CHAPTER 5.  Diseases Of The Respiratory Apparatus

 1--Diseases of the Nose
      A--Acute Coryza
      B--Hay Fever
   2-Diseases of the Larynx
      A--Acute Catarrhal Laryngitis
      B--Chronic Laryngitis
      C--Edematous Laryngitis
      D--Spasmodic Laryngitis
      E--Tubercular Laryngitis
      F--Syphilitic Laryngitis
   3--Diseases of the Bronchi
      A--Acute & Chronic Bronchitis
   4--Diseases of the Lungs
      C--Pulmonary Hemorrhage
         1--Hemoptysis or Spitting Blood
   5--Diseases of the Pleura
      A--Acute Pleurisy
      B--Purulent Pleurisy
      C--Chronic Pleurisy


   Definition.--This is what everybody knows as a cold in the nose or cold in the head.

   Etiology.--Its cause is toxin poisoning from intestinal decomposition of food. Toxin poisoning is the chronic state of the patient when catching cold becomes a habit. The exciting cause of a cold may be overeating, resulting in an extra amount of indigestion or constipation. Lowered resistance from any influence that uses up nerve energy may be the cause of a cold.

   Symptoms.--The patient feels indisposed. Perhaps he has a chill, headache, backache, ache in the legs; or he may simply be inconvenienced by the discomfort in his head and nose--a headache and a running at the nose. The temperature will be very light--possibly 101 F. The mucous membrane of the nose becomes very greatly irritated and swollen, so that it is impossible for the patient to breathe through both nostrils at the same time, and sometimes both nostrils are stopped up. The secretion is a thin, clear fluid, almost like water. But it is sometimes very irritating to the mucous membrane, and also to the skin of the lips and face with which it comes in contact. Sometimes the tear-ducts are swollen, so that the water runs out of the eyes profusely, The eyes themselves become engorged. Where the disease extends down the nasal passage, there may develop pharyngitis, and even laryngitis. After twenty-four or thirty-six hours the secretion becomes thicker and heavier, perhaps yellowish. In thirty-six hours the secretion is a greenish yellow.

   Treatment.--Stop eating, drink freely of hot water, and compel the bowels to move thoroughly by using several enemas, if necessary. There is no objection to a laxative, on the order of castor oil. But if the patient wants to get well quickly and thoroughly, he should stay away from food.


   Definition.--This is a chronic disease of the mucous membrane lining the nose, accompanied by gastric symptoms on the order of chronic subacute gastritis. The general opinion today appears to be that the disease is caused by the pollen of certain grasses and plants, also dust, irritating the mucous membrane. The very latest cure is an infusion made from pollen, etc. But those who would like to get well should understand the etiology. It is chronic catarrh, with chronic irritation of the stomach. Hearty eating--eating heating foods, such as starch, sugar, and fats, beyond the system's need--produces such a sensitive state of the mucus membrane of the nose and stomach that, when the atmosphere is filled with dust and pollen, those who have the disease highly developed suffer a great deal. In fact, any fine particles of dust drawn into the nose with the air will make the hay fever subject very uncomfortable. These patients catch cold frequently in the winter as well as in the summer.

   Treatment.--Stop all food and drink hot water freely until the patient is entirely relieved. Then it would be proper to keep away from food until the subject can go out in the weeds and be free from suffering, even though he breathes the dust from the grasses. Then he should have fruit twice a day--morning and noon. In the evening he may have a little lamb, chicken, fish, or eggs, with a combination salad and one or two cooked, non-starchy vegetables. The meat dinners may be taken about every other day; the alternate days any of the decidedly starchy foods may be taken, with cooked, non-starchy vegetables and a salad. This style of eating should be adhered to until the frost comes. A complete fast right at the start of the symptoms will soon bring relief. Those who have eaten meat twice or three times a day will do best to go entirely without meat until health is restored. Those subject to this condition should never use much carbohydrate food, and should shun sweets of all kinds.

