Pneumothorax from gaseous secretion of the pleura.-The pleura, according to Laennec, in very rare cases takes on the secretion of air like the other serous membranes. This may take place singly, or the elastic fluid may accompany an aqueous or puriform effusion. This variety has not been decidedly established by the observation of other pathologists since the time of Laennec, and we record its existence merely on his case of it, in which, however, this origin was not unquestionably proved. (Clinique Méd. t. ii. p. 512.) Pneumothorax from the opening of an em pyema into the lung.-The bursting of an em pyema into the lung is not a very unfrequent occurrence; and yet this is an extremely rare source of pneumothorax. When it takes its origin in this way, the empyema has generally been cir cumscribed. This variety of pneumothorax is that in which the operation is fairly entertained (See EMPYEMA); and we believe that the cases which recovered after it, where it was proved by the fluctuation to have existed, must be referred to it. We allude to the remarkable cases of Dr. Archer (Trans. Dublin Association) and Dr. Hawthorne, (Edinb. Med. and Surg. Journal, No. 61,) &c. but it is very plain that he speaks only of the pre- | other methods by which authors have described it sent relief which paracentesis procured, and not to arise. of the ultimate consequences. The following are his words: “Interdum flatus tam violenter distendit pulmones, ut præfocationem, adferat, ni succurratur aperto thorace per ipsam paracentesim, quod sæpius factitatum Parisiis, magno ægrorum emolumento, et thoracis levatione, etiamsi aquæ nullæ effluxerunt, sed flatus cum violentia displosus." (Riolan, Encheiridion Anatomicum. Lib. iii. cap. 2.-Med. Obs. & Enq. p. 394.) Monro's case, in which the operation was successful, is re-authority, and on that of Andral, who relates a corded with considerable accuracy; and we think that any one conversant with those matters, who examines it, will at once deny that it belongs to this class; it seemed, in fact, very probable that the air escaped into the chest by the rupture of some of these distended subpleural vesicles, which are not uncommon in emphysema of the lung, under which apparently the patient laboured for many years. (See Halliday on Emphysema, p. 49.) Universal experience of its failure, as well as the great weight of authority, is against the operation; for no case has recovered after it, of this variety of pneumothorax, since it has been possible to recognise it by auscultation. Its failure appears to have for its cause the readiness to take on a bad inflammation, which the false membrane and pleura possess in this species, in consequence of which it is very common to find a gangrenous state of these membranes occurring after the wound, propagated originally from its edges. Notwithstanding its not having succeeded hitherto, there is still a decided leaning to perform the operation whenever a case occurs. This in some measure is caused by the fact, that the old ideas which connected fluctuation and simple empyema are not yet perfectly exploded, and partly from the too generally applied notion, " melius est anceps experiri quam nullum,"-an adage which is sometimes erroneous, and founded on a forgetfulness of the part which nature takes in the removal of morbid action. The writer confesses it to be his own opinion that the possibility of cure which he has above professed to believe in, lies not in the appliances of art, but in the operations of nature.* Pneumothorax from gangrenous perforation, and from rupture of the pleura in emphysema of the lung.-The first of these cases has been occasionally remarked, but the latter is extremely rare. Monro's case of successful operation was, as we have before stated, very probably of this nature. In it the rupture took place during a fit of cough. ing, and it was succeeded by general emphysema of the cellular tissue as well as pneumothorax. Laennec thought that he observed its origin from this cause in one case. Pneumothorax from lesions of the thoracic parietes.-We should mention under this head, 1st, that consequent on penetrating wounds and lacerations of the lung by fractured ribs, called hitherto by surgeons emphysema thoracis. Dr. Hennen remarks that the fears which exist as to This terminates the subject of pneumothorax its arising from these causes are greatly exagge from perforation of the lung by a tubercular ab-rated, as it is in fact a very rare occurrence in miliscess. We have purposely devoted the bulk of tary surgery. (Hennen's Military Surgery, third this article to the consideration of this one species edition, p. 380.) 