THORACENTESIS; 
WITH 
ILLUSTRATIVE CASES. 
BY 
S. C. CIIEW, M. D., 
PROFESSOR OF THERAPEUTICS AND CLINICAL MEDICINE IN THE UNIVERSITY 
OF MARYLAND, BALTIMORE, MD. 
PREPRINTED FBOM THE NEW YORK MEDICAL JOURNAL, SEPT., 1876.] 
NEW YORK: 
D. APPLETON & COMPANY, 
549 & 551 BROADWAY. 
1876. APPLETONS’ PERIODICALS. 
APPLETONS’ JOURNAL: 
A MONTHLY MISCELLANY OF POPULAR LITERATURE. 
rsTErW" SERIES. 
TWENTY-FIVE CENTS PER NUMBER. THREE DOLLARS PER ANNUM. 
Appletons Journal is now published monthly; it is devoted to popular literature and all matters of 
taste and general culture—published at a price to bring it within the reach of all classes. It contains su- 
perior fiction, in the form of serials and short stories; papers graphically descriptive of picturesque places; 
articles upon men of note, and upon the habits of different peoples; essays upon household and social topics; 
articles of travel and adventure; scientific and,industrial articles written in a graphic and popular style. 
In brief, the aim is to be comprehensive, including in its plan all branches of literature and all themes of 
interest to intelligent readers. Each number is illustrated. 
Terms: 1 hree dollars per annum, postage prepaid, to all subscribers in the United States; or 
I wenty-five Cents per number. A Club of Four Yearly Subscriptions will entitle the sender to an extra 
subscription gratis; that is, five copies will be sent one year for twelve dollars. For $7.20, Appletons’ 
Journal and The Popular Science Monthly (full price, eight dollars), postage prepaid. 
THE POPULAR SCIENCE MONTHLY. 
Conducted by E. L. YOUMANS. 
This periodical was started (in 1872) to promote the diffusion of valuable scientific knowledge, in a 
readable and attractive form, among all classes of the community, and has thus far met a want supplied by 
no other magazine in the United States 
Containing instructive and interesting articles and abstracts of articles, original, selected, translated, 
and illustrated, from the pens of the leading scientific men of different countries; accounts of important 
scientific discoveries, the application of science to the practical arts, and the latest views put forth concern- 
ing natural phenomena, have been given by savants of the highest authority. Prominent attention has 
been also devoted to those various sciences which help to a better understanding of the nature of man, to 
the bearingsof science upon the questions of society and government, to scientific education, and to the 
conflicts which spring from the progressiye nature of scientific knowledge. 
Ihe Popular Science Monthly is published monthly in a large octavo, handsomely printed on 
clear type, and, when the subjects admit, fully illustrated. 
.Terms: $5.00 per annum, or Fifty Cents per Number. Postage prepaid to all Subscribers in the 
United States. 
THE ART JOURNAL: 
A11 International Gallery of Engravings, 
BY DISTINGUISHED ARTISTS OF EUROPE AND AMERICA; 
The Art Journal is a monthly publication, quarto size, superbly illustrated and printed, and specially 
devoted to the world of Art—Painting, Sculpture, Architecture, Decoration, Engraving, Etching, Enam- 
eling, and Designing in all its branches—having in view the double purpose of supplying a complete illus- 
trated record of progress in the Arts, and of affording a means for the cultivation of Art-taste among the 
people. Each number is richly and abundantly illustrated on both steel and wood, and no pains are spared 
to render this “ Art Journal ” the most valuable publication of the kind in the world. It contains the 
Steel Plates and Illustrations of the London Art Journal, a publication of world-wide fame (the exclu- 
sive right of which, for Canada and the United States, has been purchased by the publishers); with exten- 
sive additions devotedpriiicipally to American Art and American topics. Published monthly. Sold 
only by Subscription. Price, 75 Cents per Number; per Annum, postage prepaid. 
Subscriptions received by the Publishers, or their Auents. Agencies: 22 Hawley St., Boston ; 922 
Chestnut St., Philadelphia; 22 Post-Office Avenue, Baltimore; 53 Ninth St., Pittsburg; 100 State St., 
Albany; 42 Statr St., Rochester; 103 State St, Chicago; 30 W. 4th St., Cincinnati; 305 Locust St., St. 
Louis; 20 St. Charles St , New Orleans; 230 Sutter St., San Francisco. 
With Illustrated Papers in the Various Branches of Art. 
Id. APPLETON CO., Publishers, 549 & 551 Broadway, N. Y. THORACENTESIS; 
WITH 
ILLUSTRATIVE CASES. 
s. c. }sJew, m. d., 
PROFESSOR OF THERAPEUTICS AND CLINICAL MEDICINE IN THE UNIVERSITY 
OF MARYLAND. BALTIMORE. Ml). 
IREPRINTED FROM THE NEW YORK MEDICAL JOURNAL. SEPT.. 1876.] 
NEW YORK: 
D. APPLETOY & COMPANY, 
549 & 55 1 BROADWAY. 
