think it rational and scientific, and in harmony with physiological and pathological principles to cleanse an abscess wherever it be found.

Anstie thinks that in a majority of cases the only thing necessary is to wash out the cavity with simple tepid water, and advises the use of tincture of iodine in cases where the discharge is fetid. Fräntzel says: "That a few days after the operation, simple water should be replaced by a solution of common salt, 2 grs. to the ounce. Should this prove insufficient, compound tincture of iodine, or a solution of permanganate of potash, 1 gr. to the ounce, or carbolic acid, 2 grs. to the ounce, will prove serviceable." Lucas-Championnière recommends solution of boracic acid or weak solution of chloride of zinc. König recommends carbolic acid injections of 2 to 5 per cent. strength, as they are much less liable to cause poisoning than weaker ones, as they cause coagulation.

The great antiseptic is the bichloride of mercury, and I have used it with good results in strength from 1 to 8,000 to 1 to 2,000. When the side is so collapsed that the ribs are very near each other, or where the drainage tube will not secure complete disinfection, it becomes necessary to resect one or more ribs. The operation appears to have been first employed in this country by Dr. Warren Stone, of New Orleans. The operation has since been recommended by Roser, Paltary and Estlander, and practiced with good results by numerous surgeons, including T. G. Richardson, Simon, Taylor, House, Thomas, Ashby, Marshall, König, Wagner, Lange, Fenger, Bruglocher and J. W. White. -International Encyclopædia of Surgery, '54, p. 463. The operation permits the introduction of the finger, or even the entire hand, for exploration and breaking up adhesions, so that no separate pockets of pus may remain, and irrigation may be complete. It also facilitates the proximation of the chest walls and collapsed lung.

The simple operation of thoracentesis is sometimes followed by alarming or even fatal results. Two classes of accidents

result from the operations for empyema; immediate, and due to causes connected with the operative procedure, or with the condition of the thoracic organs; and reflex, which occur usually within the first month as monoplegia, hemiplegia, and similar results. The reflex accidents are mentioned by Hoffman, Raymond, Lefine, Goodhart, J. Simon and others, but are no contradictions to the operation.

As to the immediate accidents, M. Sevester says: "Death may occur either suddenly or after some hours or days, but it is of such exceptional occurrence, when compared with the number of times that thoracentesis is performed, that it cannot reasonably be considered a contra-indication to the operation. Proper precautions, however, should always be taken, especially in debilitated or very impressionable individuals; the pain, which is ordinarily insignificant, should be avoided as much as possible, and in order to accomplish this a small trocar should be used; the fluid should also be withdrawn slowly, so as to avoid the sudden afflux of blood to the lungs. Finally, the patient should be cautioned to lie quiet after the operation."

A review in the Medical Times and Gazette gives the following reasons for doubting that the operation or injection causes death. "(1). Sudden death has occurred in simple pleurisy as well as during other diseases, such as typhoid fever and cancer. (2). There has been no uniformity in the stage after thoracentesis at which sudden death has occurred. (3). There has been no uniformity in the mode of death, nor in the pathological conditions found after death."

The antiseptic method I advocate, so far as it relates to cleanliness of hands, instruments, patient, and surroundings. Large quantities of carbolized oakum, or other antiseptic dressings should surround the parts to catch the discharge.

I do not lay down cast-iron rules. Any particular method of operation, and after treatment, should depend on the nature of the individual case. I am aiming at a general principle.

The conclusions I sum up as follows:

1. Expectant and medical treatment cannot be relied on in

empyema.

2. Aspiration is only palliative, except possibly in children.

3. Free drainage and cleansing the cavity is the treatment. This is accomplished by free incision at the lowest part of the purulent collection and inserting a drainage tube. If double incision be made, the tube should pass around two or more ribs. The effect is (a) prompt relief to the mechanical impediment to respiration; (b) diminution of the danger of internal perforation ; (c) less danger of septicæmia; (d) the membranes have an opportunity to heal or become united; (e) it allows applications to be made, in case the necessity should arise; (ƒ) it diminishes the chances for developing pneumothorax.