III. EPISTAXIS (Nosebleeding)

   Etiology.--Excessive eating to hyperemia, and a catarrhal inflammation of the mucous membrane of the nose, are often the basic causes of nosebleeding. Young people develop a catarrhal inflammation and ulceration of the mucous membrane of the nose which is so annoying that they fall into the very bad habit of picking at the nose, and, by poisoning the mucous membrane with the fingernails, a very raw and irritable state of the mucous membrane is produced. The wounding of the mucous membrane with the fingernails develops in time an ulceration. This ulceration is often deep enough to cause a necrosis of a blood vessel of sufficient size to cause profuse bleeding. Again, the nosebleeding may come from constitutional derangements--a high blood pressure, dysemia, anemia, uremia, etc. This condition, with a little catarrhal ulceration, may cause the subject to be very much inclined to bleed at the nose. This style of bleeding is more profuse than the other. Then there is a nosebleeding which is due to a deficiency of fibrin in the blood. When this element is deficient, the blood loses its power to coagulate. Such cases as this make bleeding very dangerous. Cases such as this have been known to bleed to death. Unfortunately, the more these cases bleed, the easier it is for them to bleed.

   Apoplectic subjects are inclined to have nosebleed. It is a conservative measure; for the oftener and the more the nosebleeds, the less becomes the blood pressure, which is one of the causative symptoms. If relief from the excessive blood pressure in the head is not had in some way, a blood vessel is liable to rupture, and the patient will then be in a state of apoplexy, with a clot on the brain and partial paralysis, if death does not occur very soon after the hemorrhage takes place.

   Treatment.--In the first class of cases the patients must be instructed to keep their fingers out of their noses. Digging at the nose must stop. The mucous membrane should be greased frequently with camphor ice. This will prevent a drying, and also relieve the irritation that causes the patient to dig at the mucous membrane.

   The eating should be corrected. Too much starch, sugar, and fat are being eaten. If these are cut down decidedly, or suspended entirely for a while, the nose will have an opportunity to get well. In bleeding from congestive headaches, with high blood pressure, the patient should lie down, have the bowels washed out thoroughly, stop eating, and, as soon as the pulse drops down, there will be no more bleeding. In cases of high blood pressure, with a perverted state of the blood, profuse bleeding is an indication of arteriosclerosis and an apoplectic state of the blood vessels of the brain.

   Those in this peculiar state must go without food until the blood pressure is completely overcome. Plugging up the nose may give a temporary and unpleasant relief; but this is not a proper treatment--it is inexcusable, bungling, and unscientific. Reduce the blood pressure; keep food and fluid away from the patient; keep the patient quiet; and in a reasonable time the bleeding will stop. Then the patient should be instructed to be careful about eating and drinking of any fluid, because there is no assurance that apoplexy or paralysis will not ensue before relief from the bleeding can be had.

   It is dangerous for blood pressure to remain high enough to cause an occasional nosebleeding. The eating for people who have high blood pressure should be fruit, vegetable salads, and very light meals of meat; but starch, sugar, and fat should be kept away from them until they are safe--until the blood pressure is brought down to the normal.



   Acute inflammation of the larynx may come on with a cold, or following a cold.

   Etiology.--Catching cold, or over-use of the voice, may be the cause of the irritation and inflammation in this disease. It is a derangement which public speakers often develop. Foreign bodies may lodge in the air-passages and create trouble. It may be brought on from accidental poisoning.

   Symptoms.--A tickling sensation is felt in the larynx. Cough follows. Where the irritation and inflammation are severe the patient may lose his voice. He will talk in a whisper or in a husky voice. If he is a lawyer or a public speaker, and uses his voice under such circumstances, he may lose his voice completely. The edematous state of the mucus membrane caused by the inflammation may become so great that the voice will be lost. This, of course, is only temporary. Talking or singing increases the edema.

   Treatment.--Rest the voice. Stop food for a few days; then eat fruit for a few days following the fast. Gradually increase the amount of food; but if a few days of fasting do not restore the voice, the fasting should be continued. As soon as the voice has returned, if there is still a little soreness, the patient may use fresh, uncooked fruit morning, noon, and night until the symptoms have passed away.


