tuberculous, as we were confidently informed a few years ago. Pleurisy may be ushered in by a chill, followed by sharp pain in the side, worse on inspiration; but in many cases the onset is insidious, with shortness of breath, weakness and loss of appetite as the prominent symptoms. In the latter form it is not uncommon to find one pleural sac well filled with serum, the intercostal spaces bulging, the whole side dull on percussion, and the heart pushed over to the other side, when the patient first consults his physician. Dry cough, suppressed by the pain induced, hiccough, rapid pulse and hurried respiration, with fever rising to 100°-102°, and difficulty in lying on the unaffected side, are the usual symptoms. XXV. Pain along the lower costal cartilages, shooting up to the neck and shoulder, or an inch or two from the middle at the level of the tenth rib, indicate diaphragmatic pleurisy. Hiccough is somewhat more frequent in this form, and sometimes there is much embarrassment of respiration with great distress. But in one case there was simply aching in the right side, with slight jaundice and disorder of the digestion which induced me to make a diagnosis of hepatic abscess. The man died of double pneu monia. A temperature of 104° in the evening, preceded by chills and followed by sweating, with a heavy fall of the fever, indicate the occurrence of suppuration, or empyema.x The debility then becomes more pronounced, and rapid emaciation proceeds. When the inflamed pleura are separated by the exudation the pain is relieved, and both dyspnea and fever subside, unless the distention is very great, when there is a sense of weight and oppression. If the heart is pushed out of its usual situation there may be pain under the lower part of the sternum. Cyanosis may also occur. In the early stages, before exudation has occurred, a friction sound may be heard, on auscultation; but this "leather creaking" cannot always be distinguished from crepitation, and is generally gone when the doctor is called. The bulging intercostal spaces, absence of respiratory motion, displaced heart, and dullness on percussion, with the absence of crepitus, and the dry cough, are the main diagnostic points. The dullness is best demonstrated at the back. The fluid does not shift with the patient's change in posture, as in hydrothorax, because in pleurisy the inflammation at the margin of the exudation soon glues the pleura together and circumscribes the effusion. The vesicular sound is diminished and bronchial respiration heard, in proportion to the degree of compression to which the lung is subjected. The transmission of voice-sounds is diminished. Baccelli affirms that a whisper is transmitted thru a serous but not thru a purulent exudate. If recovery takes place, the serum is reabsorbed, rapidly at first but more slowly as the exudate becomes thicker. Persisting fever indicates the chronic form. If the compressed lung has been consolidated by inflammation, or covered by a fibrous investment, it may not expand to its former dimensions.The vacuum is then filled by sinking in of the intercostal spaces, the intercostal spaces, compensatory emphyema, retraction of ་ the heart, and in some cases the ribs come in apposition and the upper part of the patient's body is drawn over to the affected side. Persistence of the exudation, or its increase by successive attacks, are suggestive of tuberculosis. Empyema destroys the pleura, and the pus may perforate the intercostals and appear under the skin; usually in the fifth intercostal space near the sternum, The cardiac pulsations are transmitted by the pus, simulating aneurism, especially in left pleurisies. A puncture by the hypodermic needle is harmless in any case, and shows whether we have to deal with serum, pus or blood.x The prognosis depends on the cause. Death may be caused by interference with the heart, by pulmonary edema and hyperemia, or from pulmonary embolism, in the height of the attack. it occur later, it will be due to exhaustion or to the causal disease. If The treatment varies so with the nature of the case, that only general principles can be laid down. The pain in the side is better relieved by a tight bandage than by leeches or blisters, tho dry cups are sometimes useful. A hot mush jacket assists in relieving the con gestion; but for this the sovereign remedy is aconitine. Of this a granule of gr. 134, of the amorphous form, should be given every half-hour until effect; aided by glonoin, gr. b, and atropine, gr. so, to dilate the cutaneous capillaries and withdraw the blood from the inflamed area. If the pulse requires steadying, strophanthin, gr. do, should be added instead of digitalin, as the former does not contract the vessels so much. The bowels should be opened by full doses of saline laxatives. As soon as the congestion and pain have been relieved, pilocarpin, gr. 7, should be given every half-hour until free sweating occurs, and the dry diet rigidly