1876. THORACENTESIS; WITH ILLUSTRATIVE 
CASES. 
Our knowledge of the pathology and diagnosis of pleurisy 
is so extensive and accurate that the discussion of these sub- 
jects is hardly called for. I shall, therefore, refer to them 
only incidentally in this paper, and consider chiefly some 
questions connected with the treatment of the disease. 
The therapeutic measures proper to the various stages 
and conditions of pleurisy have been the subject of much con- 
troversy, and involve some questions of great interest, about 
which there is even now very earnest dispute. 
The questions I refer to are these: When a pleurisy is en- 
countered in which effusion has taken place to such extent as 
to cause dullness and absence of respiratory murmur over the 
greater part or the whole of one side of the chest, is medical 
treatment to be discarded and the assistance of surgery in- 
voked ? Should the presence of fluid in large amount be con- 
sidered as ipso facto and independently of accompanying cir- 
cumstances an indication for surgical interference ; or is it 
possible to obtain in this stage, from medical means in the 
strict sense, better results than those promised by surgery l 4 
Are we to regard the operation of paracentesis of the thorax 
as in all cases justifiable and advisable when the effusion has 
reached any considerable amount; oris it to be resorted to 
only in certain special conditions, the larger proportion of cases 
being best dealt with by medical means ? 
Of late years, and more especially since the publication of 
Dieulafoy’s work, the operation has been strongly advocated 
as a measure generally applicable to all cases of pleurisy ; but 
I am fully persuaded that the advocac}7 of this measure has 
been carried too far, and that there is need for a recall from 
the shorter and apparently more attractive course of surgical 
procedure to the older and more reliable methods of medicine. 
It is not meant here to undervalue the operation of paracen- 
tesis in cases to which it is really adapted, for it undoubtedly 
affords at times the only hope of restoring the function of 
a lung and thus of ultimately saving life; and, in other 
cases where respiration is seriously embarrassed by a sud- 
den effusion, it may give deliverance to one who is ready to 
perish. 
But with due regard to such cases, and speaking from con- 
siderable personal experience in the operation, and from ob- 
servation of its effects as used by others, I think that there 
are limits beyond which its use cannot be carried except at 
the risk of doing more harm than good. It is as important a 
point of therapeutic knowledge to be aware that many cases 
will recover without tapping as that some imperatively require 
the operation. The application of the principle of pneumatic 
aspiration for the removal of fluid from the closed cavities 
and other deep portions of the body has rendered the surgi- 
cal treatment of pleurisy much simpler than it formerly was, 
and has done away with that special danger of the operation 
which was found in the possibility of air entering into the 
pleural sack. But it is certainly questionable whether the 
very readiness with which the operation is performed may not 
lead to an undue, not to say reckless and dangerous, use of it. 
The ease with which a thing is done may cause a proneness 
to do it; audit, may happen in medicine as in morals that 
“ Oft the sight of means to do ill deeds, 
Makes deeds ill done.” As for the operation of thoracentesis in itself, it is by no 
means a grave one; and while it may accomplish remarkable 
physical results in the removal of a large quantity of fluid,, 
yet, the more obvious and striking these are, the simpler is 
the operation, for the larger the amount of fluid contained in 
the chest, the easier is the diagnosis of the condition, and the 
greater the assurance that the needle or trocar will enter the 
fluid only and will not pierce the lung. 
The real importance of this operation is found in the facts 
that life may be saved by it in conditions of extreme peril, 
and that it presents an available measure when medicine fails 
to give relief. These propositions I shall illustrate presently 
by cases directly in point. As there are conditions, then, in 
which aspiration is not only indicated, but is altogether the 
only resource at our command, it is highly important to deter- 
mine what those conditions are. 
Because it is an advisable and salutary measure in some 
cases, it seems to have been too hastily inferred that it is 
advisable and salutary in all; and there is thus furnished 
another one of the many instances of a tendency to hasty 
generalization, of which the annals of medicine are only 
too full. 
Look at some of them in the past and in the present.. 
Febrile symptoms were found associated with gastric and 
enteric inflammation; and from these cases Broussais too 
quickly inferred that gastro-enteritis is the essential and 
underlying cause of all fevers. 
A congested spleen is often found in malarious disease 
and Piorry, forming a hasty generalization, and adding to 
this the additional fallacy of confounding effect and cause,, 
proclaimed enlargement of the spleen to be the pathological 
condition upon which all the symptoms of intermittent fever 
depend. 
Alcohol is certainly of immense value in certain forms 
and stages of pneumonia and other inflammatory diseases; 
and, through this same tendency to generalize, the stimulant 
school of practitioners have contended that all inflammations 
are to be treated with alcohol as the most potent of apyretics, 
and of universal application in all phlegmatic©. Hasty generalization and illogical inference are no doubt 
the greatest obstacles to real progress in any science. It is 
alleged, and not without some reason, that the advance in 
medicine is not commensurate with that which other sciences 
have made in recent years; yet it would be easy to find, on 
the part of some of the most distinguished votaries of other 
branches of physical science, instances of as shallow philoso- 
phizing as any that have retarded the development of medicine. 