   This is the same as the preceding, except that the patient has been imprudent; he has continued eating, and has developed more or less indigestion. He has continued to use the voice until the inflammation has become chronic. Patients in this state have a hoarse, rough voice. Sometimes it is altogether lost. The feeling is such as to cause the patient to want to clear the throat; but every effort is a failure, because there is nothing to be cleared, except perhaps a little mucus. The feeling that there is something there is caused by the swelling of the mucous membrane, which partially closes the passage.

   Treatment.--If there is any trouble with the nose--chronic inflammation or ulceration, or growths in the nose--these should be treated with a spray; or, if the spray is not desirable, by a strict diet. Fasting for a few days or a week, and then living on a light diet, such as fruit and salad, will bring the disease to an end gradually. Fruit then may be taken in the morning, and fruit, with buttermilk, at noon; simply buttermilk at night. Continue this until all symptoms ,are well overcome; then a full diet: fruit for breakfast, fruit and whole-wheat bread for lunch, and the usual meat and starch dinners, in alternation.



   Etiology.--Edema of the glottis is a very serious affection. It is not often met with. Of course, it is caused by wrong life.

   Symptoms.--There is difficult breathing, gradually increasing in intensity. It strikes terror to the patient, and fear increases the trouble. It may be brought on by various influences--scarlet fever, diphtheria, typhoid fever. In all these cases there is a kidney derangement, and perhaps albumin in the urine.

   Treatment.--The patient must be examined to find out what is the matter. If there is anything wrong with the kidneys, it must be corrected. Just what the application should be to the throat, should be left to the patient. If ice feels most comfortable, it should be applied. If heat feels more comfortable, then very hot cloths should be applied. If the symptoms are urgent, and death is threatening, a spray of cocaine may give relief. Before resorting to this kind of relief, however, the physician should make up his mind as to whether the case is desperate enough to justify tracheotomy. It should not be postponed too long. Possibly using the spray of cocaine or other drugs might cause the disease to travel down the trachea. This would complicate affairs by causing edema to spring up in the trachea at perhaps the point where the tracheotomy tube would be inserted; and should the edema establish itself below the point of the tracheotomy tube, the patient would be tortured with the operation for no purpose, as death will soon take him from his torment.


(Laryngismus Stridulus)

   This disease is started up by a slight catarrhal cold. Then, if the child is of a nervous character, the difficult breathing may cause it to be irritable; it will struggle, and the struggling causes the suffocation to be greater, or it may cause a spasm to take place in the larynx. Some authorities claim it is purely a nervous affection.

   Treatment.--Place the child in a hot bath. At the same time wash out the bowels with a fountain syringe. Whatever is wrong with the child should be corrected. If it is teething, and the gums are very much swollen, lancing them will relieve the irritation, and possibly through this relief the laryngitis will be relieved. Inasmuch as this disease is of a nervous character, anything that will produce nervous irritation will have a tendency to make the disease worse.



   Etiology.--The same causes that produce pulmonary tuberculosis will cause this trouble. There must be the history of wrong life coming on for several years before. Children, however, who are born with the tubercular diathesis, and in whom this predisposition is marked, win not have to live many years in contempt of proper living before they develop tuberculosis in some part of the body. If there is a predisposition for the trouble to locate in the throat, it may start up in the larynx. Sometimes this disease of the throat starts up a few months before pulmonary tuberculosis develops. 'Then again the disease may be wholly confined to the throat, and carry a patient off in what is known as "galloping consumption."

   Symptoms.--The first indication is a huskiness. Following this is a hoarseness, which in turn is followed by a whisper. Patients get to the point where it is impossible for them to get the voice above a whisper. Where there are pulmonary symptoms it is a very easy matter to diagnose the disease. The history, and the build of the patient, together with marks of a predisposition to develop such diseases, are usually sufficient for a diagnosis.

   Treatment.--Rest the voice; build up the organism as much as possible. Patients should stay out in the fresh air and sunshine. The disease is not easily controlled; in fact, as in pulmonary tuberculosis, if there is inherited a decided predisposition for the disease, and the disease is well developed, palliation is all that can be given.