enforced. DaCosta pointed out the value of this method years ago, but the observation never received the attention it merited. By decreasing the serum of the blood the effusion of the exudate is checked, the effects of pressure prevented, and absorption begins speedily. This method is much more pleasant than the ancient custom of leeching, blistering and purging, calomel and diuretics, and indubitably more effective. The infective element, whether pneumonic, tubercular or pyogenic, requires the use of calcium sulphide, gr. % every half-hour until saturation; with suppositories containing ten to twenty grains of quinine every eight hours. Small doses of calomel promote intestinal antisepsis and favor absorption, whether they lessen the fibrinous exudation and combat serous inflammation or not. xvxxx If the effusion causes oppression, it should be drawn off by the aspirator. This operation is easy, safe and effective. There is no special objection to its performance at any time, and good reasons for resorting to it early. It is impossible to tell how long the lung may be compressed and still and still resume its dimensions and functions; but in some instances a very few days suffice for its irretrievable ruin. If the inflammatory tendency is lessened by judicious treat. ment there is less danger; but whenever the exudation shows signs of remaining, of increasing, or of developing into empyema, the aspiration should be at once performed. Bowditch recommended it when even a moderate effusion lasted more than a few weeks, but if under the above treatment the exudation is not evidently subsiding in a few days, it should be withdrawn. Full antiseptic precautions must be enforced. The skin should be washed with soap and water, then with ether, and finally with hydrozone, one part to five of water. The aspirator needle should be boiled, and passed thru the flame immediately before using. The usual point for puncture is the seventh intercostal space, below the center of the axilla.) The skin may be anesthetized by a jet of ethyl chloride, and the needle introduced at the upper margin of the eighth rib. During the flow of the effused liquid the patient must be watched carefully, and at any indication of weakness the needle withdrawn; tho if syncope occurs, it is auto-suggestive. The amount of fluid withdrawn depends on the case; but if care be taken to avoid wounding the lung, by withdrawing the stylet and leaving only a canula, and if no signs of weakness occur, there is no advantage in leaving much of the exudate. But if the surfaces of the pleura on coming together, at once give rise to pain, with the friction sound, the aspiration should not continue longer. If the fluid is pus, and a single aspiration does not cure, a free incision should be made, the cavity flushed with warm boric acid solution, and drained. The inhalation of compressed air has been recommended to favor expansion of the lung; and this should always be tried. The other treatment required is that of the causal affection. WILLIAM F. WAUGH, M. D. 103 State St., Chicago. Homeopathic Treatment of Coughs. By A. C. Cowperthwaite, M.D., LL.D., Professor of Materia Medica and Therapeutics in the Chicago Homeopathic Medical College. Editor MEDICAL WORLD:-In presenting an article on the homeopathic treatment of coughs to non-homeopathic readers, it is quite important to take into consideration some facts that it would not otherwise be necessary to mention. In the first place it is probably pretty well understood that a homeopathic prescription is based solely and only on the symptoms of the individual case, and the remedy must correspond to these symptoms or it is not homeopathic. This does not, however, simply mean subjective symptoms; objective symptoms are equally as im portant, and pathological states when well defined go far towards indicating the remedy. Yet it will not do to prescribe on pathological symptoms alone; this will lead to error, as we well know the diagnosis of certain supposed pathological conditions is quite often wrong; and a remedy based upon such conditions would be equally wrong. Nor is that all; even tho a drug produce a certain pathological state, that is no evidence that it is a specific for that condition, nor even a remedy for it unless the symptoms of the case correspond with the drug. There has been considerable effort in the homeopathic school during the last fifty years to make a short cut towards the treatment of diseases by pathological prescribing. For instance, Majendie experimented with some drugs; he found that tartar emet. would produce hepatization of the lungs; therefore he assumed at once that tartar emet. was a specific in hepatization of the lungs. Experience, however, has proven that his conclusions were altogether wrong. Tartar emet. is seldom a remedy in hepatization of the lungs, and is usually one of very little value in that condition, to say nothing of its not being a specific. This is simply