A leader in modern biology maintains that the whole idea 
of the relation of cause and effect is an assumption and a delu- 
sion ; thus denying a primary concept of the mind, because it 
is inimical to his own theory. And another eminent writer, 
who occupies a foremost place among physicists, warns his 
hearers against accepting, on the authority of Newton, a 
proposition relating to spiritual truths, on the ground that 
Newton, having been mainly occupied in a different sphere 
of thought, was disqualified for forming a judgment upon 
such matters. With what incisive force the argumentum ad 
hominum might be directed against himself, this eminent 
writer apparently does not see. 
While we admit that there are shallows and quicksands in 
medical philosophy, we may be pardoned for deriving con- 
solation from the reflection that flippant and foolish reason- 
ing may be quite justly imputed to some who are esteemed 
lights of science beyond the pale of medicine. 
There are three classes of cases in which the question of 
pneumatic aspiration of the thorax must be entertained. 
To return, however, from this digression to our theme. 
I. The first consists of those cases in which a large pleu- 
ritic effusion has suddenly occurred, and has overwhelmed the 
function of one lung before there has been time for the supple- 
mentary action of the other to be brought fully into play ; or 
again, where hvdrothorax, as distinguished from pleuritic 
effusion, has occupied both sides of the chest in such amount 
that respiration is dangerously embarrassed. In this class of 
cases the aspirator must be immediately used, because there 
is no time for medical means to act, and we are to be guided 
not by the auscultatory signs alone, but by the clinical condi- 
tions of the case. II. The second class is composed of cases in which, judg- 
ing from the physical signs alone, we might be tempted to use 
the aspirator, and are certainly bound to examine carefully 
whether the conditions requiring its use actually exist, but in 
which the clinical state is found on such examination not to 
demand immediate interference with surgery. For respira- 
tion may not be seriously embarrassed, even though the effu- 
sion be very large; the rapidity with which it has occurred 
being a more important factor in the production of dyspnoea 
than the amount. In these cases, if the condition has not con- 
tinued long, it is best to use medical means, of which the most 
efficient are the tincture of the chloride and the syrup of the 
iodide of iron in doses of from half a drachm to a drachm; 
and, notwithstanding that their efficac\T is denied by some 
distinguished authorities, I make bold to urge the repeated 
application of fly-blisters. These agents are, I am sure, of 
great value ; whether they act by a direct stimulant influence 
upon the absorbents, or by merely removing serum from the 
capillaries of the chest-wall, and thus rendering them better 
instruments for absorption, or yet, again, by an action on the 
vaso-motor nerves, are questions of interest, it is true, but of 
secondary importance to the general one as to whether they 
do good clinically; and, that they do, I am fully convinced. 
For, though I have used them always of late years in conjunc- 
tion with iron, yet I have seen the line of dullness fall so 
rapidly under this treatment as to feel sure the change was 
due more to the blistering than to the small amount of iron 
as vet taken. Yet the ferruginous medicines perform an im- 
portant part by increasing the solid elements of the blood, 
and thus lessening the tendency to transudation, while, in 
virtue of their diuretic action, they help to remove what has 
already accumulated. 
But it is contended by some that, even in these cases where 
there is no urgent need for interference, results better, because 
quicker, can be gotten by an immediate resort to aspiration, 
instead of waiting for the slower influence of medicine. It 
should, however, be borne in mind, that in adopting the 
medicinal treatment we are effecting relief in the same way 
as when the case recovers spontaneously. If the vessels of the pleural surfaces, on the removal of 
the fluid, remain still in the same condition in which they 
were when it was effused, it will continue to be formed, and 
the operation must needs be repeated as long as the effusion 
goes bn; whereas, when the removal takes place by absorp- 
tion, the pathological action is changed, and the tendency to 
effusion has ceased. 
Again, if adhesion of the compressed lung has taken place,, 
the sudden entrance of an increased amount of blood into the 
vessels of the lung, and of air into its vesicles, may produce a 
strain upon the lung tissue left unsupported by the withdrawal 
of the fluid that has been pressing on its surface; and thus 
may be explained the sense of painful constriction, with ten- 
dency to syncope, from which patients sometimes suffer under 
these circumstances. This occurrence, so often observed in 
cases which ultimately do well, may indicate in less degree a 
condition of things which in greater degree may prove dan- 
gerous. 
Deaths occurring suddenly or rapidly, during or shortly 
after the operation of thoracentesis, have been reported in 
French medical journals within the last year, and have given 
rise to important discussions in the Medical Society of Paris 
and in the Pathological Society of London. Opinions have* 
varied as to the way in which the operation may have occa- 
sioned death, some attributing it to cardiac syncope, from the 
withdrawal of accustomed pressure on the heart—others to 
cerebral anaemia, from the rapid afflux of blood to the ex- 
panded lung. 
