Confining oneself to the specimen, the course of events would appear to be as follows:-When the ligature is applied it forms a deep constriction, which, by the bulging of the tissues on each side, causes the living to come in contact with the strangulated tissues, plastic lymph is thrown out, glueing together the opposing surfaces, and its organisation establishes a vital connection between the two, so that sloughing is prevented. This result is also favoured by the fact that by displacement of the tissues immediately embraced by the loop of the ligature, in course of time the loop ceases to exert any force; and it is possible that the capillaries ultimately become pervious. No sooner has the organisation of the lymph taken place, and the capillaries have become pervious, than the absorbents begin their work and remove not only such portions of the tissues as are unable to maintain their integrity, but the ligature itself yields to the forces at work. The experiments of Drs. Spiegelberg and Waldeyer show that this destructive action begins within a few weeks in the case of the ligature, and the specimen confirms this; while it further shows that the strangulated portion also suffers at an early period. Their experiments do not appear to have been continued to their fullest extent and to ultimate results, but the specimen furnishes a complete account. It shows how the growth of peritoneum completely obliterated all trace of the ligature and wound, and how the interruption of a through current interfered with the nutrition of the proximal portion of the pedicle and subsequently led to atrophy of the included Fallopian tube.

Dr. Bantock concluded by stating that, while entertaining the opinion that the extraperitoneal method by clamp was absolutely superior to all other methods of treatment, his case demonstrated the safety of the ligature; and he should have less hesitation than formerly in adopting the ligature whenever the shortness of the pedicle prevented the application of the external clamp, or involved the risk of retraction of the stump from destruction of adhesions.

ON THE TREATMENT OF EMPYEMA IN

CHILDREN.

By W. S. PLAYFAIR, M.D., F.R.C.P.,

PROFESSOR OF OBSTETRIC MEDICINE IN KING'S COLLEGE; OBSTETRIC PHYSICIAN TO KING'S COLLEGE HOSPITAL, AND PHYSICIAN

TO THE EVELINA HOSPITAL FOR CHILDREN.

WE were told in our late President's farewell address that the subject of diseases of children, which forms an important division of the work of the obstetrician, has not received sufficient attention in this Society.

In deference to that hint I propose to bring under your notice to-night a point of great practical importance in connection with infantile disease. All who see much of children's diseases will admit that pleuritic effusion is far from uncommon, and that it is frequently a very troublesome affection. In its slighter forms it is frequently overlooked, or mistaken for some other complaint. The graver forms, in which there is a large amount of fluid effusion, lead to very serious consequences-debility, emaciation, often lifelong deformity from contraction of the chest-wall over the flattened and unexpanded lung, and not unfrequently to secondary tuberculosis. It is of the utmost importance, therefore, that we should carefully study the best means of managing this affection, with the view of preventing, as far as possible, the very serious results which so frequently ensue. To enter at length, however, into the general question of the treatment of pleuritic effusions is impossible within the short limits into which it is necessary to compress this paper.

I propose, therefore, to confine myself simply to the best mode of managing those cases in which there is a considerable amount of fluid in the pleural cavity, and in which the fluid is purulent; to cases of empyema, in short, as contradistinguished from simple serous pleurisy. In children, as is well known, such cases are much more frequent than in adults. In them pleuritic effusion soon becomes purulent, and often is so from the commencement of the disease. Into

the general question of the advantages of paracentesis I shall not enter. This is a subject which has attracted much attention, and on which the views of the profession have been greatly modified. Of late years the opinion has been steadily gaining ground that even in simple serous effusion, paracentesis, performed in such a way as to prevent the entrance of air into the chest, is not only a perfectly justifiable operation, but one which may be considered practically harmless, and likely to materially lessen the suffering of the patient, as well as shorten the duration of the disease. This view I cordially endorse, but do not now intend to discuss. To those who wish to make themselves thoroughly acquainted with the arguments in its favour, I should recommend a perusal of my friend Dr. Anstie's admirable monograph on pleurisy in the third vol. of Reynolds's System of Medicine,' where they will find all that can be said on the subject fully set forth.