2nd. Where it is consequent for the convenience of arrangement, as well as on the opening of an anthrax or abscess through because it is incomparably more frequent than the the intercostal spaces. Of the former we wit whole of the other varieties. To have discussed nessed an interesting case in the Meath Hospital, the latter separately would have involved us in a in which all the phenomena were remarkably mass of tedious repetitions; and it seems certain perfect. To the latter belongs the singular case that he who is acquainted with the species which described by Dr. Duncan, in which a diffuse abwe have chosen for its description, can be at no scess spread from the arm to the chest, and peneloss fully to comprehend its pathology and diag-trated the costal pleura and lung, upon which a nosis, should he meet with it arising from other circumscribed pneumothorax formed, communisources; or at least we trust that the foregoing ac- cating with the external abscess, and producing count of it will place him in such a position that elastic tumours on the side. (Trans. Med. Chihe will be enabled to investigate them for himself.rurg. Society of Edinb.) 3rd. The species which In conclusion, we shall now briefly mention the *If ever the perfecting of diagnosis shall arrive at distinguishing the cases where pneumothorax is caused by the bursting of a single tubercle, or of a small mass, we conceive that in such a case the operation may be yet practised with success. succeeds to the evacuation of the purulent matter after the operation of empyema. This is an invariable conséquence, but we believe that its prejudicial effects are too much insisted upon, as patients sometimes live many years with a fistulous opening in the side, and enjoy a tolerable state of POISONING.-See TOXICOLOGY. POLYPUS OF THE UTERUS.-See UTERUS, DISEASES OF. PORRIGO.-Porrigo is the generic appellation for several pustulár diseases affecting the scalp chiefly, but occasionally other parts of the body, agreeing less in their symptoms than the species of almost any other of the genera of cutaneous diseases in the classifications of writers. It is synonymous with the tinea of Avicenna and various authors. Porrigo is defined by Bateman, " an eruption of straw-coloured pustules, concreting into yellow or brownish crusts or cellular scabs;" but this definition accords with three only of the species usually arranged in this genus; and, indeed, the genus actually comprehends three diseased states of skin, differing not only in their symptoms, but requiring distinct modes of treatment. But as little advantage perhaps would be derived from an alteration of arrangement, or the division of this genus into three distinct genera, we propose to arrange the species so as to bring together those that accord, and separate others the characters of which are evidently distinct. They may be all arranged under the three following sections. SECT. I. PORRIGO, true porriginous eruption, comprehending Species 1. P. larvalis; 2. P. lupinosa; 3. P. favosa. II. ECZEMATOUS PORRIGO. 4. P. furfurans. III. ANOMALOUS PORRIGO. 6. P. decalvans. 1. True Porriginous Eruptions. These are characterized by the pustules assuming those forms which have been denominated favus and achor, and by being unaccompanied with fever. The different forms may be regarded rather as varieties than distinct species, as they sometimes exist simultaneously on the same person. They affect both sexes and all ages, but are most frequently observed in infancy and youth. In many instances it is difficult to trace them to any peculiar predisposition; but in general they may be referred to some deranged condition of the digestive organs, to improper food, and occasionally to depressing passions. None of the true porriginous eruptions are contagious, nor does the treatment applicable to all of them materially differ. that have broken; these break, and, as the former, pour out their fluid, which encrusts in its turn; whilst the old scabs are thickened and extended by the fluid continuing to ooze out from below them, so that by degrees the whole of the face becomes covered by these scabs, as if with a mask; thence the specific term larvalis. At this time the crusts exhale a rank peculiar odour, which Alibert likens to sour putrid milk. The eruption varies in severity: sometimes the inflammation is intense, the exuded humour very abundant, and so acrid as to excoriate the cheeks and other parts; at other times it is moderate in quantity and mild in quality; the pustules are few, slow, and suc cessive in their development, and the crusts thin and dry. Besides the forehead and cheeks, patches appear behind the ears, around the mouth, and upon the chin, yet they rarely appear upon the nose and eyebrows. Small patches occasionally break out about the neck and breast, and sometimes even on the extremities. When they rise upon the hairy scalp they assume a chronic character; the bulbs of the hairs sometimes inflame, and baldness, temporary or permanent, may be the result. In whatever part the eruption is seated, it is accompanied with itching, sometimes with stinging pains, which are more severe, the younger the patient is, and in infants not only greatly disturb the natural sleep, but derange the digestive function. This is particularly the case in plethoric children, and especially when the eruption spreads over much of the neck and breast. The eyes and eyelids are often inflamed, and discharge a purulent matter; when the discharge on the scalp is absorbed, the parotid glands swell. In strumous and highly irritable subjects the mesenteric glands also inflame, and marasmus, diarrhoea, and hectic may supervene and destroy