because the symptoms of tartar emet. seldom correspond to those of hepatization of the lungs. Then again, in writing on homeopathic treatment for non-homeopathic readers it should be borne in mind that while the mass of the homeopathic profession are agreed in therapeutics, there are unfortunately two extremes of the school who differ with us somewhat, and bring discredit upon the system. One branch of these extremists arrogate to themselves the title of "Hahnemannian," and in the name of Hahnemann, whom they designate as their "Master," they assume to outdo Hahnemann himself in the prescription of what are known as high potencies, based exclusively upon symptomatology. This branch number but a comparative few, but they make noise enough to have it appear that they are the whole thing. As a rule they are narrow minded and bigoted, with little medical knowledge outside of symptomatology, which they work on the principle of a piece of machinery. The other branch I refer to are those who swing a homeopathic shingle for commercial purposes, but who rarely prescribe homeopathically, depending on palliatives very largely in the treatment of disease. The true homeopathist will use a palliative in cough or any where else when his fallible judgment fails to find the remedy that cures. And permit me to say that I thoroly believe that any failure in the prescription of the homeopathic remedy for cough is entirely due to lack of knowledge or judgment upon the part of the prescriber, and is not due to a failure in the remedy itself. With these prefatory remarks I can only give the indications for the remedies most often prescribed for cough, which are as follows: Bryonia.-Perhaps this remedy de-serves first place, but not so much because it is oftenest prescribed for cough as for the fact that when indicated it usually comes in ahead of other remedies. It is often the first remedy indicated when an acute catarrhal condition is first localized in the respiratory tract, and a cough is developing, which is usually dry and rough, with a little thin mucous expectoration, and accompanied with considerable soreness of the chest. The cough is always worse in a warm room, espe cially on coming in from the cold air, and is worse from moving about. Bryonia is a remedy most useful after the violent general symptoms of an acute inflammation have begun to subside, and localization with product formation is about to take place or has already just occurred. This holds true in other localities, but is especially applicable in respiratory inflammations, whether they be tracheitis, bronchitis, pneumonia or pleurisy. In the latter the well known sticking pains of bryonia causes it to be often indicated, and these pains may be present and assist in indicating bryonia when the pleura are not involved. This drug is unfortunate in being nearly always handicapped in its good work by being prescribed in alternation with some other drug, notably aconite. The stage of use 50 fulness for bryonia only begins when that of aconite et al. ends; and on the other hand, that of bryonia ends when that of phosphorus et al. begins. These various drugs follow each other well and are complementary, but their alternation is neither scientifically nor practically correct. Phosphorus.-It is altogether likely that, in a general way, phosphorus deserves first place as a cough remedy. As has already been suggested, its sphere of usefulness usually begins after bryonia and similar remedies would cease to be indicated, whether in an advancing catarrhal condition ending in laryngitis, tracheitis, or bronchitis, or in pneumonia. Phosphorus is never indicated early, but only after product formation is fully established. In the first mentioned the cough is dry, caused by tickling in the trachea, some mucous expectoration, and accompanied by soreness, oppression and constriction of the chest, the latter being an important differentiating symptom. The cough is usually worse when the patient lies on the left side, worse from and contalking, laughing or reading, and contrary to bryonia, is better indoors and worse when going from warm to cold air. In pneumonia phosphorus is indicated where there is a dry cough with bloody mucous, or rust colored expectoration, with violent oppression or tightness of the chest. It may also be useful in tuberculosis when the hollow, hacking cough is present. Kali bichromicum.-This drug is frequently prescribed for, and is of great value in subacute and chronic inflammations of the lower air passages, but is never of value in the early stages. The cough is usually dry, deep, rough, hoarse and accompanied by a difficult, tough, stringy mucous expectoration. Kali is often needed for the hard, deep coughs that prevail after a common cold. While the tightness and constriction of phosphorus are not present, yet there is no element of looseness in the cough itself, wherein it differs from hepar sulphur. The cough is usually brought on by tickling in the trachea or at the bifurcation of the bronchi, and according to clinical observations, is worse after eating, when undressing and in the morning on waking, better after getting warm in bed and when exercising. The usefulness Hepar Sulphur.