   Symptoms.--There will be a hoarseness, as well as a history of an infection. Possibly there will be an ulcer that can be observed through the laryngoscope. There will be mucous patches on the mouth, the hair will fall out, and there will be more or less skin eruption. It is possible that such cases have been treated for syphilis. If so, they have taken arsenic; the mouth trouble or any trouble with the skin or mucous membrane will probably be due to the treatment.

   Treatment.--The life must be corrected. The diet must be made perfect. For the first month of treatment the patient is to be kept on a fast, and fresh, uncooked fruit and vegetables. The first week may be a fast. If the case is very severe, the fast should be of two weeks' duration. The second week a diet of fruit may be given; and the third and fourth weeks there may be had a dinner of vegetables and meat every other day, with a combination salad, and for the alternate dinners a starch in the place of meat. In all cases of laryngeal disease there should be given a hot bath every night before going to bed. If, however, bathing in the evening causes nervousness, it may be taken in the morning, followed with cold sponge-bathing; and the baths are to be followed with dry towel-rubbing. The same treatment should be given laryngeal syphilis that is recommended for constitutional syphilis; and constitutional syphilis is to be treated the same as all other diseases; namely, by correcting the life of the patient.

   From my standpoint, most of these cases are drug diseases, brought on from treating so-called syphilis--a disease the patient never has had.



   Bronchitis is as common as tuberculosis, and the two are often confounded. It is said to be bilateral, and to affect either the large or the medium-sized tubes, or the small bronchi. It has not been my experience that it is confined to one side of the chest, or one lung, more than to both lungs. In fact, ordinary bronchitis, which gives so much of a resemblance of tuberculosis, is usually confined to the large bronchial tubes, not extending beyond the medium; and it is a very common thing to have asthma as a complication.

   Etiology.--Acute bronchitis is, in common, everyday language, catarrh--the same as catarrh of the nose and throat, or catarrh of the intestine, such as colitis, etc. Every cold that is caught means an exacerbation of the chronic bronchial disease. Many cases are quite free from bronchorrhea, or the symptoms of cough and expectoration, during the summer, but in the winter frequent colds keep the subject of bronchitis constantly coughing and expectorating. An acute attack, without any previous history of the disease, may be simply an extension of an acute catarrh or cold from the posterior nares through the pharynx to the trachea, and then to the bronchial tubes. Bronchitis is associated with deranged digestion, intestinal toxemia, measles, typhoid fever, and malaria. Subjects of curvature of the spine are liable to have a bronchial cough. Kidney disease and heart disease are frequently accompanied by a chronic form of cough. The disease may appear in children at the breast, and extend all through the different ages to old age. There are people who seem to be predisposed to take on bronchial cough, but these are what I would call cases of chronic bronchitis. The only reason why they have no cough and expectoration all the time is because they are not living in such a way as to encourage this catarrhal state all the time. Some people are out-of-doors so much of the time in summer, and eat so much of fruit and vegetables, and abstain to such an extent from heavy diet, that they get almost normal. There is no disease to which flesh is heir that is so susceptible to the influences of wrong living as chronic bronchitis.

   This disease is often the result of imperfectly cured measles or other eruptive diseases. Anything that builds a catarrh in any part of the body will build a catarrhal state of the bronchial tubes, or bronchitis. There is no difference at all between bronchitis and colitis, except in the location and perhaps in degree. It has been my experience that asthma is nothing more than chronic bronchitis affecting the capillary bronchial tubes, because this disease is brought on, and caused to continue in existence, by exactly the same mode of life that will feed up acute or chronic bronchitis, or. a catarrhal state of any part of the body.

   Symptoms.--In acute bronchitis all the symptoms of an ordinary cold extending into the bronchial tubes are present. This makes as good a description as can be given. There will be sneezing and coughing, and the eyes will water almost as much as in a case of coryza--and what is a coryza but a cold? The fact of the matter is that catarrh of the mucous membrane about the face, nose, eyes, ears, throat, lungs, is all related. It requires the same constitutional derangement, and identically the same treatment is proper for all.