the patient. But this aggravation of the disease is a rare occurrence. W When the disease is yielding, whether spontaIneously or to remedies, the pustules form more slowly, exude less, and the crusts fall off and are not renewed, but they leave behind them a red, tender cuticle, which is sometimes marked with deep lines, and occasionally exfoliates several times. Sometimes it appears as if about to yield, and then returns with greater severity. In this manner we have seen it vary during the whole period of dentition, and yet, unless the nails have been much at work, no cicatrices remain. This species of porrigo is not contagious; but in a case mentioned by Alibert, in which an infant was inoculated with it, the disease was taken. It occurs in infants during the cutting of the first teeth, and also in children during the second dentition. We have never been able to trace it to any state of the breast milk when it appears in infants, but in every instance the stomach is in a very irritable state, and much acid is present in it. We have been able to trace it to the too free use Species 1. Porrigo larvalis; milk scall or of acescent food, such as fruit-tarts and puddings, crust. This species of porrigo appears on the sugar, and various articles of confectionary into forehead or cheeks, in the form of small, yellow-which it enters, in children of full and gross haish, white, superficial pustules, upon a red surface, in irregular groups. On breaking, they pour out a greenish-yellow fluid, which concretes into thin lamellated scabs, usually of a brownish hue. New groups of pustules form in the vicinity of those bits of body. Rayer says that it is less frequent in the Parisian hospitals than the porrigo favosa, the proportion being as seventy-one to nine hundred and eight.' The disease most likely to be confounded with porrigo larvalis is porrigo favosa; but to careful | barley-gruel, and sweetened slightly with lump observers the circular depressed crusts of the latter sugar. The quantity should be moderate, and readily distinguish it from the former. None of any thing like voracious appetite in the child rethe other species of porrigo, except porrigo furfu- pressed. is likely to be mistaken for it; but in porrigo furfurans the crusts dry and become very hard and greyish, which distinguish it. rans, In general the disease runs its course without danger, but, as we have already stated, the mesenteric glands may be in a diseased condition, in which case it becomes formidable, and may induce diarrhoea, marasmus, hectic, and thus prove fatal. The sudden cessation or repulsion of the discharge is also said to indicate an increase of some deeper-seated disease; but our experience has not led us to form such a conclusion. We concur in the opinion of Dr. Underwood, (Treatise on the Diseases of Children, 8th edit.,) that infants who suffer much from the milk crust are always healthy in other respects, and cut their teeth remarkably well. Dr. Starck (Starck's Diss. de Crusta Lactea Infantum, &c.) affirms that the prognosis is always favourable when the odour of the urine resembles that of the cat. We have not seen this remark verified; indeed, unless the disoccur in very young, ill-fed, and badly nursed children, or in those of an hereditary strumous constitution, our prognosis may always be favourable. ease Porrigo larvalis requires both constitutional and local treatment. In children of more advanced age, during the second dentition, when the pulse is quick and full, the face flushed, and the nights restless, it may be necessary to apply a few leeches either behind the ears or under the angle of the jaw; and in very obstinate cases to apply a blister on the nape of the neck, or between the shoulders, and keep it discharging for ten or twelve days. Gentle aperients, merely to regulate the bowels, are necessary, but we have never seen any advantage de rived from a course of purging. were required. In conclusion we may remark that we are ac quainted with no eruptive disease in which there is so complete an obliteration of every thing that could indicate the existence of the previous eruption after the crusts fall; and in none have we perceived less mischief to result from checking the eruption. With regard to local applications, if the eruption occupy the scalp, it is scarcely requisite to say that the hair must be removed by scissors, for it seldom admits of being shaved; after which the separation of the crusts should be aided by a dressing of the oxide of zinc or the subacetate of lead-ointment on lint, covered with an emollient poultice. If the discharge be considerable and very acrid, the denuded surface should be washed with a solution of zii. of bicarbonate of soda in f3viii. of bitter almond emulsion, or of milk with the addition of f.ss of hydrocyanic acid. In very young children, however, it is advisable to leave out the hydrocyanic acid. As soon as the local irritation is subdued, if a return to the healthy state of the scalp seems to be retarded When the disease appears in infants at the only by the crusts becoming dry, hard, and adbreast or during the first dentition, it is essential herent, their