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Show 236 or nu: PARACENIESIS manners. or THE mnsccnrnsrs monitors. then rigors and more Oppression, a teazing cough, and hectic. There is an oppression and difficult breathing in the recum. bent posture, and an inability of lying on the side affected. But the side afl‘ected must be distinctly larger than the other. There must be a softness and oedematous state of the tion of matter has taken place, the cavity of the chest is dis skin on the whole of that side, before the operation can be thought of ; or, better still if there is a heaving up, and separation of two of the ribs, and a distinct pointing of the matter. If the matter points thus, there the operation is to be done; but if we adventure on it, where there is only a general 237 minished, the diaphragm rises much higher than usual. So that I have opened a body where it was in contemplation to perform the operation for empyema; and where, if the opening had been made betwixt the sixth and seventh rib, they must have cut into the abdomen more readily than into the chest. In the case of a second opening being necessary, when the first has closed, I should imagine the recollection of this circumstance, and the ready adhesion of the diaphragm to the pleura costalis, when matter has been evacuated, to be of very essential importance. swelling and enlargement, the point of election, as it is called, is bet" ixt the sixth and seventh rib. We may, however, be directed to a particular spot, by the long continuance of a fixed pain there. It shrunken"! ‘ ""fl'7/'RMI H. («lithium m, at- OPERATION. We out directly on the middle of the con: vexity of the seventh rib, the length of two inches, then drawing the integuments upward, so that the incision is over the intercostal muscles, we continue it through these intercostal muscles, and then taking the trocar, we pierce a litv tle obliquely over the upper edge of the sixth ribas. Or the operation is completed with the scalpel, by continuing the incision through the intercostal muscles and pleura, just so as freely to admit the matter to flow; and in this case it will be necessary to introduce a bougie, or leaden canula, at- ter we have made the incision. But, for my own part, if the matter continues to flow, and this we must expect, I think the canula less likely to produce the inflammatory change 01-. the surface of the cavity, which is the point of danger in the first instance. The discharge continues long, and unless the constitution be good, and the collection entirely local, the patients too often sink at last. I need here scarcely remind my reader of the anatomy. that when the chest is distended, the diaphragm is pushed down. But though this be the first efiect, yet if expectorm '* The intercostal artery lying in the groove cfthe lower edge. ‘ ' mm Maser/H |