died of cholera infantum, without ever having had the slightest symptom referring to any lung complication.

Necropsy.-Body well nourished. As there had been no noticeable abnormal condition other than the inflammation of the bowels, the abdominal and thoracic cavities only were examined. No peritonitis; the mucous membrane of the bowels presented the appearance of recent acute inflammation and cause of death. The left thorax and contents were normal.

On removing the right lung it was found adherent at several points, by pleuritic bands at the superior and posterior border, which, from the ordinary lung action, were becoming less and less, showing places where former adhesious had existed, but had been entirely overcome, leaving points of deposit of old fibroplastic exudate.

Over the surface of the parenchymatous pleura, deposits of this fibrinated lymph were visible, but almost the entire serous pleural membrane had resumed its secreting and shining smooth surface. The lobes were all inflatable. On cutting into the parenchyma, the only abnormal conditions existing were four or five portions of compressed lung about the size of nutmegsnot the slightest sign of degenerative disease. There were no cheesy or tuberculous deposits found in any part of the body, demonstrating that a return to perfect health may be expected after empyema or thoracentesis.

Spontaneous cure of empyema by discharge per bronchi.

Niemeyer states that a penetration of the pus into the lungs, and its discharge by way of the bronchial tubes and mouth, rarely ends in recovery. I have had a patient thus cured by nature, when as much as thirty ounces of thick, creamy pus came up by the mouth in a single day. He was occasionally during the intervals of rest placed in the most favorable position to favor drainage by the air-passages. At the end of the first week his distressing cough was relieved. Convalescence steadily continued, and in a letter to me one year and four months afterwards, he stated that he was in good health, and was able to perform all the duties of an active business man.

In one instance, the pressure from within the chest from the accumulated fluid was so great that a disarticulation at the sterno-clavicular junction followed; and it is in accordance with

statistics, that openings made by nature are generally either at the apex or base of the thorax.

After I had operated, I reduced the dislocation; the parts were easily maintained in their normal position, and perfect cure followed.

An empyema entirely cured without the operation of thoracentesis.

The following instance clearly shows that the conservative hygienic measures resorted to fully justified my decision not to operate so long as no alarming symptoms occurred, and where all that skill and wealth could possibly do to hasten recovery were at our command.

Boy, three years of age, passed the acute stage of purulent pleurisy, his right thorax becoming so filled with liquid that the rotundity of the chest was increased, and the lung on the right side was for weeks rendered useless.

This little boy had a waxy countenance, was very leucocy thæmic, had a short hacking cough, hectic fever, and nightsweats, irregular, frequently palpitating heart, and was extremely emaciated.

Tonics were given, combined with the tincture of the chlo ride of iron in ten-drop doses. His parents lived in one of the most salubrious parts of New York City, which early in the season they left for a pleasant country residence, and during the midsummer, for a long season, kept the child in the out-door air of the Adirondack Mountains. All the pathological conditions gradually left, and at the end of one year the lung had resumed its normal condition, the liquid all absorbed, and in two years, from being a feeble, fretful, irritable child, he became happy, and so active that he is now the joy of the house, promising not only to become a healthful, vigorous man, but bright and intellectual.

An opposite pneumonia, occurring while the empyema is being treated by a free incision, and the lung is consequently in a state of collapse, is one of the most dangerous complications that can arise.

I had one fatal instance where this took place at a time when the patient had almost entirely recovered of his pyo-thorax, but where this complication coming on deprived him of the use of the lung that had almost carried him through a convalescence;

and, as no lung was left in a normal condition, death followed, as occurs in simultaneous double pneumonia.

Is the operation justifiable, when far advanced tubercular phthisis is known to exist?

The good result following the removal of sixty ounces of pus from the following young lady, aged 21 years, I think conclusively answers in the affirmative. On June 23, 1868, I was hastily summoned, for the first time, to see Miss A. F., whom I found supported by friends in the sitting posture, gasping for breath, bathed in cold perspiration, and suffering from intense lancinating pleuritic pain.

On examining the chest, I found complete dulness over the entire surface of the left lung; diagnosticated a large collection of pus in the thoracic cavity, rendering completely useless the left lung, and pressing on the opposite diseased lung, causing her to be in the greatest misery and apparently dying.

By a very small and almost painless incision with the scalpel, I opened the chest on its lateral aspect, at the seventh rib, introduced through the opening a No. 8 male silver catheter, at the end of which a Davidson's syringe was attached, and, by slow, steady aspirations, withdrew sixty ounces of offensive, thick, putrid pus.