separation and cicatrization are fato allay the general irritability of the mucous cilitated by the unguentum hydrargyri nitratis, membrane, which is the source of the acescent diluted with six or seven parts of lard. We have state of the stomach; and as soon as that is ac- never met with a case in which lotions of the complished, to aid the general powers of the sys-hydro-sulphuret of potassa or sulphureous baths tem by mild tonics. For answering the first of these indications we have seen much benefit derived from the hydrargyrum cum creta, in doses of gr. iii. to gr. vi. given night and morning; or in older children, when the mesenteric glands were enlarged, and the abdomen was tense and tumid, from calomel, in doses of one-tenth of a grain combined with one-fourth of a grain of ipecacuanha and half a grain of the powder of conium, given every eighth hour for a week. For fulfilling the second nothing answers so well as a combination of carbonate of soda, powder of calumba, and rhubarb, in doses proportioned to the age of the child and other circumstances, given twice or three times a day. Under such a plan of constitutional treatment we have witnessed the disease to yield in a very short time without any local applications except those which cleanliness requires. We have had no occasion to employ sarsaparilla, cinchona bark, the rumex aquaticus, nor the viola tricolor recommended by Dr. Starck. (Ibid.) During dentition the warm bath at bedtime is highly salutary, especially when the itching is so troublesome as to interrupt the sleep of the little patient. Nothing is more important than to examine the state of the milk: if this be thick, the nurse should either be changed, or her allowance of porter, animal food, and other stimulant nutriment should be diminished. If the infant be undergoing the uncertain experiment of being brought up by hand, the food should consist solely of milk diluted with an equal quantity of 2. Porrigo lupinosa; lupine scall.-This species of porrigo is distinguished by the achores, which arise in small separate clusters, forming when they break circular scabs of a yellowish white colour, set deeply in the skin, with a central indentation or depression, sometimes containing a white, scaly powder. When seated on the scalp or on the temples, they acquire nearly the size of a sixpence, and there is sometimes an intervening thin white incrustation, which exfoliates, or occa sionally forms an elevated crustaceous covering, The eruption sometimes displays itself on the shoulders, the thorax, the abdomen, and the extremities; but in these places the scabs never attain to the size which they do on the scalp. The eruption exhales an offensive odour, not unlike that of mice; it affords a harbour for pediculi in the crevices of the crusts; and when the acrid discharge is absorbed, the cervical glands swell; whilst long-protracted cases terminate in baldness. When left to itself, the disease is very long before it wears itself out, and even unde proper treatment it is tedious of cure. It is not contagious; and it is the least frequent of all the species of porrigo. Its predisposing it causes inflammation and scabbing on any sound cause seems to be a low state of the habit, result-part with which a diseased part comes in contact; ing from the miseries attendant on poverty. as for instance the breast with the chin, or the The treatment of porrigo lupinosa consists hands and arms with the face in young children. chiefly in the application of emollient poultices, The breast of the nurse may become affected in and soap and warm water; the mechanical re- the same manner. It occurs at all seasons of the moval of the crusts; and, after this is effected, year, and in both sexes; but it is more common the assiduous use of an ointment made with two in infancy and childhood. The strumous diathedrachms of the finely powdered seeds of the coc-sis, bad nourishment and poor clothing; damp, illculus Indicus and one ounce of lard. In very obstinate cases, the hard crusts may be touched with diluted sulphuric or muriatic acid, or treated with a lotion made with liquoris potassæ 3j, olivæ olei Zij, aquæ 3j. When the crusts are removed, and the surface appears red and covered with numerous small ulcers, exuding a viscid, fetid, yellowish fluid, the diluted ointment of the nitrate of mercury is the best application to assist cicatrization, and complete the cure. ventilated houses, prisons, and the miseries of poverty in all their forms, may be regarded as its predisposing causes. This species of porrigo may be readily confounded with porrigo furfurans; but as the pustules are found on different parts of the body in every stage of their progress, it is easily recognized. When the disease is of long standing, the hairs are destroyed on the affected parts of the scalp. [It has been affirmed of late that the yellow substance, which constitutes the crusts of this af fection, is an organic growth of simple structure bearing a marked resemblance to the vegetable bodies, collectively called mould. They have been examined by Remak, Schönlein, Fuchs, and Langenbeck, and Gruby, the last of whom states, that the crusts are made up of aggregated myco whether these my codermata be really vegetable; and it is certainly far more probable, that they are very simple animal growths.