in frequency and quantity, until emesis is produced. The gelseminum, also, promises to be a useful auxiliary remedy in bringing about the same result. In several cases I have succeeded in effecting diaphoresis by the use of minute doses of aconitum frequently repeated. The wet sheet, is also in many cases an easy and most effectual means of producing diaphoresis. The time and manner of its application must of course be left to the discretion of the physician. Immediately after the use of evacuents, strong tonics should be given to prevent a return of the effusion.

Diet and drinks. The diet should be nutritious. That which is at the same time easily digested, and which contains a large amount of nutriment, is in general best for the patient. All unnecessary interference with the habits of the patient should be avoided. Drinks may be given to patients in this disease in small quantities often repeated, according to the intensity of the thirst. No general rule can be laid down in regard to the quantity allowable. In some cases, copious drinking of water or other liquids, tends to produce diaphoresis, and thus acts as a curative agent. But it is in general best to be governed somewhat by the desires of the patient; directing him to use such drinks as tend to act either upon the skin or kidneys. the skin or kidneys. Cold infusions of diuretic articles, old cider, the potus imperialis,* cream of tartar whey, and in some cases of debility, gin,-all these drinks may be used to quench thirst. For the same purpose, I have directed patients to drink freely of Congress water. After the evacuation of the fluids, if the patient is debilitated, a residence near the sea, and frequent bathing in salt water, are very excellent to tone up the system and fortify it against the aggression of new attacks. In one case which came under my care, and in which the use of diuretics was not followed with very salutary effects, the frequent use of the vapor bath and mild emetics of lobelia, together with hydragogue cathartics soon removed the dropsical effusion. Debility, remaining a long time, although the most active tonics were prescribed, I recommended a residence near the sea, and frequent bathing in its water. Improvement immediately commenced, and a radical cure was soon effected.

Vide mode of preparation, U. S. Dispensatory, p. 562.

In case the remedies above described fail, paracentesis may be resorted to with some benefit, when there is reason to believe, that the disease has originated in mere vascular irritation, or inflammation of the pleura. In other cases it would be a desperate resort, calculated to afford only temporary relief, and yet endangering the life of the patient by exciting fatal inflammation.

But when sudden death threatens from suffocation, the practitioner might perhaps be justified in resorting to a temporary expedient. In all cases it should be employed as a last resort. Directions for the operation are found in the chapter on Chronic Pleurisy.

CHAPTER XIV.

EMPYEMA.

This word from its etymology & in, UV pus, signifies a collection of pus in any part of the body. Among the ancients, however, it had a signification more extensive than it now has among the moderns. The former applied it to those purulent collections which form in the cavities of the viscera, or in the interior of the principal organs. The latter apply the term empyema to effusions of blood, of pus, or of serum into the cavities of the pleuræ, as well as to that operation by means of which those liquids are removed from the interior of the chest. The effusions in the chest, whether serous, bloody or purulent, are the results of diverse diseases, of which the pathology, symptoms, causes and general principles of treatment have, in the chapter on pleuritis, been considered. I shall, therefore, consider its diagnosis, prognosis, and some of the more specific points of treatment.

DIAGNOSIS. The diagnosis of this disease, by the ancients, and the moderns, until after the discovery of the physical signs has been considered very uncertain. With pneumonitis, the ancients confounded it. Its sputum they described as "bilious, bloody, yellowish, viscous, greenish or blackish.”

The deficiency of the common signs of this disease, was acknowledged by Cullen in his work on pneumonia. "Under this

head, I mean to comprehend the whole of the inflammations affecting either the viscera of the thorax, or the membrane lining the interior surface of that cavity; for neither do our diagnostics serve to ascertain exactly the seat of the disease, nor does the difference in the seat of the disease exhibit any considerable variation in the state of the symptoms."

PHYSICAL SIGNS.-The diagnosis must depend upon the physical signs; the dullness on percussion, the absence of respiratory murmur over the affected side; while on the opposite lung, the respiration is more loud, and somewhat peurile; the metallic tinkling and amphoric respiration are sometimes heard. Fluctuation caused by succussion and the other general and special symptoms described in the chapter on Chronic Pleuritis, are often present.

PROGNOSIS. In the majority of cases, this is unfavorable. The character of the effused fluid, the constitutional disturbance, the degree of strength, and condition of the lung opposite the diseased one, should be considered in forming the prognosis. Sometimes, the pus spontaneously perforates the parietes of the chest, and is discharged during a long time. The cases of recovery are But sometimes they occur, and therefore, some hope may be entertained of relief and cure either spontaneously or from an operation.

rare.