During the operation, especially when about a quart had been removed, she experienced such relief that she exclaimed, “Oh, thank God and the doctor for such comfort." After the removal of about three pints, she had occasional radiating pleuritic pains, caused by the compressed lung expanding. Stimulants were freely given to increase the enfeebled cardiac action, and the operation discontinued, as the symptoms indicated too sudden removal on the pulmonary tissue. When nearly half a gallon had been removed, she unguardedly turned to look at the vessel containing the thick, creamy, offensive pus, and from the shock had an attack of syncope, which was in less than a minute relieved by placing her in the recumbent position and giving teaspoonfuls of brandy. All distressing symptoms were readily relieved, the operation continued, and at the termination. she was so much better that she could respire quite freely so long as no air was permitted to enter by the wound. Two or three times during the operation, and on withdrawal of the catheter, a small quantity of air passed in, producing such dys

pnoea as to prove conclusively that she could not tolerate a large incision, for the free admittance and exit of air.

The wound was, therefore, hermetically closed, and in three days had entirely healed.

She regained her strength so rapidly that in one week, I found, on visiting the house, that she had gone to Central Park (which was just opposite), and for the several succeeding days following was able to take her daily walks.

She continued to recuperate until July, when the weather became intensely oppressive, and a loss of appetite with gradually increasing exhaustion preceded an easy death by asthenia. She was apparently dying when I first saw her, in the greatest agony, and there is little doubt that the removal of nearly half a gallon of pus relieved pressure on her right lung, prolonged life, gave great ease, and allowed her, when she finally became exhausted, to die comparatively free from pain.

The beneficial effect of hermetically sealing the thorax after injury to the healthy lung and pleura, I observed in a man shot through the lung; the bullet, after passing through his chest, passed through the lung of a second, strong, healthy man, killing him. In this instance, whenever air was drawn in through the wound, his breathing ceased as the lung collapsed, and only when I held my finger over the opening was he able to draw in a breath. The chest half filled with air and blood, which I hermetically closed in, the wound healing in less than three days; severe pneumonia followed, the air and blood left in the chest were entirely absorbed, and the man made a complete recovery.

The evils of introduction of atmospheric air into the diseased thoracic cavity have been greatly exaggerated. I have observed instances of empyema where, as partial collapse of the lung occurred, great dyspnoea followed, and have, therefore, hermetically closed such a wound permanently; the air has been removed by absorption, the lung has recovered and eventually filled the chest cavity, returning to perfect health.

Point of election for performing the operation of thoracentesis. When the opening is to be closed, I prefer the lateral aspect of the chest, either above or below the eighth rib; this is known not to be the most dependent part, but with the long curved silver or soft India-rubber catheter (No. 8 Eng.), the lowest

portion of the cavity may be reached, even to the diaphragm; and, as there is no danger of the point producing injury, nothing need be feared, and the chest can be emptied of its liquid contents. But when a free incision is to be made and a constant drainage maintained, about three or four inches from the spine along the edge of the latissimus-dorsi muscles, and between the ninth and tenth ribs on the right side, and on the left side between the tenth and eleventh ribs, will be found positions most favorable to permit a constant exit as soon as liquid forms. Again, I would give the caution that in these most favorable positions the trocar ought not to be used, but an incision made with a scalpel, seeing tissue by tissue through which we pass.

Hermetically sealing the opening on the completion of the operation to secure primary union has, with me, given the best results, even when reaccumulations were expected.

A repetition of the operation one or more times has presented better results than when I have resorted to free continuous drainage as a primary procedure.

The free incision for gradual drainage cannot be used in all cases. In 1869 I resorted to this method, using a large roll of oakum to absorb the flowing pus; the child, the grandson of a New York physician, was predisposed to tuberculous trouble, and had an irritating cough, and at each violent paroxysm would forcibly expel quantities of liquid from the opening, causing terror and frightful agitation. The wound was sufficiently large to permit free exit and entrance of air, and continued to discharge for over a year.

In another instance I resorted to the same procedure in a boy twelve years of age, otherwise healthy, when the wound closed and recovery followed in six weeks; also in a boy two years old, where eighteen ounces came away by the first flow; the wound was left open, and covered with large pads of oakum; in four weeks spontaneous closure of the wound occurred, and complete recovery followed.

The objections that I would make to treating all cases of empyema by a free incision, like an ordinary abscess, are: 1st. The impossibility of compressing the walls of the thorax, and thereby, by the free admission of air, change laudable into septic purulent matter; also the almost certain degenerative change that would occur in the entire pleuritic membrane, converting it into a thick fibro-plastic tissue, incapable of ever VOL. XXXI.—53