-(E. Wilson, on Diseases of the Skin, Amer. edit. p. 322, Philad. 1843.)] 3. Porrigo favosa; honeycomb scall.-The eruption in this species of porrigo consists of small, flat, soft, straw-coloured pustules, termed favi, generally distinct, with an irregular edge, and bounded by a slight inflammation. The scalp is the chief seat of the eruption, but it sometimes occupies the forehead, the temples, the chin, the space behind the ears, the eyebrows, and occasionally it extends to the trunk and the ex-dermata. It is very questionable, however, tremities. When it appears on the scalp, the pustules are small, not very distinct to the naked eye, and the minute drop of yellow fluid which they contain does not escape, but dries within them, and acquires a deeper yellow colour, and is very adherent. The pustules, although they are usually distinct, sometimes appear in groups, and become confluent. When distinct, they are usually on elevated bases, and each is frequently traversed by a hair. In whatever manner they appear, they are always more or less accompanied with itching. If the crusts be removed by poultices, or by any lotion, they do not return, the formation of new pustules being necessary for that purpose. When the disease is left to itself the crusts are very adhesive, and remain in a dry, white, and brittle state, sometimes for months and even years. Sometimes as they assume this character in one place, fresh pustules appear in another. The hair separates with the greatest ease, sometimes leaving the part permanently bald. As the disease proceeds, if great care be not taken to keep the parts clean, pediculi harbour in the crusts, the itching augments to an intolerable degree, and the eruption exhales a most offensive odour. The excoriated surfaces, after the crusts are removed, exude a fetid reddish fluid, which concretes into irregular crusts. Occasionally they cause small subcutane-also been advantageously administered. In young ous abscesses and lymphatic swellings in the neck, which slowly suppurate; the axillary glands are affected when the eruption appears on the upper part of the trunk. Continental writers assert that porrigo favosa' requires little more than local remedies; but we have seen no case of the disease in which it was not easy to trace it to some morbid condition of the system. For this reason a gentle alterative course is required, care being taken at the same time to regulate the diet and exercise. The former should consist chiefly of light animal food, with milk and farinaceous preparations; the latter should be regular, but never carried to fatigue; and when the tepid bath can be employed, which is always more or less serviceable, the exercise, in dry and temperate weather, should be taken immediately after using it. If the habit be decidedly strumous, the glandular affections severe, and much emaciation has taken place, tonics will be found to be necessary. The chalybeates are the most useful, and none possesses more power in such cases than the hydriodate of iron, given in doses of from one grain to three grains in a large. quantity of water three times a day. The sulphate of quinia and the muriate of baryta have children we have seen much benefit derived from the hydrargyrum cum creta, given every night in doses proportionate to the age of the patient; with a combination of cascarilla and subcarbonate of soda, in full doses, given three times a day. In adults a mild course of Plummer's pill with sarsaparilla is occasionally requisite, in cases of long standing, which have resisted the usual mode of treatment. · With respect to local remedies, the first object. is to free the scalp as much as possible from the crusts, and to subdue topical inflammation. This, is accomplished by cutting the hair as short as then a few minutes afterwards to bathe the parts repeatedly with cold water. The pain excited is great; consequently, some degree of caution is requisite in applying these caustics to children of delicate habits. When the eruption appears on the trunk of the body, the ordinary warm-bath is found to be beneficial, and still more so the sulphurous vapourbath. possible, or by shaving the scalp if the eruption | feather dipped in any of the mineral acids, and admit of it; daily ablution with hot water and soap; and when the crusts are dry and very adhesive, the application of poultices. After the surface is pretty well cleared, an ointment containing equal quantities of the unguentum oxidi zinci and unguentum hydrargyri precipitati albi may be applied to the inflamed parts; or if the inflammation be moderate, the unguentum hydrargyri nitratis will answer better. The combination of the tar ointment, diluted with two [Alkaline ointments and washes; weak soluparts of lard, and one part of sulphur, forms a tions of chlorinated lime or chlorinated soda or of useful application when the crusts are very ad- creasote may be employed; and in some cases, hesive; but the pitch-cap, which was formerly solutions of sulphate