4. Continuous drainage is preferable to intermittent, as the danger of absorption is less, and the cavity is in better position to heal.

5. Where there is a double opening to permit the escape of pus as it forms, and where the pleural cavity can be daily washed out with some disinfecting fluid, the danger from admitting nondisinfected air disappears.

6. The danger of sudden death during the operation is so slight that it may practically be disregarded, and can probably be lessened by using an anæsthetic.

7. For injections, carbolic acid is not in favor, but tincture of iodine, salicylic acid, permanganate of potassium, and bichloride of mercury are used.

8. Strict antisepsis is to be observed.

9. When you have a case of empyema, operate, and then give your case unceasing attention and inexhaustible patience, and you will have the sublime satisfaction of being instrumental in saving human life.

OBSERVATIONS ON THE ADMINISTRATION

OF CHLOROFORM.

BY T. J. SULLIVAN,

Assistant to the Professor of Surgery, Ann Arbor.

In response to a request to read a paper at this meeting, I have chosen the "Administration of Chloroform," a subject which I trust will interest this Society. My aim throughout has been to write briefly, and, I hope, state intelligently the methods in use at our hospital, and in private practice, of administering chloroform, and again, to show the class of patients to whom we administer it when an anæsthetic is required; also to point out the dangers encountered in its administration, and to indicate the best manner of meeting dangerous signs when present.

The preparation of a patient for the administration of chloroform should, if possible, receive proper attention. The stomach should be empty, bowels regular, all tight clothing about the thorax and abdomen loosened, and artificial teeth removed. The patient should be placed in the recumbent position, with head slightly elevated, and so placed that the chin will not press upon the trachea, and the arms placed at the side, thus affording every means for easy and full respiration. The meal taken in anticipation should be light and liquid in character, and abstinence is requisite for from five to six hours previous to administration. It is objectionable for a patient to abstain for from ten to twelve hours, as it may lead to weakness and thus produce syncope. With a full stomach the administration of chloroform is frequently followed by shallow respiration, a dusky countenance, weak or irregular pulse, which, if allowed to pass unnoticed,

will, if the administration is continued, terminate in death; and again, when vomiting takes place, the food may regurgitate and pass into the trachea, thus causing asphyxia. Stimulants are unnecessary except in old and debilitated people, as they cause undue excitement, and are apt to produce vomiting while the patient is under the influence of the anaesthetic.

It is a well settled fact that chloroform vapor should always be well diluted with air, as vapor in a condensed form, when inhaled, enters the blood rapidly, and may cause immediate arrest of the heart's action and death. In 1864 a committee of the Medical and Surgical Society of London reported that four and one-half per cent. of vapor is the maximum which a patient can inhale with safety. The idea of administration is best carried out by giving the chloroform drop by drop and spread out over a loose cloth, through which the air can pass freely. A two ounce bottle with two tubes so arranged as to furnish a continuous drop is all that is required. A rectangular wire frame, covered with one thickness of surgeon's patent lint, forms one of the simplest and best inhalers it is possible to obtain. A person supplied with these two articles, and an ordinary dressing forceps to pull out the tongue, has all the appliances necessary. The paper or tin cone, and all other forms of inhalers which interfere with the free passage of air, are to be condemned as dangerous. It is best to commence the administration by placing the inhaler over the patient's face entirely free from the anæsthetic, and after an inhalation or two, begin by dropping slowly on the inhaler, and increasing the frequency in the course of a half minute or so.

At the beginning of an inhalation it is unwise to hold or strap a patient to the table, as it causes fright, but you can by a few encouraging words direct him to breathe naturally and easily. By holding the inhaler with the left hand and placing the fingers on the facial artery, we have the pulse and cerebral circulation under direct observation at all times. This, together with free entrance and exit of air from the lungs, and a clear countenance,