   Add the symptom of difficult breathing to a bronchitis, and you have the picture of asthma. All cases of asthma, however, do not come from catarrh of the mucous membrane of the bronchial tubes. There is a heart asthma--an asthma that is due to valvular heart disease. The treatment for bronchial asthma will not be suitable for this form of asthma. There can also be an asthma due to tumors in the mediastinum, pressing upon the bronchial tubes. There can also be an asthma produced by aneurism; but this form is a very rare disease. The rule is that, when patients have difficult breathing, the trouble is bronchial asthma,

    Treatment.--The treatment for acute bronchitis is the same as for a cold. (See the treatment given for coryza, supra.) In chronic bronchitis the treatment must be such as will restore the general health. The patient must learn to live normally--not part of the time live correctly, and then abuse himself part of the time by living incorrectly. If the treatment is started at an exacerbation period, or at a period when there is an increase of the symptoms from a recent cold, it must be the same as for acute bronchitis or for colds. The bowels must be washed out daily until the symptoms are all better. After the patient is better, if the cure is to be permanent, the excessive use of meat must be given up. Fruit should be taken for one meal, starch and fruit for one meal, and cooked, non-starchy vegetables, a combination salad, and meat, for the third meal. If the patient is light in weight, he can use starch in the dinner every other day, and the alternate days take eggs, lamb, or chicken with the cooked, non-starchy vegetables and a salad.

   Asthma should be treated about as follows: The patient should fast until the lungs are clear, so that the breathing is perfectly free. This may require one, two, or three weeks. I have had a few cases that required thirty days; but any patient is well rewarded for going without food until fully relieved. Then very great care should be exercised in eating, and otherwise taking care of the body, so as not to bring the disease back. Decided cases of asthma, or those that have been asthmatic for years, should go without milk, cheese, butter, sugar, candies, and the strong meats, such as beef and pork, for at least one year. They should eat two meals of fruit, and one meal every other day of lamb, chicken, fish, or eggs, with cooked, non-starchy vegetables and salad, and the alternate days a decidedly starchy food, with vegetables and salad.



   Definition.--There are two forms--passive and active. It is doubtful if this disease is ever more than symptomatic. It accompanies pneumonia; it is found in asthma, in poisoning by morphine, and in some forms of heart disease--those in which there is an obstacle to the return of the blood to the heart. This is a condition that is often found in low forms of fever, it is called hypostatic congestion. Old people, when confined to the bed from any cause, are liable to develop this state of the lungs. A patient suffering from any disease that forces him to keep in one position is liable to develop this state of the lungs. Injuries that keep old people in bed will sometimes cause a hypostatic pneumonia.

      Treatment.--Remove the cause, whatever it may be. If there is a heart affection, it must receive attention. What ever disease is instrumental in bringing about this derange ment, that disease must receive special attention. The eating should be very light; if the symptoms are urgent, no food should be given. The extremities should be kept warm. All the water desired should be given. Rubbing and bathing are always in order. It is doubtful if deep breathing would be proper in these cases, because patients are usually very weak who develop this form of disease --especially the passive form.



   This is a form of congestion where there is a transudation of serum into the air-cells. I have never seen more than one case. This case, however, I diagnosed pleuritic effusion. The attending physician had diagnosed it edema. I insisted on drawing the water out of the pleura, and the doctor kindly held a vessel for me into which to aspirate the fluid. After taking out about half a gallon of fluid, he was as satisfied as I was that it was hydrothorax and not edema. I presume there are cases of edema of the lungs manifesting in the last stages of Bright's disease, heart disease, angina pectoris, valvular lesions, etc. Any disease that will break down the patient and cause an effusion in any part of the body is liable to appear in the air-cells. The cavity of the pleura and the cavities of the pericardium are more liable to fill up with fluid than the air-cells of the lungs. Such cases as have been described by Osler have not fallen under my observation; hence I take pleasure in enumerating the symptoms as set down by that author:

   Symptoms.--The onset is sudden, with a feeling of oppression and pain in the chest, and rapid breathing which soon becomes dyspneic or orthopneic. There may be an incessant short cough and a copious, frothy, sometimes blood-tinged, expectoration, which may be expelled in a gush from the mouth and nose. The face is pale and covered with a cold sweat; the pulse is feeble and the heart's action weak. Over the entire chest may be heard piping and bubbling rales. The attack may be fatal in a few hours, or it may persist for twelve or twenty-four hours and then pass off. Steven, of Glasgow, has reported a case which had seventy-two attacks in two and a half years. I have seen this recurrent form in angina pectoris, each paroxysm of which was associated with intense dyspnea and all the features of acute edema of the lungs.