of zinc or of sulphate of copmuch employed, is apt to excite a highly inflam-per or of nitrate of silver have been of great ser matory state of the scalp, and a considerable vice. The citrine ointment, unmodified, or redegree of symptomatic fever, consequently it reduced, according to circumstances, has been adshould be used with caution. In addition to vised by many. In the author's experience more these topical applications, much advantage has good has been derived from the ointment of iodide been derived from the introduction of a seton in of sulphur than from any other application. Codthe nape of the neck or in the arm; indeed we liver oil is likewise said to have been used with have rarely witnessed the most obstinate cases advantage; but it would be endless to enumerate resist the beneficial influence of such a drain con- all the topical applications that have been advised. tinued for a month or six weeks. (For a further detail see the author's Practice of Medicine, 2d edit. ii. 126.)] Of all the local methods of treatment, that pursued by two brothers of the name of Mahon, in the Parisian hospitals, has been found the most efficacious; and therefore we shall give a brief sketch of it. The hair is first cut, so as to leave it throughout about two inches long; the crusts are next cleared away as completely as can be done by the aid of linseed-meal poultices and soap and water, a part of the treatment which occupies from four to five days. Having thus prepared the scalp, the affected parts are next covered with an ointment composed of chalk, silex, alum, oxide of iron, a small quantity of subcarbonate of potassa, some lime, and a little charcoal rubbed up with lard, but in proportions which are kept secret. This ointment is applied on alternate days for upwards of a month; whilst on the intermediate days a comb is passed gently over the parts to detach the loosened hairs with as little pain as possible. At the end of this time a powder, the same as that which was employed in forming the ointment, but without any charcoal, is sprinkled over the affected parts; and after using the comb on the following day, the former ointment is again resorted to; and by continuing this method the disease yields, and the skin again acquires its natural and healthy condition. We have had no experience of this method of treating this species of porrigo; but from its reputation in Paris we are of opinion that it merits the attention of British practitioners. In conclusion, it is necessary to recollect that in no cutaneous eruption is a change of measures more necessary than in this species of porrigo; the employment of any single remedy, however judicious, is not likely to be followed by success. II. Eczematous Porrigo-Species 4. Por rigo furfurans; furfuraceous scall. This is the teigne amiantacée and teigne furfuracée of Alibert; the eczema de cuir chevelu of Biett, Rayer, and some other French writers: but as there can be only one opinion as to its pustular nature, it cannot be regarded as a variety of eczema, although it may be characterized as an eczematous porrigo. The eruption most commonly appears on the nape of the neck, at the margin of the hairy scalp, or on the temples. It commences with a crop of minute achores, the pus in which being unusually transparent has led them to be mistaken for vesicles. The discharge is moderate, and soon concretes, forming thin, laminated, exfoliating scales, accompanied with much itching and soreness when the disease, as is most commonly the case, is seated in the scalp and extends to the temples, ears, and neck. The discharge is also viseid, and exhales a nauseous odour; it adheres to the hairs; and on drying forms a powdery scurf, which the slightest friction separates; and when confined under these scales, it is absorbed, and the glands of the neck well and become painful. This also occurs in old cases; whilst the inflammation extending to the bulbs of the hairs, these fall off and baldness appears. This species of porrigo generally attacks adults, females rather than males, and always those of a lymphatic temperament. The eruptions with which it is most likely to be confounded are psoriasis, and lepra when the latter affects the scalp. We have seen it also assume the appearance of impetigo. The pustular origin of the disease, as it appears at irregular periods, enables us very readily to form a correct diagnosis; and independ Many other local stimulants have been employed with various success; for example, ointments composed of powdered charcoal, peroxide of manganese, and oxygenated lard; cantharides ointment, and pommades made with white precipitate, or calomel, or bichloride of mercury. Different anodyne cataplasms also have been re.commended, made chiefly with strong decoctions of conium maculatum or of the twigs of dulcamara; but at best these may be regarded simply as palliatives to allay local irritation. In obsti-ent of this, we observe no moisture nor ulceration, nate cases, after removing the crusts, it has been :found useful to touch the raw surfaces with a nor any diseased condition of the hair in either psoriasis or lepra; nor are these eruptions conta |