Case 2.-Mrs. J. on the third day after delivery of her third child, had a rigor -was found with hot skin, quick pulse-lochia small-no abdominal pain or tenderness; but with sensation of weight in the pelvis, and difficult micturition. Febrifuges prescribed. The pulse continued to range high-tongue furred-milk deficient-pelvic uneasiness increased into pain, in the region of the left ovary. Vaginal examination proved this canal to be hot, hard, inelastic. Local anodyne injections-hyd. cum creta with opium-antifebrifics-leeches thrice repeated. In three days a copious purulent discharge from vagina, which lasted ten days. A pint of porter daily, with generous diet, and bark. Phlegmasia dolens succeeded, treated by leeches, fomentations, &c. The phlegmasia afterwards attacked the other side, with great violence. Convalescence was slow.

Case 3.-On the morning of the thirteenth day after delivery, was attacked with rigor, followed by considerable re-action-pain in the left iliac region-pulse 120, small-furred tongue-pain on pressure in left side of abdomen. Twelve leeches to the painful part-hot anodyne fomentations-calomel, castor-oil, antifebrifics. Amelioration of symptoms; but subsequent exasperation, and recourse to antiphlogistics, with mercury till the gums were affected. In the course of a few days purulent fluctuation just above Poupart's ligament, left side. On incision, six ounces of matter were discharged, very fætid. The discharge continued eleven days. She took quinine, porter, and the mineral acids. Her convalescence was protracted for two months, when she recovered.

In the fourth case, the abscess also burst externally on the right side, the abscess being preceded by the usual symptoms of suppuration. The patient refused to have the tumor opened; but it burst and discharged for a month, when she recovered.

The fifth case was distinguished by a double abscess, one of which burst into the vagina, the other was punctured, and the patient recovered.

The sixth case was a primipara, where the abscess burst into the vagina, five weeks after delivery. Recovery took place.

Nine cases are related altogether; but the above are sufficient samples of all. The following judicious remarks, by the author, are worthy of record here.

1." Seat and origin of the disease.-It is without doubt a very difficult question to decide whether the disease in the foregoing_cases commenced in the uterine appendages, strictly so called, viz. the ovaries, Fallopian tubes, and broad ligaments, or whether the cellular tissue was the structure primarily affected. In the only case I had the opportunity of examining after death, the evidences of previous mischief were found in all these structures (see Case 8); and it is hard to conceive that one can be seriously implicated without the participation of the others. That the cellular tissue of the pelvis is involved, will, I think, be readily granted, after a careful perusal of the cases. The tumefaction felt both externally and internally; the hard, tense, inelastic condition of the vagina; and the channels by which the pus evacuates itself, its effecting its exit without the peritoneum; prove to my mind, very satisfactorily, that in such cases the tissue which intervenes between the pelvic fascia and serous membrane is involved.

2. "Causes.-This disease may follow an attack of acute inflammation; or it may remain as the sequent of puerperal fever (see Case 1). In the greater number of the previous cases, anomalous symptoms displayed themselves soon after delivery. Cold, falls, blows, &c. are said to have produced the disease. In but two cases were the labours unnatural; viz. Case 3, in which the operation of version was performed; and Case 5, delivered by the forceps. In two cases the right side of the pelvis was affected; in five the left; and in two matter was evacuated from both sides: in one, the right preceding the left; in the other,

Case 9, the pus was evacuated from the left side externally, and from the right side, through the bowel.

3. Symptoms: General.-The symptoms may commence a day or two after delivery, or they may supervene some days and even weeks after labour. The disease is mostly preceded by rigors, or a sensation of coldness over the surface; followed by heat of skin, quickened circulation, and pain in the region of the pelvis. The febrile paroxysms may remit, but their intervals of recurrence are at varying intervals. The uneasiness and pelvic pain continue, and, as the disease progresses, increase: usually there is some degree of stiffness in the side affected, and not unfrequently pain in the course of the vessels of the thigh and leg: this may proceed to the development of phlegmasia dolens (see Cases 2, 6, and 7). The pulse is seldom below 100-110: the tongue remains loaded; there are frequent calls to pass the urine, which is scanty and high-coloured: at one time there is constipation of the bowels, at another, diarrhoea associated with tenesmus; and the secretion of milk is usually scant, or altogether suppressed.

