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trouble followed. The case, however, would be different in the thoracic cavity, where the nearly unyielding walls could by no possibility contract and obliterate a space which had been occupied by ten pints of pus.
DR. FERGUSON remarked that he had made that point in his paper.
DR. MOORE further remarked, with regard to the comparison to suddenly emptying the over-distended bladder, that a long time ago he lost a patient by this procedure.
DR. ROCHESTER desired to make a few remarks upon Dr. Ferguson's paper before his own was discussed. He had performed paracentesis a great many times, and had learned from experience the dangers of withdrawing all the liquid from the pleural cavity at a single operation, as they had been set forth by Dr. Ferguson and by most recent writers upon the subject. He had known hæmorrhage to occur into the pleural cavity for the reasons set forth by Dr. Ferguson ; and he had also known serious hæmorrhage to take place from the lung during paracentesis. It had, therefore, been his practice for many years, in using the aspirator, to draw off only ten or twelve ounces of liquid at a time, and to stop the operation as soon as the patient began to show the slightest signs of distress ; but he might aspirate as many as eight or nine times subsequently, until liquid was no longer secreted by the serous surfaces. In some cases he had found it unnecessary to repeat the operation after having withdrawn eight or ten ounces of liquid, the rest being disposed of by absorption. He thought that, under the precautions enjoined by Dr. Ferguson, the aspirator could be used with safety. He kept the patient quiet, and usually painted the chest with iodine or strapped it very firmly with adhesive plaster. Both these procedures he regarded as useful and conducive to recovery..
DR. FERGUSON.-Before writing my paper, I requested my assistant to look up the literature of the subject of aspiration of the chest ; and I myself read what I had at hand as to its bearing upon the points brought out in the paper. I have been unable to find any mention of the dangers to which I have called attention. I cordially agree with Dr. Moore in the statements which he has made with regard to aspiration of the thorax. At the present time, I have several patients carrying a drainage-tube, some of whom have been doing so for several years ; and I feel quite sure that had these patients not been so treated they would have died from chronic suppurative disease. Within a short time, I have seen three cases of empyema which had been cured by the single withdrawal of a few ounces of pus by aspiration just below the angle of the scapula. Less importance, in my opinion, is to be attached to the statement made in my paper with regard to the seriousness of the use of the aspirator than has been given to it in the discussion. I have said that the aspirator is an instrument of great value, but I consider that the field for its use should be well defined. As to the use of the aspirator in abdominal and pelvic troubles, I believe that in some cases it would be of great benefit; but if it is to be employed for diagnostic purposes, I should advise caution, for there is danger, even after the employment of a small needle, that fluid may escape into the peritoneal cavity and give rise to peritonitis.
DR. ROCHESTER.-I regard it as a waste of time to use the aspirator in empyema, and it is very liable to become a source of danger. I have tried it repeatedly, and in one case I aspirated the patient twelve times, drawing off in all twenty quarts of pus, without introducing, however, a drainage-tube. The patient died within two years, of what was believed to be pyæmia. In my judgment, some cases of empyema may recover after treatment by aspiration, but the probability is that they will not. With the drainage-tube, suppuration will continue, and there is always some danger of absorption of pus. There is, however, an important point in the use of the drainage-tube which I have failed to mention ; namely, that, after allowing the discharge of a certain quantity of liquid, a clamp is placed on the tube, and, after some hours, it is again opened. I have been in the habit of placing absorbent cotton or oakum upon the wound, thus preventing odor and sufficiently excluding air. By this method of treatment, I have obtained a cure in a number of cases of empyema.
One of these was the case of a child sent to me by Dr. Flint, in which I aspirated repeatedly; and, as the patient did not do well, I inserted a drainage-tube, after which recovery was complete. I have used the drainage-tube in a number of cases in adults, with no ill consequences. I have one or two cases under observation at the present time, in which the patients are wearing drainage
tubes, the cure being imperfect, but, had the tube not been employed, death would have taken place long since.