The statement has been made, and a most significant one 
it is, if proved by accurate statistics to be true, that there has 
been an increase in the mortality from pleurisy since thora- 
centesis has been more generally practised. Granting this to 
be true in even greater degree than is at all likely, it would 
not follow that the operation should be abandoned, for the 
greatest triumphs of surgery are won by operations admitted 
to be perilous, but affording a prospect of rescue from greater 
peril. But the consideration, of even slight danger should 
teach us that thoracentesis is not to be used indiscriminately 
as a thing of mere routine; and it should certainly make us- 9 
give due weight to what can be accomplished by medicinal 
means, in imitating and aiding the curative action of nature. 
For nature cures pleurisies, in the many cases in which they 
get well spontaneously or under the influence of medicine, 
by the fluid being absorbed and not directly evacuated. 
III. The third class of cases consists of those in which, as 
in the first class, thoracentesis is plainly required as the only 
means likely to afford relief. Into this category some cases 
belonging to the second class just spoken of may pass; cases, 
that is, in which although at first there may have been a well- 
founded belief or hope that they would recover under medical 
treatment, yet either this hope has been proved by time to be 
fallacious, or the cases when first seen by the physician have 
manifestly passed beyond the period within which it would 
be worth while to wait longer for the action of medicine. 
For here there may be risk of ultimate danger accruing to 
the lung through long-continued pressure causing carnifica- 
tion. In this third division I would place also those cases in 
which there is good reason to believe that the effusion is puru- 
lent ; hence the importance of being able to decide this ques- 
tion with certainty; for, the purulent nature of the fluid once 
determined, it is useless to continue medication with a view 
to its removal. Nothing remains but mechanical evacuation. 
In any case where the fluid is suspected to be pus, an explora- 
tory puncture may be made with a fine aspirating needle, 
which may thus be a diagnostic as well as a therapeutic 
means. 
But it is sometimes desirable to determine this question 
beforehand, inasmuch as a patient may be more willing to 
submit to the operation, if he knows that the fluid is of such 
character that absorption cannot be expected. 
With this view, the method recently suggested by Prof. 
Baccelli, of Rome, certainly promises assistance to our diag- 
nostic means. “ It is founded on the physical law”—I quote 
from the article on the subject in the Medical Times and 
Gazette of March 18, 1876—“ that the vibrations of sound in 
liquids are transmitted inversely to their density. In a serous 
fluid, therefore, the sound passes more readily than in a puru- 
lent ; and it is found that whereas the whispered voice can be heard clearly, accompanied with bronchial expiration at 
the base of a serous effusion, the spoken voice is not trans- 
mitted, nor bronchial breathing heard over & purulent exuda- 
tion.” Perhaps this is a somewhat exaggerated statement of 
the case, but there is certainly a marked difference in the vi- 
brations transmitted through the two fluids respectively. We 
have, therefore, in feebleness or absence of vocal or respira- 
tory sounds, a highly probable indication that the fluid is pus, 
and an earlier sign of empyema than the occurrence of hec- 
tic fever, the continued presence of the unabsorbed effusion, 
and other general symptoms. 
The several conditions, then, which 1 would group to- 
gether in the third class as clearly requiring the use of the 
aspirator, are these : 
1. Where the purulent character of the effusion is indi- 
cated with certainty or with high probability. 
2. Where an effusion reaching half-way up one side of the 
thorax is undiminished by medical treatment persistently ap- 
plied for three or four weeks; and, a fortiori, if it have in- 
creased in spite of such treatment. 
3. Where with a large effusion, previously not alarming 
in character, sudden and urgent dyspnoea has occurred. Lives 
have, no doubt, often been lost from the operation having been 
delayed or not performed in such conditions ; but, with its 
use, under the most threatening circumstances, prompt relief 
and deliverance have many times been given. 
The following cases are selected as illustrations of the 
principles of treatment that have been referred to, and of the 
conditions which are to be regarded as respectively indicating 
or not indicating the use of the aspirator. As to the first 
class, I would remark that they very seldom require tapping; 
and I have never had occasion to use this measure in treating 
such cases. The urgent dyspnoea which sometimes comes on 
early in pleurisy, even when the amount of effusion is not 
large, generally abates pretty soon by the supplementary ac- 
tion of the other lung being established ; and it may often be 
promptly relieved by an hypodermic injection of morphia; and 
cases of hydrothorax are in general better treated by diuretics 
or hydragogue cathartics, especially elaterium, which drains away the fluid with astonishing rapidity, and thus produces 
marked relief. But, when the pleuritic effusion is at once 
very large in amount and rapidly poured forth, it may become 
necessary to tap from the urgency of the symptoms; and in 
hydro thorax there may be occasionally need for the same in- 
terference when the effusion rises rapidly on both sides. Such 
cases are, however, exceptional. 