"These symptoms may continue for an indefinite period; when, if the disease be overlooked, or if the remedies employed do not succeed in checking its progress, they are followed by the attendant signs of suppuration, and the matter may be evacuated either by an artificial or natural opening."

"As a

The patient generally directs to the seat of the disease, where will be visible or tangible a swelling, or a hardness, very tender to the touch, and very variable in extent. On examination, per vaginam, we shall sometimes find no indication of disease-but often "a morbid permanence of the state of puerperal hypertrophy ;” to use the quaint and somewhat mystified expression of Dr. Simpson. general rule, it will be found, that wherever pelvic inflammation occurs soon after delivery, a long period will elapse before the uterus returns to its original state. In other females, the upper part and side of the vagina will be found hard, tender, firm, and inelastic; and, by pressing upon the swelling felt through the abdominal parietes with one hand, and keeping the forefinger of the other in the canal, we are able to satisfy ourselves that the hardness and swelling felt in both situations arise from one and the same cause."

Diagnosis. The disease may be confounded with abscess seated in the parietes of the abdomen, caused by rupture of some muscular fibres during parturition, or without any mechanical cause. "It will be well, therefore, to mark the diagnosis between simple abscess of the abdominal walls, and those collections of matter which issue from the pelvis behind, and external to the peritoneum, presenting themselves in either iliac region. In the early stage of the latter, the skin, as well as the muscular parietes, may be readily rolled over the tumor; evidently demonstrating their non-connexion: while, if the abscess be seated in the abdominal walls, by moving the one we move the other. This method of diagnosis is most satisfactorily applied when the patient is in a prone position.'

Morbid enlargements of the uterus, continuing after delivery, may be confounded with the malady in question. In these cases, Dr. Lever thinks that much valuable assistance may be obtained from explorations by Professor Simpson's Uterine Bougies.

Feculent Collections. It is not so very easy to distinguish accumulations in the caput coli and in the sigmoid flexure, from ileo-cæcal and other pelvic abscesses, since, in fact, those said accumulations too often produce inflammation, suppuration, and ulceration. Our author, however, thinks otherwise.

"The early period at which they occur after delivery; the tympanitic condition of the abdomen; the frequent expulsions of flatus, both by mouth and anus; the frequent colicky pains; the occasional vomiting; the loaded tongue; the state of the pulse; will enable us to frame a correct diagnosis. And further, upon inquiry, we shall find that for some time the patient's bowels have

been in a constipated state; while the exhibition of purgatives, and the administration of cathartic glysters, by their effects will remove all doubt from the case."

We shall not dwell on the diagnosis between the disease in question, and sciatica and some other affections with which it has been confounded. The history and symptoms will generally lead the practitioner to a proper conclusion.

The Termination is sometimes by resolution, when the disease is early treated; but more frequently it proceeds to suppuration, pointing outwardly-into the cavity of the peritoneum-into the vagina-or into the uterus-and into the bladder or intestines.

The Sequela are immobility of the uterus-an impervious condition of the Fallopian tube or tubes-ovarian disease, &c.

Treatment.-The great object is resolution; but as the patients are not generally in a state to bear heroic remedies, the milder means will be preferable. Leechings will be generally preferable to venesection. They may be applied either to the seat of pain, or to the vagina, with warm fomentations or cataplasms. Mild mercurial preparations, in small doses, just to gently affect the system, will be beneficial. The kidneys and the bowels must be kept in actionand diaphoresis promoted. The suffering of the patient must often be attended to and relieved by opiates, either by the mouth, or as suppositories.

If suppuration cannot be avoided, it must be promoted, and then the constitution supported.

"1. The first object will be accelerated by the continued application of medicated poultices and fomentations, which soothe the pain, and lessen the patient's sufferings. When the symptoms plainly indicate the formation of matter, and fluctuation is evident, the abscess should be opened: this may be done externally, through the abdominal parietes; internally, through the vagina, by means of the speculum and a guarded lancet; or through the rectum, by means of a trocar, as in Dr. Simpson's case.

