or leeches applied in the neighborhood of the inflamed part. Local bloodletting, in some cases, is more convenient than general; but, so far as the abstraction of blood is concerned, it is difficult to conceive that it is a matter of much importance from what part of the body or vascular system it is taken. Whether it be abstracted by means of cups, leeches, or the lancet, the benefit or injury will depend on the quantity withdrawn in a given period. Whatever advantage may accrue from the removal of a certain amount of blood by cups or leeches, over the abstraction of the same amount by venesection, must be derived from the operation of the former as revulsive mea

sures.

With these few remarks, leaving the consideration of bloodletting, and reverting to the question concerning the curative and palliative measures to be employed in the first stage of acute pleuritis, we are led to the consideration of opium. And, with respect to this remedy, certain considerations. may here be presented, which will apply to the treatment of most other inflammations.

A great change has taken place, within the last few years, with respect to the use of opium in acute inflammations. It was formerly used with much reserve, under the apprehension that, acting as a stimulant, its influence upou the local disease must be unfavorable. It was regarded as antagonistical to the antiphlogistic plan of treatment. Clinical experience and sounder pathological views, however, have led to the knowledge of its great value in the treatment of inflammatory affections wherever situated. It is valuable, not alone as a palliative, but as a curative remedy. Its palliative efficacy is, of course, intelligible; and we can also, to some extent, understand its curative influence. By relieving pain, it diminishes the determination of blood to the inflamed part, for pain is alone sufficient to occasion an increased afflux of blood to a part. This fact is illustrated by cases of neuralgia affecting a superficial nerve. Neuralgia of the supra-orbital nerve, for example, may lead to a determination of blood to the conjunctiva, so that this membrane appears to be inflamed, and the congestion may disappear directly the pain is relieved by a full opiate. Opium exerts also a curative influence by preventing or diminishing the constitutional disturbance which inflammations are apt to occasion. It places the system in a condition to tolerate better the local affection. The severity of an inflammatory disease depends much on the amount of constitutional disturbance which it occasions, and, with respect to the latter, different cases differ widely, although in each the degree and extent of the local affection may be the same. Life is often destroyed, not in consequence of the injury done to the inflamed part, but because the powers of life are inadequate to bear the continuance of the disease. These considerations afford some insight into the utility of opium, especially when patients are of the class who are able to take this remedy without inconvenience-there being, as is well known, a great difference among different persons in this regard. The evidence of the curative value of opium, of course, is derived from experience, and there is ample ground for the belief that by its judicious use in acute inflammations, not only is their course divested of much of the suffering which would otherwise be experienced, but their intensity is lessened, and the danger of death diminished, in those inflammations which tend to destroy life by asthenia. The immediate effects of this remedy are often very strikingly manifest in improvement as regards the local and general symptoms

Considering now the use of opium in the first stage of acute pleuritis, after the abstraction of blood, if this be deemed advisable, or, after a saline purgative, if this be employed in lieu of bloodletting, it will generally be judicious

to prescribe opium,' in some form, in doses sufficient to relieve pain, and place the system fairly under an anodyne influence. If the pain be severe," and the constitutional disturbance considerable, the use of opium need not be delayed for the operation of a purgative, but may be at once entered upon. This is, perhaps, the most judicious course in the majority of cases, a purgative being deferred until a distinct anodyne impression has been produced and maintained for some hours by opium. Conjoined with the use of opium, sedative remedies, addressed to the circulation, may be employed. These should not be pushed to the extent of producing disorder. ́ If, for example, tartar-emetic be given, it should not be carried beyond the point of slight nausea; and the veratrum viride, if given, should occasion no appreciable effects beyond a reduction of the frequency of the heart's action. These remedies, it is to be borne in mind, are addressed, not to the disease per se, but to the symptomatic phenomena of the disease, viz., those belonging to the febrile movement.

A summary of the treatment of the first stage of acute pleuritis, then, will embrace, bloodletting in some cases, the use of opium given sufficiently to relieve pain and tranquillize the system, a saline purgative, and remedies designed to act as sedatives upon the circulation. The importance of the latter is somewhat questionable. Blisters should not be applied in this stage. They occasion general disturbance more than enough to counterbalance any effect by way of revulsion or substitution. They add an inflammation of the skin to the existing inflammation of the pleura. A sinapism, turpentine stupes, or fomentations to the chest, will secure all the benefit of vesication without the annoyance and other evils of the latter. Moreover, a blister is an obstacle in the way of those examinations of the chest which are of importance as affording the only reliable information respecting the progress of the disease.