Case I.—W. S., about twenty-five years of age, entered the 
hospital of the University of Maryland, in my service, on the 
26th of February, 1876, complaining of slight shortness of 
breath, which had not been preceded by pain nor caused him 
to suspect any serious trouble in the chest, lie had been much 
exposed to wet and cold in prosecuting his business, which was 
that of an artesian-well borer. 
On examining his chest I found the left side flat upon per- 
cussion from diaphragm to clavicle ; vocal fremitus absent; 
respiratory murmur inaudible; and on the right side puerile 
respiration well marked. On measurement the left side 
was found to exceed the right in bulk by one inch and a quar- 
ter. The physical signs thus showed plainly the existence of 
large pleural effnsion ; but as there was little discomfort, and 
the-dyspnoea was so slight that the patient could sleep all 
night in the recumbent posture, the clinical condition did not 
require the use of the aspirator, and I determined to try med- 
ical treatment alone, directing thirty minims of the syrup 
ferri iodidi to be taken three times a day, and a fly-blister, six 
by eight inches, to be applied to the lateral and posterior sur- 
face of the left side. The blister drew freely ; and, before the 
surface to which it was first applied had healed, it was again 
placed upon the anterior part of the same side. In five or six 
days from the commencement of treatment the dullness under 
the left clavicle had sensibly diminished, and a respiratory 
murmur of a bronclio-vesicular character was feebly audible. 
This was regarded as an indication for persevering in the 
medical treatment, and fortified the opinion that aspiration 
was not required. The iron was continued, and the blister re- 
appb'ed at different places several times. 
In three weeks the line of dullness had fallen to the top of 
the middle third of the chest, respiratory murmur being dis- 12 
tinct above that line ; and the difference in bulk between the 
two sides was reduced to three-quarters of an inch. The dull- 
ness continued to diminish slowly, and vesicular murmur be- 
came more generally diffused over the chest, when on the 15th 
of April the patient left the hospital, still presenting at that 
time some dullness and feebleness of respiratory murmur at 
the base of the left side. On the 1st of June he returned for 
examination, when all signs of the effusion had disappeared. 
The case is interesting as presenting a condition in which the 
auscultatory signs alone would suggest the use of the aspirator, 
while the general clinical condition warranted the trial of 
medical means, under which perfect recovery took place. 
Case II.—D. W., about twenty-eight years of age, came to 
my office to consult me on the 15th of October, 1875. He had 
recently returned from travel in Europe, and, though of rather 
delicate constitution, had enjoyed pretty good health until about 
ten days before he applied to me, when being overheated by a 
long walk he lay for some time upon the damp grass, and in 
a few days began to experience shortness of breath, chiefly 
noticeable on going up-stairs. He had had no chill, and, hav- 
ing felt no pain in the chest, he was surprised when I in- 
formed him that his right side was the seat of large effusion. 
This was rendered evident by dullness throughout its whole 
extent, absence of respiratory murmur and vocal fremitus, and 
the existence of well-marked cegophony at the upper part. 
Under the use of syrup f'erri iodidi and the repeated applica- 
tion of blisters, improvement in resonance in thesubclavicular 
region, with distant and feeble respiratory sound, became evi- 
dent in about ten days. At the end of three weeks the dull- 
ness was limited to the lower part of the posterior region of 
the right side, and was attributable mainly to thick, fibrinous 
deposit, inasmuch as vesicular murmur was comparatively 
clear. The patient made a good recovery, and has lately gone 
again to Europe. 
This case, like the last, was one of latent pleurisy, in 
which the auscultatory signs showed effusion so large as to 
suggest the possible necessity of aspiration, but which never- 
theless cleared up perfectly under medical treatment. 
Case ILL—H. Y., aged about forty-five years, a native of 13 
Alsace, presented himself at my clinic at the University Hos- 
pital, May 23, 1876, suffering with urgent dyspnoea, about 
the origin of which he gave no clear account, but which, ac- 
cording to his report, had increased to such degree that for 
four months he had been unable to lie down. On inspection, 
the right side was manifestly larger and more rotund than the 
left, its measure being an inch and a half greater, and the in- 
tercostal spaces were effaced. Percussion sound was perfectly 
flat on this side from the base to the summit of the chest; 
respiratory murmur and vocal fremitus were imperceptible, 
and the heart was displaced beyond the left mammary line. 
The physical signs thus established the diagnosis with preci- 
sion ; but the clinical condition put the case in a different 
category from those related above, and demanded mechanical 
relief; for, with such impairment of respiration, rapidly fatal 
dyspnoea might occur at any moment, and the danger was in- 
creased by the dislocation of the heart, and the great pressure 
to which it was subjected. I therefore decided to aspirate the 
chest; and, introducing a No. 2 needle in the eighth inter- 
costal space, just below the angle of the scapula, I drew off 
eighty-one ounces of yellow serum, in which pus corpuscles 
were beginning to appear, but were not present in sufficient 
number to give the fluid a purulent character. The patient 
bore this without the least sense of constriction, such as is 
often felt when so large an amount is removed at once. The 
lung expanded somewhat, but not perfectly, after the removal 
of the fluid, the respiratory sound being plainly audible, but 
distant and bronchial in character; the heart removed par- 
tially but not completely into its normal place. But the 
•clinical condition was immensely improved ; the dyspnoea, 
which had been extreme, disappeared entirely, and on that 
night the patient slept lying on his back, for the first time, as 
he assured me, for four months. In six days he left the hos- 
pital, declaring that he felt well, and has not returned. 