   Treatment.--Should I meet with a case presenting such symptoms, I should give a hot bath, preparing the bathroom so as to have as much fresh air in it as possible. Have the outside window and the door open. Then have cool water on the patient's head, and allow frequent sips of cold water. I would not dare give such remedies as morphine; for morphine produces passive congestion of the lungs, and if that should be added to edema, it appears to me that the chances for the patient's recovery would be greatly lessened. The hot bath should continue as long as the patient can safely be kept in the tub, and the water should be as hot as can be borne. I should expect this to relieve the breathing. If necessary, the patient should be returned to the hot bath in three hours, again continuing as long as possible; and then again returned to the hot bath, if necessary, until permanent relief is secured. Certainly no food is to be given, and the bowels should be washed out with copious enemas.



   This disease occurs in two forms: hemorrhage into the bronchial tubes, called bronchorrhagia, in which the bleeding is into the bronchial tubes and is expectorated; and the form known as apoplexy of the lungs, called pneumorrhagia, the hemorrhage taking place into the aircells and the lung tissue. Both can be brought on from injury

(1) Hemoptysis, or Spitting of Blood

   This results from a variety of conditions. In full health, it may take place without warning. After continuing for a few days, it subsides and never appears again. It may be due to a slight ulceration. It may have been brought on from a slight injury. Such hemorrhage is often recognized as indicative of tuberculosis, and altogether too often patients have this opinion saddled upon them. Either they have it saddled upon themselves by their own opinion, or some physician may be indiscreet enough to cause them to believe that because they had hemorrhage they must have latent tuberculosis, or are in line for taking on the disease. If there is any predisposition on the part of the patient to take on lung trouble, this discouraged state--or perhaps I would better say this state of fear--that is created because of the hemorrhage, will go very far toward impairing digestion and nutrition. The patient, seeing this change, will have his fear confirmed that he is really developing tuberculosis. This may cause a change of climate; it may cause a great deal of unhappiness and discontent. The physician should be very sure that he is right before he pronounces a case of this kind the beginning of tuberculosis.



   This disease is not to be treated any differently from pneumonia.



   This disease may be divided into the dry, or adhesive, pleurisy, and the wet, or pleurisy with an effusion.

   Symptoms.--The disease will set in with a chill, boneache, backache, and a sharp cough that nags the patient in the side, making it very painful to cough. This is where the disease commences with very severe symptoms, everything taking on an acute type-fever running high, pulse high, and a little expectoration that is sometimes frothy and colored. This indicates that the lung over which the pleura rests is involved. It would be called pleuro-pneumonia. There is an insidious form which comes on slowly, with no marked symptoms. Children cry and fret, but they will not complain particularly of pain. By keeping their hands over the seat of the pain they may indicate that there is some discomfort in that particular region. The pain is characteristic--in fact, diagnostic. I will say, however, that years ago, when in general practice, many cases of so-called pleurisy I found on examination to be no pleurisy at all. The so-called pleurisy came from indigestion, which developed a great quantity of gas, the pressure of which was so strong on the diaphragm that it interfered with the heart action and caused the patient to cough and complain bitterly of pain in the side. No observing physician should be led into the error of diagnosing such a case as pleurisy; yet I have seen this done many times. Where the young physician is in doubt at any time, he can very quickly distinguish between the pain from below the diaphragm and pleuritic pain by giving twenty to thirty grains of bicarbonate of soda. Put it dry on the tongue, and have the patient drink a glass of hot water. If it is due to acute indigestion, the patient will be relieved in a very few minutes. The soda neutralizes the acid, and relief comes quickly.