In the second stage, so long as the quantity of liquid effusion is small and a further accumulation may be expected to take place, the indications belonging to the first stage may continue. If the pain be still acute and the febrile movement have not abated, measures to relieve the former and lessen the latter are indicated. Bloodletting is rarely called for, but depletion by purgatives may be useful, not only by lessening the febrile movement, but by restraining the amount of effusion. Diaphoretic remedies are useful by contributing to the two ends just stated. Opium is indicated in proportion to the pain and constitutional disturbance, and the sedative remedies addressed to the circulation may be employed.

These measures cease to be appropriate when considerable effusion of liquid has taken place, when pain is no longer a prominent symptom, and the febrile movement has either ceased or become much diminished The object of treatment now is to promote absorption of the effused liquid. The means which may be employed for this object are, bydragogue purgatives, diuretics, blisters, and the use of certain remedies which have been supposed to act directly as sorbefacients.

Hydragogue purgatives act most promptly and efficiently. The more active hydragogues, which are drastic in their operation, should be given circumspectly, and generally need not be employed. Reference is had to snch remedies as elaterium and gamboge. The sedative purgatives, such as the bitartrate of potassa, the citrate or sulphate of magnesia, are to be preferred as sufficiently effective and less severe. These will sometimes effect

a rapid decrease of the liquid.

1 The word opium is here used as a general term, including the alkaloids morphia and codeia.

Diuretics are sometimes equally but less rapidly effective. They effect the object with less disturbance of the system and are less debilitating. The union of several diuretic remedies is more likely to prove effective than a single remedy of this class. The squill and digitalis may be combined, and, in addition, the diuretic salts of potassa, or the iodide of potassium, may be given dissolved in an infusion of some one of the various vegetable diuretics. The mustard whey is a favorite remedy of my colleague, Prof. McCready, and I have found it to act upon the kidneys efficiently.

The regulation of the amount of drink ingested is an important point, with reference to the promotion of absorption. The elimination of water by the bowels or kidneys is of little avail, if the patient be allowed to take fluids into the system abundantly. The quantity of liquid ingested should be as small as is compatible with comfort. The treatment is often rendered inefficient by inattention to this point.

Blisters, in this stage of the disease, doubtless contribute to the object under consideration. If the other means are effective, however, they may be dispensed with. Their interference with examinations of the chest is a matter of considerable consequence, and the annoyance which they frequently occasion is not an inconsiderable objection. If employed, small blisters successively applied in different situations, removed as soon as vesication commences, and the vesicated surfaces allowed to dry up rapidly, accomplish all the good to be effected in this way, with the smallest amount of inconvenience both to the physician and patient.

The remedies supposed to act as sorbefacients, are mercury and iodine. Mercury I have long ceased to employ for this end. Of doubtful efficacy, the annoyance and other evils incident to mercurialization render it objectionable. The efficacy of iodine is, perhaps, equally doubtful; but it is not open to similar objections. It may be given internally, or applied externally in the form of either the ointment or tincture.

It is an important injunction not to continue measures with a view to promote absorption too long, or to push their use too far. After the decrease of liquid effusion has reached a certain point, it is apt to take place slowly, for reasons already stated. Whenever this point is reached, the measures to promote absorption should be discontinued, or employed with moderation, else they will be likely to do harm rather than good, by weakening the patient. And if, at any time, these measures appear to impair the general condition, the propriety of continuing them is doubtful. A leading object in the second stage of the disease is to maintain the constitutional strength. For this object, the diet should be nutritious; tonic remedies are useful, and a little wine or spirit may be allowed. These measures should constitute the treatment, after those designed to promote absorption have been sufficiently carried out, and should take the place of the latter whenever there is evidence of the strength giving way.

It is very rarely the case that this disease tends to a fatal ending by asthenia. Should such a tendency be manifested by the symptoms, viz., frequency and feebleness of the pulse, muscular prostration, etc., the measures which constitute the supporting treatment are of course indicated. These measures, which form the most important part of the treatment of the diseases involving danger by asthenia, consist of alcoholic stimulants, nutritious. alimentation, and tonic remedies. They will be noticed more fully in connection with diseases in the treatment of which they are oftener called for.

A fatal result in acute pleuritis may be due to rapid and excessive effusion of liquid, as already stated. If the liquid accumulate sufficiently to endanger life, it should be at once withdrawn from the chest by the operation of thoracentesis. This operation is much more frequently indicated in chronic

pleuritis, and will be considered in connection with the latter variety of the disease.