"M. Martin recommends the application of caustic potass to the abdominal parietes, for the double purpose of having an external opening and securing previous adhesion of the containing sac to the abdominal walls. This method of practice appears to have been very successful in his hands; but still there are cases to which its inapplicability must be obvious.

"In some of the cases related, the patient's sufferings would have been diminished had an earlier opening been made.

"2. The constitutional powers must be maintained by a generous, nutritious diet, porter, wine, &c.; the administration of tonics, and sedatives.

"Where inflammation takes place in the course of the veins and absorbents, leeching along the line of the inflammed vessels, followed by hot spirit fomentations, will be found of service; taking care, at the same time, to allay pain and irritation by sedatives, and to support the system by mild tonics.

"In some cases, where the inflammation does not proceed so far as suppuration; and in others, where pus has formed and has been evacuated; there will remain considerable induration of the affected structures. Its absorption will be promoted by the exhibition of the pot. iodid. two or three times a day, in the dec. sarzæ c., or the dec. cinchona, and by the application of blisters."

This paper of Dr. Lever, is equally creditable to himself, as a practical physician, and to the character of the valuable publication in which it appears.

ON PARACENTESIS THORACIS. By Messrs. Dr. HUGHES, and EDWARD Cock. [Guy's Hospital Reports.]

In the April Report of the work above cited, is an interesting memoir on the

operation in question, and on its comparative success. The paper opens with general observations on thoracic effusions requiring the operation. The authors have found the operation more easy, and much more efficacious than has been represented in writings. Dr. Bennet states that Boyer had never been successful in Paracentesis Thoracis, while Dupuytren had seen only two favourable cases out of fifty. Sir A. Cooper met with only one fortunate case. We need not go farther for unsuccessful terminations in paracentesis thoracis; and it is our pleasant duty to turn to a brighter page in the history of the operation.

Within the last four or five years, paracentesis thoracis has been performed at least from twenty to thirty times in Guy's Hospital. The operation was resorted to, merely for temporary relief; and though life was not ultimately saved, in all cases, great mitigation of suffering was obtained. The diseases for which paracentesis may be resorted to, are hydro-pericardium-sanguineous effusion into the pleura-hydrothorax-pneumo-thorax-and empyema.

Our authors are of opinion that the operation in pneumo-thorax can hardly ever be successful, but only to be employed to relieve urgent dyspnoea. The same observation, however, applies to the operation in all cases. Hydrothorax is rarely or never an idiopathic affection, but the effect of some disease-too often an organic one, and therefore beyond the reach of medicine. But the dreadful sufferings from dyspnea are almost intolerable, and the relief from them by tapping is well worth the risk and pain of the operation.

"The indications, then, for paracentesis in empyema, or chronic pleuritic effusion, appear to be, in the first instance, the presence of a large quantity of fluid in the pleura rapidly effused; in the second, the distress of the patient dependent on the great accumulation of fluid; and, in the third, the existence of a considerable amount of effusion, together with such a state of constitution, or of the general health, or such other circumstances, as would render a prolonged purely medical treatment injurious or undesirable."

We shall here abbreviate some of the cases adduced by our authors, but first introduce a passage from Mr. Cock, respecting the operation itself.

"It now only remains for me to describe the operation itself; which, as regards the pain it inflicts, is so trifling, that by avoiding all unnecessary display and preparation, the patient may be led to consider it as little more than the sequel of the discipline to which he is occasionally subjected when it is considered essential to make a thorough examination of his chest; the same position of the body being alike adapted for the one process as for the other. It will be found most convenient to let the patient sit across the bed, so as to admit of his body being readily lowered and supported over its edge. The spot having been determined upon, it is advisable to make a small puncture in the skin, just at the upper edge of the rib, with a narrow-bladed lancet; through which opening the exploring needle and subsequently the trochar may be inserted. This preliminary step is not absolutely necessary; but as the skin is by far the most impenetrable and resisting of the tissues to be traversed, its previous division will render the introduction and withdrawal of the canula more easy, less forcible, and attended with a minor degree of pain and alarm to the patient. The exploring needle having been first introduced and the presence of fluid ascertained, the trochar and canula may then be carried into the chest through the same track, giving the instrument a slight obliquity upwards, which will enable it to clear the edge of the rib. The depth to which the trochar must be passed will of course depend much on the thickness of the parietes, the presence of fat, muscle, or oedema, for which due allowance should be made; and, in most instances, the penetration of the pleura will be appreciated by the sensation conveyed to the fingers of the operator, especially if the integument has been previously incised so as to diminish materially the friction.

