SECTION II.

ASTHENIC PLEURITIS.

PATHOLOGY. This form of pleuritis is usually met with in persons who have been debilitated by previous acute or chronic diseases. Most frequently it occurs in the intemperate, or during convalescence from febrile diseases of a typhoid type, from exanthematous and puerperal fevers, from erysipelas; or it arises from organic changes in the kidneys, from phlebitis and diffusive inflammation resulting in the formation of abcesses.

With acute or painful local symptoms, this form of the disease is seldom attended. The disease is, for the most part, latent, effusion often existing long before the disease is detected. Rarely a primary affection, it is most often associated with some other disease, or with some structural change. Its presence is indicated at first, by shortness of respiration, the position of the patient, and the sinking of the powers of life, more than by any severe local distress. The diagnosis, prognosis and treatment of this variety of pleuritis, are so similar to those of the chronic form of the disease, that no separate description is necessary.

SECTION III.

CHRONIC PLEURITIS.

Pleurisy varies greatly both in severity and in duration. It may be acute, in respect to the degree of suffering, and the rapidity of its progress; it may be latent in its character and slow in the progress of the successive changes attending and consequent upon it. Between these extremes, the intermediate grades of morbid action are almost innumerable. The term chronic, then, in respect to pleuritis, seems to be more of a conventional term, than when applied to most other diseases. In pleuritis the transition of the acute to the chronic state is so indefinite, and the symptoms of the recent disease sometimes have so little of an acute character, while that of a long duration occasionally mani

fests so much greater an intensity of irritation, that the terms acute and chronic would seem to be less applicable to pleuritis than to other diseases. This difficulty arises from the anatomical relations of the pleura. Being a shut sac, its acute inflammation is liable to be made chronic by the retention of inflammatory products. And the chronic is liable to be changed into the acute by the irritation of effused fluids.

But, notwithstanding these difficulties, there seems to be no impropriety in ascribing to the disease, when highly inflammatory and until the inflammatory symptoms seem to arrive at an acme, the term acute. If after that period, lingering fever continues, evidently excited by the products of previous inflammatory action, then the term chronic may, with as much propriety, be applied to the disease after, as the acute to the disease before the acme. In some cases, however, such an acme never seems to exist; and, to these the name sub acute may with propriety be applied.

PATHOLOGY.-The anatomical appearances caused by chronic pleuritis are very similar to those of the acute form of the disease. Of course, the influence of time would tend to produce certain modifications. In general we find the membranes thicker, often composed of several adherent layers, the earliest deposits being harder than those subsequently formed. The character of the liquid, too, is subject to various changes in the onward progress of the disease. It is less limpid, more prone to become turbid with flocculi of a fibrinous character. In some cases it even appears in consistence like jelly. The quantity is greater, and consequently the displacement of adjacent viscera is much more apparent. The lung by continued compression is altered in its appearance, and often becomes wholly destitute of its normal crepitation on pressure. Here and there adhesions are often formed, between which in some cases, little sacs of fluid are enclosed. Under the best treatment, the disease, when uncomplicated, will generally advance to a favorable termination. But it often is the case, that the morbid products cannot be absorbed, and, consequently, they remain and pass through a series of pathological changes, sometimes ending in gangrene. Cartilaginous laminæ,

bony plates, abscesses, tubercles and hemorrhagic effusions, are among the successive steps in the progress of chronic pleuritis.

"Sometimes," says Dr. Wood, "the walls of the chest are forced inward contrary to their elasticity, so that, when a puncture is made from without, the air rushes in to supply the vacuity produced by their resilience. In some instances secretion goes on as rapidly as absorption, and the liquid accumulation remains for a great length of time. This is especially the case in empyema, or collection of pus in the cavity of the pleura; sometimes the pus makes its way into the substance of the lung, and a fistulous communication is formed between the bronchi and the pleural cavity, through which pus is discharged and air admitted.

"In other instances the liquid takes an external direction, and by means of ulceration escapes into the cellular tissue without the chest, and, traveling occasionally for a considerable distance, produces subcutaneous abscesses in various parts of the chest, which ultimately open, unless life is previously worn out. In thus traveling, the pus has been known to occasion caries of the ribs and vertebræ, sometimes the purulent collection is found to be connected with a tuberculous vomica."