The measures which have reference to the promotion of absorption are indicated in the third stage; that is, for a certain period during the progress of absorption. When these measures have been carried to a sufficient extent, and the amount of liquid is considerably reduced, the patient may be considered as convalescent. During convalescence the object is to re-establish the normal health of the patient. This is to be done by tonic remedies, a nutritious diet, and other hygienic means. Solid food, embracing a fair proportion of meat, may be allowed whenever taken with relish and digested. Alimentation is important; and if the appetite be small and the digestion weak, remedies to improve both are indicated. No apprehension need be felt that a diet as nutritions as can be taken without inconvenience, will do harm; on the contrary, the more nutritious the food which can be taken and digested, the more rapid the convalescence. Wine or spirit, or beer, in small quantities taken with meals, will expedite recovery. Going out of doors, and gentle exercise, are to be encouraged. The patient will gain. more rapidly as regards appetite, digestion and strength, if he do not confine himself within doors; and, with proper precautions, no risk of harm is incurred. The removal of the liquid which remains, the absorption of lymph, and the development of new tissue leading to adhesions, will go on rapidly in proportion to the rapidity with which improvement in the general condition takes place.

In the foregoing account of the treatment of ordinary acute pleuritis, it is assumed that, exclusive of a small number of cases in which this disease destroys life either by asthenia or apnoea, its course is toward convalescence, without becoming chronic. This is the rule, to which there are exceptions. If the disease become chronic, the measures of treatment indicated are those which will be considered under the head of chronic pleuritis.

The prevention of acute pleuritis hardly claims consideration. The abrupt and rapid development of the disease precludes the employment of prophylactic measures; there are no premonitions which warrant our anticipation of its occurrence.

Marked dulness on percussion over the affected side, especially at the inferior portion, may continue for some time after the liquid effusion has disappeared, the symptoms, general and local, denoting recovery, and the vesicular murmur of respiration heard over the whole of the side. This shows that lymph remains to be absorbed, and need occasion no apprehensions. In a patient discharged from hospital on the day these remarks are penned, the liquid effusion has nearly or quite disappeared, as shown by vesicular breathing and vocal resonance extending to the base of the chest ; yet considerable duluess remains, and will probably continue for several weeks.

СНАРТER III.

VARIETIES OF PLEURITIS.

Chronic Pleuritis-Anatomical Characters-Clinical History-Pathological Character-Causation-Prognosis-Treatment-Thoracentesis-Suppurative Pleuritis, or Empyema-Diagnosis-Prognosis-Treatment-Pleuritis with Pneumothorax-Anatomical Characters-Clinical History-Diagnosis-Prognosis-Treatment-Pneumothorax-Circumscribed Pleuritis

-Hydrothorax.

Of the varieties of pleuritis, the first to be considered is the simple or ordinary chronic form of the disease. Other varieties are suppurative pleuritis, or empyema, and pleuritis with pneumothorax. Circumscribed pleuritis will claim some consideration. This chapter will be devoted to these affections, including a brief account of pneumothorax without pleuritis, and hydrothorax.

CHRONIC PLEURITIS.

ANATOMICAL CHARACTERS.-The anatomical characters in ordinary chronic pleuritis are essentially the same as in the acute form. The pleural cavity contains serum and lymph in variable relative proportions, but, as a rule, the quantity of lymph is less, and the accumulation of liquid greater, than in acute pleuritis. Liquid effusion frequently takes place to such an extent that the affected side is more or less dilated. The lung is compressed into a small solid mass usually situated at the upper and posterior part; the thoracic walls are expanded in every direction; the intercostal spaces are pushed out to a level with the ribs or even beyond this level, and show no depression with the act of inspiration; the diaphragm may be depressed, pushing downward the abdominal organs situated in proximity to it, viz., the stomach, spleen, and liver; the lateral pressure on the mediastinum may be sufficient to move the heart from its normal situation, and, if the effusion be in the left side, the heart may be carried quite into the space belonging to the right side of the chest.

The dilatation decreases as absorption of the liquid takes place, and contraction of the affected side succeeds. This arises from the fact that the compressed lung does not readily resume its former volume when the pressure of the liquid is removed, in consequence of the layers of lymph with which it is more or less invested, and, sometimes, because pleuritic adhesions have already taken place. Other things being equal, the extent of contraction is in proportion to the amount of the previous dilatation and its duration. Usually the dimensions of the affected side in every direction are lessened, the shoulder is lowered, and lateral spinal curvature is apt to ensue. In some cases in which the lung expands to a certain point and becomes fixed by permanent adhesions at that point, the removal of the liquid below leads to a deep depression; the chest presents an appearance as if the lower ribs had been crushed inward. The contraction succeeding a large effusion is generally permanent. It becomes less marked after several months or years, in some cases, and, if the patient be quite young, it may,