TREATMENT.—In case the spontaneous discharge of pus is great, and the system shows signs of depression, means should be used to keep up the strength. For this purpose nourishing diet and the strongest tonics should be used. If there is a purulent expectoration, this should be promoted by expectorants, and if there is evidence that the digestive organs suffer from any collection of morbid matter, an emetic adapted in thoroughness or mildness to the exigencies of the case should be administered. In all cases in which purulent or sero-purulent matter is absorbed in large quantities into the blood, the emunctories should be stimulated to action. This effect is produced by the use of the vapor bath. In case there is not much febrile excitement, alcoholic drinks when combined with tonics, expectorants, and nourishing food, are not

inadmissible. Pure wine, porter, or ale, and if the kidneys are inactive, gin may be given to keep up the strength of the system, while the suppurative process is going on. These last means are most serviceable, when the empyema is the result of tuberculosis. In such cases, even when the hectic fever is considerable, their use may be persevered in. If, however, there be fear of producing over-excitement, alternately with the administration of alcoholic stimulants, a pill of extract of lobelia, or some other relaxing and sedative agent should be given.

Mr. MacDonnell has written an interesting article on empyema, in which he relates several cases wherein tumors appeared on the surface of the chest. These were red, tense, pulsating, and shining. At length they burst, giving exit to a large quantity of pus. The empyema attended with these pulsating tumors, he calls the Pulsating Empyema of Necessity.

Mr. MacDonnell relates several cases of much interest. In one of them, two tumors appeared on the left side, one near the spot occupied by the apex of the heart, the other between the tenth and eleventh ribs near the spine. The opening of the tumors gave relief, but the patient subsequently died of phthisis. In another case, two tumors, each about the size of a hen's egg were observed, one just below the nipple, the other between the tenth and eleventh ribs, about two inches from the spinal column. These tumors were rather tender to the touch, a few turgid veins surrounded their bases, the integument covering them was discolored, and reddish, and they both possessed a well-marked fluctuation, and a distinct, perceptible, and diastolic pulsation. Other cases of a similar nature are related by Mr. Mac Donnell. In one case of empyema, the pus made its way into the bronchial tubes, and was removed by expectoration.

These tumors arising from the "Pulsating Empyema of Necessity," may be distinguished from Thoracic aneurism, by (a), The history of the case. (b), The dullness extending over the whole side, the pulsation being felt only in the external tumor. (c), The absence of thrill. (d), The absence of bruit of soufflet. (e), The extent and nature of the fluctuation. From encephaloid disease of the lungs and mediastinum, by (a), The absence of expectoration resembling black currant jelly. (b), The absence of

persistent bronchitis. Such cases as above described are not often found. Occasionally they may supervene in consequence of badly treated acute pleuritis. I have seen one case similar to those described by Mr. MacDonnell. The fistulous opening was upon the left side of the spine, about an inch exterior, and between the tenth and eleventh ribs. From a gill to a pint of pus was discharged daily for about a month, gradually diminishing in quantity, until at the end of three months it ceased. By the use of mild emetics and tonics, of which the wild cherry, and sirup of the iodide of iron were the most important, a comfortable degree of health was obtained. The affected side was left permanently contracted. Empyema has a peculiar effect upon the functions of the liver. This organ is enlarged from an engorgement with blood. This enlargement is evidently identical with that which takes place in other affections of the lungs and heart, where, in consequence of the partial suspension of their functions, an additional amount of labor is thrown upon the liver. The removal of this enlargement is one of the first signs which indicate the subsidence of the effusion, and the return of the compressed lung to the performance of its normal functions.

CHAPTER XV.

PHTHISIS.

The word phthisis, from the Greek qow to waste away, signifies a gradual decay of the body. By this term is meant a state. of continued and slow consumption, not exclusively of any one part, but of the general system. It is a generic term, applying equally well to organic changes in the various organs of the body. Such specific terms to the generic, are appended as most definitely indicate the location of the disease. Accordingly we have laryngeal, pulmonary, intestinal or mesenteric, hepatic and gastric consumption, described by authors. These distinctions are somewhat arbitrary; all kinds of consumption being a constitutional rather than a purely local affection.

The term pulmonary is used to denote a decay of the lungs;