It is sometimes difficult to determine the causes which change ordinary acute pleuritis into the chronic form. Evidently in many cases, too much depletion, the too free use of mercury and other articles making up the antiphlogistic regimen, tend to the production of chronic pleuritis. Often, when a case seems to be cured by such means, the impoverished state of the blood, caused by the use of the lancet, thus rendering the system more liable to be affected by low grades of inflammation, develops a new and unwelcome train of symptoms admonishing the physician that the supposed cure, was after all, delusive.

Dr. Gallup, defining chronic rheumatism, says that it is acute rheumatism half cured. So it may with equal propriety be said, that chronic pleuritis is the acute variety half cured.

DIAGNOSIS.-The general inflammatory symptoms of acute pleuritis may gradually disappear, but, unless the morbid products of the diseased action are removed from the pleural sac, the fever will recur and change its type, now very closely resembling

hectic, now becoming identical with it. This recurring fever is one of the most troublesome and alarming symptoms of chronic pleuritis; for in other respects the patient does not suffer in a manner proportionate to the extent or the duration of the effusion. Dr. Gerhard observes, "I once saw a patient who had performed the full duties of a sailor, going aloft, with an enormous pleuritic effusion. When he returned from sea, it amounted to two or three gallons. This is an exceptional case; but it is very common to find patients who can perform many laborious occupations without much inconvenience. This is generally the case if the dyspnoea is not severe; and we find that some patients complain of little difficulty of breathing with an extent of pectoral disease which will give rise to great distress in other individuals. The symptoms which so frequently characterize chronic organic diseases, are extremely variable in this variety of pleurisy. These are emaciation, loss of the firmness of the muscles, harshness and dryness of the skin, and slight oedema of the legs. Sometimes they are nearly as well marked as in tuberculous disease of the lungs; in other cases they are very slight; hence, they constitute a diagnostic sign of the disease; and, if we find them well characterized, we will do right to regard the case as one, probably, complicated with tubercles. If our impression be erroneous, we will soon rectify it, as the symptoms will gradually become more decided in the latter case, and slowly disappear if the pleurisy be followed by recovery."

The diagnosis of chronic pleuritis without the aid of the physical signs, is often very difficult. Its general symptoms simulate those of phthisis. But the physical signs are far more reliable. When these are present there is no difficulty in ascertaining the true character of the disease. If it is complicated with tuberculous deposition, the case should be regarded with much anxiety; for the diagnosis then becomes much more obscure, and the prognosis more unfavorable.

PROGNOSIS. In this variety of pleuritis, when attended with copious effusion, the prognosis is doubtful. The liquid consisting. mainly of pus, causes irritation, sometimes so severe as to produce marasmus, and to deprive the system of all that recuperative

power ever necessary in the progress of recovery. Sometimes it proves fatal in consequence of the obstruction to respiration; sometimes by the occurrence of metastatic abscesses in parenchy

matous organs.

This latter result, however, is not very common.

TREATMENT. The treatment of chronic pleuritis differs from that of the sthenic character, less in the kind of remedies used, than in the manner of their application. Whatever means are applied should be such as tend to prevent effusion and promote absorption. For these purposes gentle emetics, followed by the use of vegetable tonics, are very serviceable. Of the utility of occasional emetics of lobelia in chronic pleuritis, there is much evidence. Their operation, in my opinion, is more sure than any other means, to prevent effusion and promote absorption, and to prepare the digestive organs, for the successful administration of tonics. Those who are anæmic seldom bear well the effects of emetics, especially of thorough ones. But those whose digestive organs are inactive, accompanied with febrile excitement, with dry and hot skin, and headache, with derangement in the circulation of the blood, will receive benefit from their occasional use. In connection with them, the vapor bath, or in cases where proper reaction is sure to result, the pack sheet, may often successfully be applied.

Counter irritation is useful in this variety of the disease. For this purpose podophyllum or podophyllin sprinkled upon the surface of an adhesive plaster and applied to the side, will, in a short time, produce free suppuration. The same and perhaps a better effect may be derived from the use of Dr. Hill's irritating plaster. Senega and squill may be employed with benefit. To promote absorption, the iodide of potassium has been highly praised. When hectic symptoms appear, they should be combatted with tonics. The infusion or the sirup of wild cherry, I have found more efficacious than many other tonics. I prescribe this, in connection with the sirup of the iodide of iron. One ounce of the latter, added to one pint of the sirup of the former article, makes a good compound.

If there is great debility sulphate of quinine, salicine and hydrastine should, either separately or in combination, be adminis