-This is the chief Rumex Crispus.-This remedy is of great value in coughs accompanying acute catarrh of the larynx or bronchi, or from laryngeo tracheal irritation. The chief feature of the drug is that the cough is always produced by tickling in the throatpit, and has invariably associated with it a raw sensation behind the Under such circumstances its The cough is sternum. effects are marvelous. generally incessant and fatiguing, and is aggravated by pressure, talking and especially by inspiring cold air, and in the evening after lying down. Ipecac. This remedy is useful in bronchial coughs, where there is a great accumulation of mucus in the air passages, causing rattling respiration, but little expectoration; much wheezing, dyspnea and inclination to vomit. It is often indicated in the capillary bronchitis of children, being similar to tartar emetic, but there is less prostration and tendency to collapse. The cough is usually spasmodic and recurs in paroxysms. The same holds good in whooping cough, where we also find hemorrhage from the nose and mouth, vomiting, loss of breath, face pale or blue, body rigid. Antimonium tartaricum.-This drug is very useful in coughs which are accompanied by a great accumulation of mucus in the chest, causing rattling respiration and suffocation, even to cyanosis, but with little or no expectoration, relief coming promptly if expectoration occurs. It is the chief remedy in capillary bronchitis, where there is much rattling of mucus in the chest, oppressed breathing, rapid pulse, nausea, vomiting and drowsiness. It is often indicated in whooping cough, asthma, broncho-pneumonia and pleuro-pneumonia, and is frequently required in ordinary catarrhal conditions and incipient bronchitis. Stannum.-Stannum is an invaluable remedy where there is an easy, profuse mucous or muco-purulent expectoration, which is usually of a greenish color. It is easily differentiated from tartar emetic by the fact that while there is a great accumulation of mucus, it is usually located in the trachea, does not cause any great amount, if any, rattling, and is very easily expectorated. Neither does it cause the cyanotic symptoms of the latter and is not accompanied by vomiting and nausea. An almost ever present characteristic is a great weakness in the chest. The expectoration of balls of sweetish mucus is also characteristic. It is most often indicated in tracheitis, bronchitis, laryngeal phthisis and phthisis pulmonalis. Belladonna.-This drug, more than any other, gives a typical dry cough. It is caused by tickling in the larynx, and is usually worse in the evening after going to bed. There is great dryness in the larynx, even at times causing a husky hoarse voice, and sometimes threatening suffocation. It is most often indicated in acute laryngitis or bronchitis, catarrhal croup, spasm of the glottis and whooping cough. Nux Vomica.-This drug is not as often prescribed for coughs as it deserves. It is valuable in bronchial catarrh, with a dry cough, and accompanied by roughness, rawness and scrapping in the chest, this reminding us of rumex, but being less acute in character. Violent, dry, fatiguing cough, worse early in the morning. It is quite useful in reflex coughs arising from gastric troubles and mental exertion. Spongia.-This remedy may be of value in dry, hoarse, barking cough in either children or adults, but its well known value is in the treatment of croup, where it is often prescribed regardless of indications, and where iodine, bromine or some other drug might answer a better purpose. It is not indicated where there is high fever and a dry, hot skin, but in cases where this condition is not present or has been already subdued by aconite, a dry, barking, croupy cough and anxious wheezing, whistling, sawing respiration still remaining. It is of little value after membranes have formed. In addition to the remedies considered we should not forget the characteristic nervous coughs of gelsemium, hyoscyamus, ignatia, kali bromatum, and other drugs whose indications it is not necessary to give in detail. Venesection and other Heroic Measures in Pneumonia. Editor MEDICAL WORLD:-Late in the fall of 1847 it was my fortune to listen to a clinic by Prof. Brainard, in the hospital connected with Rush Medical College, on pneumonia and its treatment, giving particular attention to the neces sity and usefulness of venesection in this disease. The clinic commenced about as follows: "Gentlemen, we here have a case of pneumonia of eight days standing. Both lungs are engorged and, as you see, the patient is already greatly cyanosed, and with shoulders elevated and head thrown back, he is laboring and gasping for breath, the lungs being so engorged as |