Very little consideration will show that paracentesis in serous pleurisy stands on a very different footing from the same operation in empyema. In the former the physician. taps the chest not to remove the whole of the contained fluid, but so to diminish it as to admit of the remainder being more readily absorbed. That nature is capable in the majority of cases of effecting the entire absorption of the effused fluid is not doubted; but this often requires a long time, and involves a protracted illness. The operation is practised, therefore, to hasten the cure-to facilitate, as it werenature's work. All that is required is, that it should be done in such a manner as to exclude as much as possible the entrance of air. For this purpose, no doubt, Bowditch's syringe, with which that physician has obtained such admirable results, or Dieulafoy's aspirator, which are recommended by Dr. Anstie, are the best instruments at our disposal. But they are complicated and expensive, and not always at hand, and, for all practical purposes, I believe that a small trocar and canula, with an elastic tube attached, opening under water, will answer quite as well.

In empyema, however, the chance of the entire absorption. of the pus, even when a portion of it has been removed, is

reduced to a minimum. I do not mean to say that the fact of the fluid being purulent precludes all hopes of a cure when tapping is not performed; but the chances are comparatively small, and the evil effects of protracted cases of this sort are familiar to all who have studied the subject. I believe that what we should seek by paracentesis in such cases is, not only to evacuate as much as possible of the fluid, but to secure the escape of all the pus subsequently formed; to effect, in fact, a constant drainage of the pleural cavity. Now, all the methods by which this is accomplished, save the one shortly to be described, involve the free admission of air into the sac of the pleura. The one most frequently adopted is, simply to treat the pleura like a large abscess, to lay it open freely by an incision in a depending position, and sometimes to promote the cessation of the discharge in the manner recommended by Trousseau, by washing out the pleura with a solution of iodine.

It was a decided improvement on this rough-and-ready method to introduce a Chaissaignac's drainage tube by two openings, so that the pus should drain away as soon as it was formed.

The great advantage, however, of a plan by which this result could be obtained, and the entrance of air at the same time effectually prevented, will be manifest to all. Whatever we may think of the germ theory, the practical good effect of completely excluding all access of air to the cavity of an abscess can hardly be doubted. How important must this be when the pus-secreting surface is so great as the whole serous lining of one side of the chest! Again, one of the chief objects we seek to effect is, that the compressed and flattened lung may again expand. The more completely it does so the less will be the subsequent shrinking and deformity of the chest. Draw away the pus, and, provided no air enters, there is every hope of the lung regaining its former dimensions, especially in children, in whom the lung is rarely bound down by false membranes, as frequently happens in adults. But lay open the pleura, and subject the lung for weeks or months to direct atmospheric pressure, as is necessary when the plans I have mentioned are adopted,

and you can scarcely be surprised at the permanent collapse of the lung so constantly observed under such circumstances. For these reasons I believe the plan I am about to describe, and for the first idea of which I am indebted to a conversation with my friend Dr. T. J. Walker, of Peterborough, will, I feel confident, materially aid our treatment of these important cases; and, should further experience confirm the good results already obtained, it will have the effect not only of greatly shortening the duration of the illness, but of leaving the patient in a much more favorable condition than has hitherto been possible.

It will enable us to contrast the results following these various methods of treatment if I briefly relate the particulars of two cases, in one of which the old Galenic method of freely laying open the pleural cavity was practically, though not intentionally used, and in the other the continuous drainage with a Chaissaignac's tube, which was first employed in this country, I believe, by Mr. de Morgan. The results in both were extremely satisfactory, insomuch as I believe that the treatment adopted actually saved the lives of both children, which were in extreme peril, but at a cost to their health far greater than in the cases treated by the method of subaqueous drainage.

Annie Webb, æt. 4 years, was admitted into the Pantia Ralli Ward in King's College Hospital on the 11th of July, 1871, under the care of my colleague, Dr. Priestley. The general history of the case I need not relate, but it will suffice to say that all the signs of extensive pleuritic effusion were well marked, the whole left side of her chest was dull, and the breath sounds distant and feeble. Appropriate general treatment was ordered, but the effusion continued to increase rather than to diminish, and the child was reduced to a state of extreme debility. This was her condition when she came under my care at the end of the first week in August, on Dr. Priestley's departure from town. At this time the dulness was almost universal, the intercostal spaces were distinctly bulging, and the heart displaced, so that the