   Pleurisy sometimes runs in an insidious form and ends in pleuritic abscess. In such cases there will be a decline in the first symptoms. There will be fever, pain, and cough. The patient will appear to get a little better, but will come to a standstill, and will continue in just about the same condition for a week or two weeks. Indeed, he may not present symptoms severe enough to cause the parents to call a physician. But when they find that the child stays about the same, running a slight fever daily, a physician will be called, who will then discover that there is pus in the pleural cavity.

   Treatment.--Hot applications to the chest; heat to the feet; no food at all; all the water the patient desires; and the bowels are to be washed out every day. When the fever subsides and the cough ceases to be troublesome, the patient may have fruit for two or three days. At the end of that time, if all is going well, fruit may be taken night and morning, and a little broth made from lamb or chicken, with a combination salad, for the noon meal. Then fruit in the morning, and meat and salad at noon, with fruit and teakettle tea in the evening. After a week has passed, toast bread, potatoes, rice, etc., may be taken for the evening meal, with fruit. Other meals as suggested. Meat need not be eaten unless desired.



   Etiology.--Pus in the pleura usually comes from a badly treated case of pleurisy. The profession pretty generally recognizes this disease as tubercular. I have treated quite a good many cases, and I have found the disease as easily cured as abscess located anywhere else that would drain as imperfectly as abscesses in the pleura drain.

   It would be well to observe that the scrofulous diathesis is most inclined to suppurate.

   Authors declare that empyema (pus in the pleural cavity) follows infectious diseases, particularly scarlet fever. Putrefaction of food in the intestine, with absorption of the consequent toxins, is one source of the necessary infection. It is my opinion that people must be predisposed to develop this disease, and then all that is necessary is to live in such a way as to get thoroughly toxemic from the absorption of toxins from intestinal putrefaction. As I see from the experience which I have had, all so-called septic and infectious diseases are made possible by a decided septic infection of the blood through absorption of putrefaction in the bowels. In the first place, it is quite logical to declare that no one will have a pneumonia, or a pleurisy, or a tonsillitis, not even a cold, la grippe or influenza--in fact, infection of any kind--without first having lived in such a way as to bring down the body's resistance, which weakens digestion and favors putrefaction of protein food in the intestine, then the absorption of the toxin which is a natural sequence. If the pleura becomes affected through an ulceration of the lung, the lung infection was brought about by the constitutional derangement above described. There will be no lung infection, and pneumonia will not develop, in a normal individual. Pneumonia, pleurisy, typhoid fever--in fact, any disease--is truly an affection, the real cause of which is to be found, primarily, in enervation and, secondarily, down in the alimentary canal, then in the blood by way of toxins. After the constitution is weakened and the blood stream is polluted, the patient loses his power to resist environmental influences. Then it is that sudden changes in the weather, or the ordinarily recognized conditions of causing a cold, bring him to an attack of one of these diseases.

   Symptoms.--Pleurisy begins, the same as any other disease, with a chill. In fact, we have described the symptoms under the head of acute pleurisy. The kind, however, that ends in empyema is inclined to come on very insidiously. The patient will be feverish, and sensitive over the region of the inflammation: there will be some cough, and the cough will be complained of as causing a stitch in the side. The fever does not run higher than perhaps 102 F.. and then there will be a decline; but after a week or two the patient does not show the improvement hoped for or legitimately expected. Then the prudent physician will make a little closer examination, and will probably find a dullness over a portion of the affected side. As a rule, the patient does not complain of oppressed breathing until there is a great quantity of pus accumulated. Then there will be much oppression, chills, fever, and other symptoms that indicate pus poisoning. I have seen cases that had carried pus for a year or two before it was discovered. In one case I aspirated a half-gallon before I took the instrument away, leaving considerable in the chest, fearing at the time that I had taken out too much.

   Where a patient has been under such a pressure for so long, to be suddenly relieved of the pent-up accumulation is liable to do serious injury by bringing on a fatal collapse. There is one symptom that will always be found in those cases where there is a large accumulation which has not been suspected, and that is that the patient will cough up pus. The ulceration has perforated into the bronchial tubes, and the pus drains into the lung, causing cough and expectoration. Probably this is the only reason why such cases can run on so long, accumulating more and more pus. There is a slight escape and relief from pressure in this way. If relief could not be had through the bronchial tubes, there is a possibility that the pus would burrow down into the peritoneal cavity or into the pericardium. If it should empty into either of these cavities, death would follow very soon, unless a quick surgical operation would give relief. This is especially true of the peritoneal cavity. Where it breaks through into the bronchial tubes and is expectorated from the lungs, the disease is often mistaken and treated as such.