In this case the operation was resorted to, not so much as 
a curative means, as for the purpose of rescuing the patient 
from great peril—which was accomplished. Life was, I be- 
lieve, saved by the operation, and could have been saved by 
no other means; but the functional integrity of the lung was 14 
not restored, as it was in the two former cases, in which medi- 
cal means alone were used. 
Case IY.—On the 9th of August, 1875, I was requested 
by Dr. J. E. Gibbons, of this city, to see with him a little boy, 
aged three years and eleven months, who was the subject of 
empyema of the right side, for which he had already been 
tapped with the aspirator three times, twice by Prof. W. T. 
Howard, and once by Prof. F. Donaldson. Learning that 
each operation had been followed by reaccumulation of the 
purulent fluid, I determined, before resorting to a drainage- 
tube, to try the effect of an injection into the chest-cavity, 
with the view of altering the condition of the pleural surfaces, 
and, if possible, bringing about adhesive inflammation. The 
entire right side was flat upon percussion, the intercostal spaces 
distended, and the breathing labored and accompanied with 
incessant cough. I introduced the needle of the aspirator 
near the angle of the scapula, and removed forty ounces of 
pus, a quantity which would very completely fill one side of 
the chest in a child of this age. There was evidently no ad- 
hesion, for the lung expanded freely, loud respiratory murmur 
and perfect resonance being at once established. 
Without removing the needle the action of the pump was 
now reversed, and three ounces of tepid water injected, con- 
taining one drachm of the following solution : 
Liq. iodinii comp., § ij. 
Acid, carbolic., 3 ss. M. 
The dyspnoea was at once relieved by the tapping, as it had 
been by the previous operations; blit for several days there 
was high fever, probably attributable to the injection. By 
September 10th, reaccumulation had, however, taken place to 
such degree that another operation was necessary, which was 
performed by Prof. Donaldson. It was noticeable that the 
fluid had undergone a change in character, being of thinner 
consistency than before; and from this time the child recov- 
ered perfectly, and is now entirely well, as is shown both by 
the general condition and appearance, and by the normal 
respiratory murmur and resonance over the whole of the pre- 
viously affected side. 15 
This case is of peculiar interest, from the age of the pa- 
tient, the very large purulent drain from the system—two 
hundred and eight ounces in all—and the entire restoration 
of the function of the lung. 
Dr. Peacock, of Victoria Park Hospital, London, has 
lately published a case of empyema in a child three years and 
a half old, relieved by paracentesis, but resulting in contrac- 
tion of the side and a fistulous opening. In the case I have 
here reported, the contour of the chest and the action of the 
lung are as perfect as though no disease had ever existed ; 
and I am inclined to attribute the result mainly to the iodine 
and carbolic acid injection ; for although the thorax filled up 
once more after this application, yet the appearance of the 
fluid at the last tapping showed that an alterative influence 
had been exercised upon the secreting surfaces, so that, when 
they were again brought into contact with each other, adhe- 
sion probably took place. Boinet was, I believe, the first to 
employ iodine injections in chronic pleurisy, and he claimed 
that with them “ cures were possible even in cases supposed 
to be necessarily mortal.” Ilis practice was followed by M. 
Aran in France, and by Dr. Brainard in this country. This 
latter gentleman reported, many years ago, a case of empyema 
caused by a wound with a knife, in which a solution of one 
grain of iodine and three grains of iodide of potassium in an 
ounce of water was injected into the pleural sac twice a day, 
with perfect success. 
Many other cases have been reported, with results similar 
to what occurred in the child whose history is here recorded. 
I think it best to make nse of the iodine injection several 
times, without resorting too early to the drainage-tube, which 
at best leaves a fistulous opening of long continuance. The 
aspiration facilitates the injection very much, as all that is 
required is to reverse the pump without withdrawing the nee- 
dle. I have never known a more gratifying therapeutic suc- 
cess than the case of this little child has afforded ; for what 
with extreme dyspnoea, incessant cough, hectic fever, and ab- 
dominal dropsy, with anasarca from pressure on the great 
veins, it presented almost as hopeless a prospect of relief as I 
have ever had to contemplate ; and it is now perfectly wTell. MEDICAL WORKS 
PUBLISHED BY D. APPLETON & CO. 
