into the ventricles; in 184, turgidity of the blood vesselsin the brain or membranes was observed; in 117, the arachnoidmembrane was thickened and opaque ; in 64, the colour of thebrain appeared changed from its natural hue; in 51, blood-points were large and numerous upon the cut surface of themedullary surface; whilst in 40 instances blood was effused,sometimes even to a considerable extent, within the cranium,and which evidently proved the immediate cause of death in

most of these patients. According to the above data, theauthor desired to repeat the same general conclusions as for-merly enunciated by him when discussing the pathology ofinsanity-viz., 1, intiltmtion of the pia mater; 2, effusion offluid in the ventricles; 3, turgidity of the cranial vessels,were the principal as also the most usual diseased alterationsof structure which pathologists might confidently anticipate inpatients dying whilst suffering under symptoms of mentalalienation.

Dr. SUTHERLAND said, he thought that we were muchindebted to Dr. Webster for bringing the subject of themorbid appearances in cases of insanity so frequently underthe notice of the Society; that its importance was recognisedmore and more every day, because greater attention was paidto the subject, and because there were greater facilities of in-vestigating it than formerly prevailed. Chemistry, the

microscope, and the balance, added much to the accuracy ofour knowledge, but still it must be confessed that we hada very imperfect notion of the connexion of symptoms withthe morbid appearances of the brain. That there was nothingcharacteristic of the brain of insanity; that it was true somedeviation from healthy structure was generally found, but thatwhen it was considered that insanity was not only idiopathic,but also sympathetic and symptomatic, dependent uponfunctional and organic disease of the brain, as well as upondisturbances existing in a comparative state of health. When,for instance, on the one hand is met with every gradation ofsymptoms between encephalitis and delirium tremens, and, onthe other, symptoms analogous to dreaming and somnambulism,it could not be a matter of surprise, not only that no charac-teristic appearances were found in the brain of insanity, butalso that in some few cases nothing abnormal was discovered.Dr. Sutherland said that he could have wished that thesymptoms had been given in Dr. Webster’s paper, so as tohave enabled the fellows of the Society to have connected thepost-mortem appearances with them, as this would haveadded greatly to their importance and their interest; that hewould not speak of the morbid appearances so commonlyfound, as these had been ably pointed out in the paper, but hewould observe that minute anatomy had taught us to lookmore particularly into the state of the cortical structure, tosee whether any distinction could be drawn between acute andchronic cases, and into that of the fibrous structure, toelucidate the symptoms of that imperfect state of palsy,known as paralysis of the insane. That in acute cases, theconvolutions were found well-developed, the cortical structureof normal thickness, and gorged with blood, and Foville’sbands were distinctly marked; that in chronic cases the con-volutions were atrophied, the ganglion globule was more orless devoid of pigment, and that Foville’s bands were nowhereseen. That the fibrous structure, as seen under the micro-scope, varied much both in size and in consistence ; that inacute cases little change was perceptible; but that in chroniccases it frequently partook of the general atrophy of the brain;sometimes that the minute fibres were softer, and more easilybecame varicose, while at other times they were together, andmore elastic than in health; that, in certain cases, there wasadhesion between the fibres, giving rise to hardening of thebrain; that the softening of the brain was caused generallyby want of nutrition, dependent either upon poverty of theblood, as in starvation, or upon congestion in the capillaries, asin cases of maniacal excitement, or upon a diseased state of thearteries. He would not detain the Society by alluding tothe morbid appearances found in the other viscera, whichwere mentioned in the paper, as they corresponded with hisexperience in these matters; but he must conclude by con-

gratulating Dr. Webster upon the valuable addition which hehad made to his former papers upon this subject.

Dr. COPLAND, after speaking of the importance of connectingthe symptoms observed during life with the morbid appearancesafter death, remarked that the cause that was assigned forinsanity was not always the real one. There was no doubtthat secret vices in both sexes were the most common causesof insanity, though their influence was rarely known. Thiswas particularly the case in unmarried persons. There was noclass of diseases, moreover, in which there was so frequentlya combination of causes at work to bring them into action.

Mr. HoLMEg COOTE concurred with the remarks of Dr.Sutherland as to the importance of connecting the history ofthe case with the post-mortem appearances. Dr. B1’ ebster,however, could not be blamed for au omission on this point, asno complete record was kept of the symptoms presented byeach patient in the hospital. He (Mr. Coote) believed, how-ever, that a better system was now in operation. With regardto the dissections, many of which he had made, he could not