W.Abbotts Smith
1862 The Lancet  
Drs. M'Dowel and Banks at Sir Patrick Dun's and the Whitworth Hospitals, and who was the subject of pleuritis, with effusion on the right side of the chest. In this case the fluid was more than once removed by paracentesis with marked benefit on each occasion. The lad begged of Dr. Banks to repeat the operation, having experienced so much relief to his symptoms when first performed, with improvement to his appetite aud general condition. When the fluid re-accumulated, his breath became greatly
more » ... ath became greatly oppressed ; his face dusky, with impending asphyxia; his appetite failing, and his nights restless. All distressing symptoms in great part disappeared on the repetition of tapping. It was gratifying to see this poor tad, after one such operation. sitting up in bed. staying his dish of mutton broth, and looking so cheerful and free from pain. I have not learned the upshot of these cases; but, even if fatal, there was undoubted evidence of markfd relief to urgent symptoms, quite sufficient to warrant paracentesis. Now a few remarks in conclusion as to the operation and its performance. These who practise and recommend it aSirm that it. is free from risk, and almost painless. We can readily admit that little or no ill effects are likely to follow from the mere penetration of a cavity lined with serous membrane now that ovariotomy has proved comparatively successful and free from danger. The chief point to be observed in eatsuringfavourable results from paracentesis seems to be the speedy closure of the aperture without waiting for the removal of all the effusion, any recurring fluid being soon absorbed. Repeated tapping is to be preferred to allowing the fluid to drain from an uncl03ed aperture, or through a tube left in s?tu. These latter methods will, in some respect, account for the indifferent results of operation I in some bands. The spot selected for puncture must, of course, depend upon the site of effusion, a complete absence being ascertained on auscultation anrl percussion of all signs indicating proximity of the lung in the'part fixed upon for puncture. The upper edge of the sixth rib posterior to the digitation of the seratus major is the part usually chosen. The integuments and intercostal muscular fibres being incised and drawn a little downwards, a small slender trocar should be quickly thrust upwards and inwards through the pleural sac. The pleural membrane is sometimes pushed before the point of the trocar through the want of a little expert manipulation. It will be advisable to use previou&ly an exploratory needle where any doubt exists as to the presence or character of the fluid in the pleural sac, purulent effusion usually requiring the most prompt operative treatment. Pressure should be made on the abdominal and thoracic parietes on the side affected, so as to promote the removal of as much fluid as possible. There have been various contrivances recommended with a view to the exclusion of air, which, however, I believe has been charged with more hurtful effects than may be properly assigned to it. The exclusion of air may be ensured byattaching to the canula a little gut, or other thin membrane, which acts as a valve on the removal of the trocar, and prevents the ingress of air on the patient's coughing, or on the cessation of the flow of fluid. The same object is secured by closing the orifice of the canula with the index finger whilst the lung is being gradually expanded by the ingress of air through the natural channel. A stream of serum will subsequently flow without the back current of air. The whole or chief part of the effusion having been removed, the canula is withdrawn, and the edges of the wound brought together with adhesive plaster. A few turns uf bandage rolled round the chest will prove useful and agreeable to the patient. The operation thus performed gives little pain, is simple, and is, I believe, divested of any injurious consequences. SENIOR ASSISTANT-PHYSICIAN TO THE METROPOLITAN FREE HOSPITAL, SENIOR PHYSICIAN TO THE CITY DISPENSARY, ETC. NOTWITHSTANDING the fact that glycerine is largely used as a bland, emollient application to the skin in several affections of that delicate membrane, its importance as a remedial agent in certain diseases of the conjunctiva appears to be considerably underrated, although several marked points of analogy exist between the two structures. Having been induced some time since by the perusal of a paper published in the Bulletin de Thérapeutique by ll. Foucher upon this subject, I have given a fair trial to the topical employment of glycerine, both uncombined and as a substitute for water in the preparation of collyria ; and the results have been such as to warrant me in recommending its use in some of the forms of ophthalmia. and other supertici;tl affections of the eye. The application of pure glycerine, uncombined, is decidedly advantageous for the prevention and removal of the hhrd crusts produced by irritation which are occasionally closely adherent to the eyelids in ophthalmia, which disorder they consequently tend to perpetuate. In ectropion, and in cises of partial loss of the eyelashes, glycerine forms au agreeable and efficient applicttioM ; and it BMll also be found similarly useful in epiphora, and in any other superficial diseases of the eye which are dependent upon diminished secretion by the Mcibomian glands. Amongst these may be especially mentioned the peculiar condition of the conjunctiva to which Von Ammon gave the name of Xerosis Coujunctive, in reference to the dry, cuticular appearance of the eyeball, and which is most commonly met with in persons of scrofulous diathesis who have long suffered from chronic ophthalmia. The free play of the eye.ids upon the front surface of the eyeball is preserved by the topical employment of the gly. cerine; and the tendency to symblepharon, or to an uncomfortable temporary adhesion of the eyelids, which occurs after sleep, is counteracted. Unctuous applications are always preferabla to watery solations in ophthalmia, both because they are not so readily washed away by the tears, and because they more closely resemble the natural greasy secretion of the Meibotuian glands, by which the conjunctival surface is lubricated in the healthy state ; and the circumstance that glycerine alone, when employed locally, is highly beneiici"tl in the ophthalmic afJ'2ctiol1s already referred to, also points to that substance as a valuable vehicle in the preparation of collyria. M. Foucher enumerates, in his paper in the Bulletin de Thérapeutique, a lor.g list of medicaments with which he has combined glycerine in the treatment of ophthalmia, in numerous cases which had come under his care at the Hôpital des Enfants. The substances which I have found to be most usefully employed in this form are the sulphate of zinc, the sulphate of copper, and laudanum ; but M. Foucher also combines glycerine with the perchloride of iron, with borax, with tincture of iodine, and other agents. It should be here stated that nitrate of silver, owing to the chemical action which ensues upon its coming in contact with organic matter, cannot be used conjointly with glycerine ; and it further remains to be mentioned that the glycerine should be well purified, in which condition it is perfectly neutral, does not possess any odour or taste, and does not produce irritation ' when it is applied to the eye.
doi:10.1016/s0140-6736(02)60939-0 fatcat:apdww3cshjgt3gxxiormc4q3xe