The point made in my paper was to facilitate opening into the chest. I have myself often experienced difficulty in this respect; but, by introducing the finger, the opening was made quite free, and no trouble was afterward experienced in introducing a drainagetube. In empyema, I attach very great importance to the drainage-tube, while I think very little of the aspirator. I fully agree with Dr. Ferguson as to his precautions against withdrawing too much of the liquid from the pleural cavity at a single operation ; but I think that the same precautions have been recommended by nearly all recent authors, and for the reasons which Dr. Ferguson has given. With regard to the method employed by Dr. Freeman, of Pennsylvania, I have tried it, but have found that the opening soon closes and the discharge of pus is arrested.
DR. Flint said he had been accustomed, as Dr. Rochester has suggested, to stop aspiration as soon as unpleasant symptoms appeared ; but, if he understood Dr. Ferguson aright, the point which he wished to make was that aspiration should be discontinued after withdrawing a small quantity of liquid, not waiting for unpleasant symptoms to show themselves.
Dr. Ferguson remarked that such was the point made in his paper, and we should by all means stop the operation as soon as patients begin to cough or to give evidences of respiratory disturbance.
Dr. W. C. B. FIFIELD, of Boston.—The precautions in the use of the aspirator mentioned by Dr. Ferguson were pointed out by the inventor of the instrument, Dieulafoy, at least ten years ago. By this instrument, the contents of the pleural cavity are made to flow into a vacuum, being received in a graduated glass bottle, thus enabling one to know exactly how much liquid has been withdrawn at any moment during the progress of the operation. Dieulafoy stated explicitly in his book that the quantity of liquid to be withdrawn from the chest is not to be estimated by any symptom presented by the patient, but that it should be fixed by absolute quantity, this being, I believe, one thousand grammes; and under no circumstances should that quantity be exceeded.
As to the treatment of purulent pleurisy, or empyema, in a
large box which accompanies Dieulafoy's latest aspirator, are a number of curved canulæ with trocars to correspond, with openings upon the shields, by which adhesive plaster or other material may be made fast for securing the tube within the opening. These curved canulæ can be left in the chest, a cap screwed on, and, whenever the surgeon so desires, he can allow liquid to escape from the pleural cavity. I have never had occasion, however, to employ this method, but I can understand how it may have advantages over the drainage-tube or a simple fistulous opening. In a case which I saw with Dr. Bowditch, of Boston, the opening between the ribs was dilated with the finger, not using a drainage-tube afterward, and complete recovery took place.
The PRESIDENT remarked that Dr. Moore, it would seem, thought that most cases of pleurisy recovered without aspiration or anything more than general treatment ; but how is it, he asked, that we see so many cases of pyothorax, if most cases of simple pleurisy recover? He knew of some physicians who had practiced withdrawing the liquid early, without waiting one or two weeks, with favorable results.
ADDRESS ON OBSTETRICS AND GYNÆCOLOGY.
By T. GAILLARD Thomas, M. D., of New York County.
November 19, 1884.
MR. PRESIDENT AND GENTLEMEN-FELLOWS OF THE NEW YORK STATE MEDICAL ASSOCIATION : If I interpret aright your wishes in requesting from me an address on obstetrics and gynæcology on the occasion which brings you together in this city to-day, you desire, at the hands of one who has paid more attention to these subjects than the general reader and practitioner, an estimate, from his stand-point, of the present status of these departments of medicine, their relations to other branches, the advances which the past decade has accomplished for them, and the most signal lines of progress which have been pursued in the accomplishment of such advancement. If my conception of your wishes be correct, my task will not prove a difficult one, nor shall I be forced to weary you with prolix and uninteresting details.
Pardon a passing reference to the infancy of the science of obstetrics, which will merely serve to remind you of facts which you know as well as I. Obstetrics as an art must always have existed, even among savage nations; and, as civilization and refinement have advanced, this art has ever become more and more perfect, keeping pace, as other arts have done, with the general progress in a people's knowledge. And thus it is that obstetrics, advancing from the ages of the past, from the period of the wonderful old man of Cos to that of Smellie and Levret, existed as a very perfect art indeed; but it was in no