Auntie on Neuralgia. 1 vol., 12mo Cloth, $2 66 
Bartholow’s Treatise on Therapeutics 
Barker on Puerperal Diseases. 1 vol l( 5 UU 
Barker on Sea-Sickness. 1 vol., lfimo 4l 
Barnes’s Obstetric Operations. 1 vol., 8vo t 4 50 
Belle cue and Charity Hospital Deports. 1 vol., 8vo 4 00 
Brnnet’s Winter and Spring on the Mediterranean. 1 vol., 12mo 3 60 
Rennet on the Treatment of Pulmonary Consumption. 1 vol.,8vo ‘ 1 50 
Billroth’s General Surgical Pathology and Therapeutics. 1 vol., 8vo... 5 00 
Sheep, 6 00 
Bastian on the Common Forms of Paralysis from Brain Diseases.... 1 75 
Bnlkley’s (L. D.) Acne; its Pathology, etc (In press.) 
Combe on the Management of Infancy. 1 vol., 12mo Cloth, 1 50 
Carpenter’s Mental Physiology ,•••••••• 3 °V 
Chauceau's Comparative Anatomy of the Domesticated Animals. Ed- 
ited by George Fleming, F.R. Gh S., M. A. I. 1 vol., 8vo, with 450 Illustrations t 6 00 
Davis’s (Henry G.) Conservative Surgery “ 3 00 
Dickson on Medicine in Delation to the Mind - 
Flliot’s Obstetric Clinic. 1 vol., 8vo 4 50 
Fcker’s Convolutions of the Brain ••••••■•■ • \ ~ 
Flint’s Physiology. 5 vols., 8vo Cloth, per vol., $4 50; Sheep, 5 50 
Flint’s Text- Book ’of Human Physiology. 1 vol., 8vo Cloth, $6 00 ; “ 7 00 
Flint’s Manual on Urine. 1 vol., 12mo Cloth, 1 00 
Flint’s Delations of Urea to Exercise. 1 vol., 8vo * “ t 00 
Frey’s Histology and ills to-Chemistry of Man “ 5 00 
Hoffmann’s Manual of Medicinal Chemicals “ 3 00 
Holland’s (Sir Henry) Decollections of Past Fife. 1 vol., 12mo “ 2 00 
Jloice on Emergencies. 1 vol., 8vo 
Hone on the Breath, and the Diseases which give it a Fetid Odor 100 
Huxley on the Anatomy of Vertebrated Animals. 1 vol “ 2 50 
Huxley and You ma ns’s Physiology and Hygiene. 1 vol., 12mo “ j *5 
Hammond’s Insanity in its Delations to Crime. 1 vol., 8vo ‘ 100 
Hammond’s Disease's of the Nervous System. 1 vol., 8vo Cloth, $6 00; Sheep, 7 00 
Hammond’s Clinical Lectures on Diseases of the Nervous System. 1vol., 8vo. 3 50 
Hamilton’s (A. McL.) Electro-Therapeutics. 1 vol., 8vo Cloth, 2 00 
Johnston’s Chemistry of Common Life. 2 vols., l2mo “ « 00 
Letter man’s Recollections of the Army of the Potomac. 1 vol., 8vo 1 00 
Lewes’s Physiology of Common Life. 2 vols., 12mo ‘ 3 00 
Markoe on Diseases of the Bones. 1 vol., 8vo 4i 4 60 
Ma ad step on the Mind. 1 vol., 8vo i4 3 
Maudsley’s Body and Mind, 1 vol., 12mo.. 1 00 
Maudsley on Responsibility in Mental Disease u * 50 
Meyer’s Electricity. 1 vol., 8vo ••• • ■ ,, “0 
Niemeyer’s Practical Medicine. 2 vols., 8vo Cloth, 00; Sheep, 11 00 
Neftel on Galvano-Therapeutics. 1 vol., 12mo Cloth, 1 50 
Nightingale’s Notes on Nursing. 1 vol., 12mo u . I? 
Neumann on Skin Diseases. 1 vol., 8vo 4 UU 
New York Medical Journal $4 00 per annum. Specimdn copies, 35 
Paget’s Clinical Lectures and Essays. 1 voL, 8vo Cloth, 5 00 
Peaslee on Ovarian Tumors. 1 vol., 8vo ' o 
Pereira’s Materia Medica and Therapeutics 1 vol., Svo.. ..Cloth, 00; Sheep, 8 00 
Richardson’s Diseases of Modern Life. 1 vol., 12mo Cloth, 2 00 
Sayre’s Club-Foot. 1 vol., 12mo ■■■■ ;•••• ‘ 1 00 
Sayre’s Orthopedic Surgery. With the Operations incident to Deformities 
With numerous Illustrations— Cloth, $5 00; Sheen, 0 00 
Sehroeder on Obstetrics. 1 vol., 8vo Cloth, 6 ou 
Steiner’s Compendium of Children’s Diseases 3 5U 
Stroud’s Physical Cause of the Death of Christ. 1 vol.,12mo ‘ OU 
Sicett on Diseases of the Chest. 1 vol.. Svo 3 OU 
Simpson’s (Sir Jas. Y.) Complete Works. Vol I. Obstetrics and Gynae- 
cology. Svo. Yol. II. Anaesthesia, Ilospitalism, etc. 8vo. Vol. III. The Dis- 
eases of Women i*er V°L Cloth, $3 CO ; Sheep, 4 00 
Tilt ’s Uterine Therapeutics. 1 vol., 8vo Cloth, 3 5U 
Fan Daren on Diseases of the Rectum. 1 vol., 12nio....................... i 50 
Fan Buren A- Keyes’s Genito- Urinary Diseases, with Syphilis. Cloth.$5; Sheep, 6 00 
Fogel’s Diseases of Children 1 vol.. 8vo Cloth, $4.50; 5 50 
Wells on Diseases of the Ovaries. 1 vol.. 8vo Cloth, 0 00 
Wagner’s Chemical Technology. 1 vol., 8vo 5 UU 
Walton’s Mineral Springs of the United States and Canada. W ith Anal- ( 
yses and Notes on the Prominent Spas of Europe * 
*** Any of these works will be mailed, post-free, to any part of the United States, on receipt 
sf the price. 
