again performing the work of a serous membrane. 2d. The permanent collapse of the lung, followed by its caruification or septic, probably gangrenous degeneration (all of which complications I have observed, even where antiseptic injections were used), the long-continued drain on the system, and the fatal result that almost inevitably followed in a very large proportion of the instances where it was adopted.

The use of sulphuric ether or chloroform has been very much feared where so large a proportion of the pulmonary tissue had been rendered useless. I have given each of these anaesthetics under the most unfavorable circumstances, and have never known a serious result; but with our present knowledge, never under any circumstances would I use chloroform as an anæsthetic, although I have given it for the removal of necrosed ribs when the pericardium was completely uncovered, and have had the ether administered when the thoracic accumulation was so great as to cause displacement of the heart and luxation of the clavicle; in the former temporary cardiac syncope occurred, and in the latter the sleep was as peaceful as an ordinary slumber.

But since Dr. Richardson's paper on Local Anaesthesia I have resorted to that simple, most effective, and perfectly safe method. I use the ordinary hand atomizer with sulphuric ether, which, in less time than it would take to produce general anesthesia, causes a circumscribed space, about one inch in diameter, to be made so insensible that the operation will be rendered almost, if not entirely, painless.

Objections to the use of the trocar for thoracentesis.

Dr. Watson' relates a case seen by him, where death was caused by using the trocar; he states that the integuments of the side were cedematous, and it was thought that a little serum issued upon the passage of the grooved needle. The serum must have come from the infiltrated areolar tissue. No liquid was evacuated by the trocar. The patient died a day or two afterward of peritonitis. The instrument had perforated the diaphragm, and entered the spleen, which was unusually large. Laennec also had death follow the use of the trocar, where the operation was performed at his favorite site, viz., between

1 Watson's Practice of Medicine, London, 1857.

2 Ibid., 1875.

the fifth and sixth ribs; he thrust the instrument, as he supposed, into the thorax, and was a good deal surprised to find that no gush of liquid followed its introduction. The patient died, and dissection showed that the trocar had entered the cavity of the abdomen after transfixing the diaphragm, which, having been forced upward by a large liver, had contracted from adhesion to the seventh rib.

Other more recent instances have occurred, where by the use of the aspirating needle of Dieulafoy the lung has been pricked. There are also recorded instances where the needle has broken off and remained in the thoracic cavity.

The removal of portions of the ribs, to allow a permanent contraction of the thorax, has been resorted to in some cases where, from the septic condition of the thoracic contents, a free admission of air from a large opening was desired, and for the purpose of washing the cavity where from known permanent loss of lung tissue a restoration of the organ to its original size could never be expected. Such an operation was also devised to hasten that sinking in of the affected side which unaided nature takes so long, if ever able in these cases, to accomplish, thereby cutting short that indefinite period of fistulous discharge and continued source of depletion to the patient.

The great inequality in the external contour, as well as in the chest cavity, has been apparent in those instances where, after years of gradually yet continually diminished lung calibre, the necropsy has shown the remaining cavity to contain one-half, more or less, of the restored parenchymatous tissue left capable of producing a change of the venous into arterial blood, and which part of lung tissue might be the means in an opposite pneumonitis of carrying the patient through all the stages of the disease until restoration would have permitted it also to resume its appropriate state, to the harmonious working or at least a partial restoration to ordinary health.

Rapid death may sometimes occur, even during the primary operation, and has been attributed to a variety of causes. I have never seen death in any way caused or hastened by thoracentesis, but on two occasions have had alarming symptoms occur, first, from ordinary syncope, the shock or dread causing the patient. to faint, and also a shock on the sudden change of position of the heart and lung as they resumed their normal positions during the diminution of pressure from the opposite side. These

distressing symptoms have always ceased when I have followed the following rules: Place the patient's head and shoulders low, and if a large quantity has been withdrawn allow the pressure to be renewed by rolling the patient on the well side, so that the organs can be again partially compressed and the heart and lung returned to where they were before the withdrawal of the fluid, give cardiac stimulants, apply friction to the extremities, and enjoin rest for a few minutes-until the circulation and respiration are harmoniously restored.

Can thoracentesis be performed during pregnancy? has been answered in the affirmative. In a paper read before the Société de Chirurgie, Paris, an account is given of an operation on a woman in the seventh month of pregnancy, without disturbing gestation; a healthy child being born at full term.1

The siphon method with the mercury manometer offers a means by which a slow, gradual, and steady flow can be accomplished, and at the same time the inter-thoracic pressure can be definitely watched. Dr. Ellis recently removed by this method from one patient one hundred and thirteen ounces in sixty-five minutes, the patient not expressing pain or discomfort, the flow being so gradual and uniform; and Dr. Garland, by opening the valve of the manometer, was able to read the amount of hydrostatic pressure in the chest.

The anhydrous method, of not even permitting water to come into contact with the external wound, has in a number of instances inclined me to conclude that empyemata do better when this method is followed; providing that no perforation of the lung has occurred, producing a pneumo-pyo-thorax; we thereby do not add another factor towards producing that molecular change in the remaining entombed pus globules which so soon occurs on the addition of water, whereby their cells are ruptured and their contents placed in a more favorable condition to undergo that septic change and decomposition unfavorable to

recovery.

Conclusions.-Thoracentesis, or removing from the lungs the diseased parts, or the accumulated results of disease from within the thoracic cavity, are operations I have successfully performed without a fatal result twenty-one times during the past fifteen years. Any physician with an accurate anatomical knowledge

1 N. Y. Med. Journal, Sept. 1876, p. 307.

2 Boston Medical and Surgical Journal, April 15, 1880.

can perform thoracentesis, when necessary, in any remote rural district without an assistant, with any small instrument having a cutting edge, and, if drainage be desirable, a piece of any hollow plant or the large quill of a feather with openings made along its side, introducing the hard end into the opening made between the ribs (if more complicated instruments cannot be had); and may thus be the means of saving a valuable life.

Thoracentesis ranks among the first operations in surgery in saving life.

Thoracentesis is justifiable to prevent pain and prolong life where an ultimate recovery of the lungs cannot be expected. Thoracentesis has been followed by a complete restoration to

health.

Complete absorption has followed when air, pus, or serum has been left in the chest after thoracentesis.

The costal and pulmonary pleural membrane may be restored to its former healthy condition under favorable circumstances after thoracentesis for the removal of either pus or serum.

General or local anesthesia may be resorted to, to prevent pain or shock of the operation.

Hectic fever, the result of unhealthful decomposition, ought to be relieved by a free incision, to promote thorough removal of the effete matter, and disinfecting cleansings of the entire lining membrane of thorax, thereby removing, as quickly as possible, all material favoring septic disintegration of the pus and blood globules prior to absorption into the general circulation.

By my recorded illustrations I have shown that thoracentesis can be successful on the nursing infant as well as on the adult; can be resorted to when both lungs are diseased, and even in far advanced pulmonary consumption, where the lungs are compressed by surrounding matter; and that relief from distressing suffocation can be obtained, life prolonged, and painful death averted.