   Physical Signs.--In percussing the chest there will be a decided dullness over the region where the pus is accumulated. Then, if the ear is placed against the chest, or a stethoscope is used, and the patient is requested to count "one, two, three," while the physician listens, the voice will not come to the ear as it does when the stethoscope or ear is placed on a part of the chest where there is no accumulation. There will be a far-off sound, whereas, if the voice comes to the ear without the intervention of an accumulation, it makes a resonant sound beneath the ear, showing that the sound comes through the chest-wall to the ear. By changing the position of the stethoscope or ear, and having the patient count each time, the physician can determine about how large an area is occupied by the pus. The physician who has had many cases will be able to tell in advance about how much pus he will find. A few cases will not present the peculiar symptoms accompanying the accumulation of pus. The physical chest symptoms will be the same, but there is lacking the intensity that pus cases present. On aspirating, these cases will show water or fluid serum. Among all the cases I can remember, in one only did I find a pint of a gelatinous fluid that came out rather heavy and resembled thin syrup. After standing over night, it had the appearance of apple jelly in color as well as consistency. The young man recovered without any further aspirating. The disease hydrothorax (water in the pleura) is not so easily controlled. Sometimes aspirating must be repeated several times. This, however, depends on the constitutional state of the patient.

   Treatment.--As hinted above, the proper treatment for such cases is to aspirate and remove a portion of the fluid, if there is a large accumulation. Then in two or three days aspirate again. While this temporary aspirating is going on, the patient must be put in as good physical condition as possible for drainage. The proper treatment, first, last, and all the time, is to make an opening between the ribs in the most dependent point in the pleura, and introduce a drainage tube. A catheter converted into a drainage tube just within that portion that will be within the chest is much better than the regulation drainage tube or fenestrated tube. The catheter is to be fastened into the wound. A few threads can be run through the sides of the rubber catheter and placed on the chest, and surgeons' adhesive plaster may be placed over the threads, or the threads may be tied on to a piece of surgeons' adhesive plaster.

   Thorough drainage is all that there is to do, aside from giving the patient the proper general care. Eating, bathing, etc., must be in keeping with the patient's general condition. While the pus is flowing very freely the patient should not have anything to eat but fruit. If such cases are fed to keep up the strength-given "good, nourishing food"--the manufacture of pus will be perpetual. The quickest way to dry up this pleuritic condition is to give the patient very little food. If the case has gone without an operation for months, and the accumulation is very great, it is just possible that the lungs have collapsed and adhesions have taken place, so that it will take months for sufficient re-expansion to occur to fill the cavity. In rare cases the extension never takes place and the cavity will not heal. Under such circumstances an operation must be performed, such as sawing through several ribs, in two different places on each rib. Then a padding and bandage are to be put on, pressing this collapsed portion of the chest into the cavity. In this way the healing will take place, and obliteration of the pus sac will be secured.



   The few hints I have given above apply to chronic pleurisy. As stated before, the fluid must be removed where the pressure on the heart or the lungs is great enough to cause dyspnea. (difficult breathing). Where there is discomfort the pressure must be overcome by aspirating.



   This is a simple transudation of serous fluid into the pleural cavity. The treatment is to aspirate and build up the constitution.



   This is a condition where there is air in the chest. It is a rare disease, and usually comes from an injury.

   Symptoms.--The disease comes on suddenly. The patient complains of suffering pain and urgent dyspnea. I have seen but one case, and the signs of distress were so tremendously marked that I shall never forget the man's suffering. He, lived only about twenty-four hours, and there did not seem to be anything that could be done for him. I realize that this was a very acute case. Other cases are developed where the accumulation is much more moderate and slower in developing. Where the distress is very great, trocar and canula. may be used to empty the air out of the chest. It would be well to put a tube into the pleura, and keep it there as long as necessary.