A large and carefully-selected stock of Medical Works, American and Foreign, constantly on 
hand. Descriptive Catalogue forwarded on application. 
Physicians desiring to have their names inserted in our Medical Directory of the United States and 
Canada, will please send them in full, with addresses. No charge. 
D. APPLETON & CO., Publishers, 549 & 551 Broadway, New York. APPLETO N S’ 
AMERICAN CYCLOPAEDIA. 
NEW REVISED EDITION. 
Entirely rewritten by the ablest writers on every subject. Printed from new typeT 
and illustrated with Several Thousand Engravings and Maps. 
The work originally published under the title of The New American Cyclopaedia vras 
completed in 1863, since which time the wide circulation which it has attained in all parts of 
the United States, and the signal developments which have taken place in every branch of 
science, literature, and art, have induced the editors and publishers to submit it to an exact 
and thorough revision, and to issue a new edition entitled The American Cyclopaedia. 
Within the last ten years the progress of discovery in every department of know'ledge 
has made a new work of reference an imperative want. 
The movement of political affairs has kept pace with the discoveries of science, and their 
fruitful application to the industrial and useful arts and the convenience and refinement of 
social life. Great wars and consequent revolutions have occurred, involving national changes 
of peculiar moment. The civil war of our own country, which was at its height when the 
last volume of the old work appeared, has happily been ended, and a new course of com- 
mercial and industrial activity has been commenced. 
Large accessions to our geographical knowledge have been made by the indefatigable 
explorers of Africa. 
The great political revolutions of the last decade, with the natural result of the lapse of 
time, have brought into public view a multitude of new' men, w'hose names are in every 
one’s mouth, and of whose lives every one is curious to know the particulars. Great bat- 
tles have been fought, and important' sieges maintained, of which the details are as yet 
preserved only in the newspapers, or in the transient publications of the day, but which 
ought now to take their place in permanent aud authentic history. 
In preparing the present edition for the press, it has accordingly been the aim of the 
editors to bring down the information to the latest possible dates, and to furnish an accurate 
account of the most recent discoveries in science, of every fresh production in literature, and 
the newest inventions in the practical arts, as well as to give a succinct and original record 
of the progress of political and historical events. 
The work has been begun after long and careful preliminary labor, and with the most 
ample resources for carrying it on to a successful termination. 
None of the original stereotype plates have been used, but every page has been printed 
on new type,*forming in fact a new Cyclopaedia, with the same plan and compass as its 
predecessor, but with a far greater pecuniary expenditure, and with such improvements in 
its composition as have been suggested by longer experience and enlarged knowledge. 
The illustrations, which are introduced for the first time in the present edition, have 
been added not for the sake of pictorial effect, but to give greater lucidity and force to the 
explanations in the text. They embrace all branches of science and of natural history, and 
depict the most famous and remarkable features of scenery, architecture, and art, as well as 
the various processes of mechanics and manufactures. Although intended for instruction 
rather than embellishment, no pains have been spared to insure their artistic excellence; 
the cost of their execution is enormous, and it is believed that they will find a v'elcome re- 
ception as an admirable feature of the Cyclopedia, and worthy of its high character. 
This work is sold to subscribers only, payable on delivery of each volume. It is now- 
completed in sixteen large octavo volumes, each containing over 800 pages, fullv illustrated 
with several thousand Wood Engravings, and with numerous colored Lithographic Maps. 
PRICE AND STYLE OF BINDING. 
In extra cloth, per vol. .... $5.00 
In library leather, per vol. . . . 6.00 
In half turkey morocco, per vol. . . 7.00 
In half russia, extra gilt, per vol. . $8.00 
In full morocco antique, gilt edges, per vol. 10.00 
In full russia, per vol. . . ■ .10.00 
*** Specimen pages of the American Cyclopaedia, showing type, illustrations, etc., 
will be sent gratis, on application. 
D. APPLETON & CO., Publishers, 
549 & 551 Broadway, New York.