"The remainder of the operation consists of getting rid of as much fluid as the strength and condition of the patient will bear, and carefully avoiding the admis

sion of air into the cavity. On withdrawing the trochar, the fluid will at first be found to flow in a steady and equable stream, slightly augmented in force at each expiration. After the lapse of a shorter or longer period, the flow will become checked at each inspiration, and then the body of the patient should be gently lowered into an horizontal posture, and turned slightly on to the affected side, so as to bring the cavity directly over the opening; and in this position he should be duly supported by assistants. The fluid will now recommence flowing in an uninterrupted stream; and when it again begins to flag, a still further quantity may be obtained, if the state of the patient permit it, by directing an assistant to make steady and continuous pressure on the lower part of the chest, by grasping it on either side with the hand."

During the process of evacuation, great attention should be directed to the stream of fluid, which should never be allowed to be completely interrupted during inspiration-the admission of air being immediately indicated by a sucking noise, which cannot be mistaken, and which is the signal for a prompt withdrawal of the canula.

Case 1.-J. P. aged 22, admitted (July 27, 1843) under Dr. Addison, having been subjected to cold while taking mercury for venereal complaints. Ten weeks ago, attacked with pain and tension in the epigastrium-eructations-tenderness on pressure, &c.—succeeded by short and oppressed respiration, hard cough, and mucous expectoration, which continued till admission, when the nose, lips, ears, and fingers were blue or rather livid, with dyspnoea-sense of abdominal fulness, and difficulty of lying on the right side or back. Tongue clean, appetite good, skin dry, bowels regular, evacuations bilious, urine natural, pulse 100, irregular, small, and feeble. Left side of chest more rounded and full than right side, little raised on inspiration, and tender on pressure in the intercostal spaces. It was universally dull on percussion-absence of vibration on speaking. The integuments were œdematous. The respiration was nul on the inferior portion of that side-became tubular as the stethoscope was passed upwards, and puerile, with sonorous sibilant rhonchi above the spine of the scapula. Below the scapula the voice was bronchophonic-and over that bone, egophonic. Nothing remarkable on the right side. The impulse of the heart could not be felt to the left of the sternum, and its sounds were most distinctly heard over the centre of the right side of that bone. Fluctuation in the abdomen-loins and legs oedematous— liver felt below the ribs. To be cupped, and take calomel, opium, and antimony. In four days the gums were affected, and no relief being obtained, fifty ounces of clear straw-coloured fluid were drawn off by the trochar. On cooling it presented a large loose transparent coagulum, floating in some clear serum. After this he had copious expectoration, sometimes bloody, sometimes muco-purulent, with various alterations, for better or worse. Mercury, diuretics, salines and other medicines produced little effect. In consequence of great dyspnoea and distress, the chest was tapped thrice, and on each occasion produced great relief. Afterwards ascites took place, for which he has been several times tapped. On the 6th March, 1844, nearly nine months after coming under treatment, he is able to walk about the ward-can lie, and occasionally sleeps on the right side; but still the effusions continue, the enlarged liver is felt, and there can be little or no hope of final recovery. There can be no doubt, however, that, had it not been for the operation, he would have died long ago.

Case 2.-W. C. a coachman, aged 27 years, had been in Hospital for secondary venereal eruptions. On the 1st Dec. 1842, Dr. Hughes was called to him, in consequence of dyspnoea, without cough or fever-tongue clean, skin natural, pulse feeble. The heart could not be felt in the usual position-its impulse felt on the right side of sternum.

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The entire left side, both before and behind, i. e. as high as the clavicle an