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ach is somewhat distended with warm water, at suitable intervals, a pill containing from gr. ii to gr. iv. of extract of lobelia, until considerable nausea is produced. Then I direct the copious drinking of warm water which in a few moments is usually followed by an easy and free evacuation of the contents of the stomach. In other cases, when the patient can bear more heroic treatment, the pursuit of the above course is not necessary, but the emetic may be given in the ordinary way. In case much distress results from the effects of the emetic, administer, in cold water, and repeat the same, acetic, or citric acid.

The means chiefly to be relied upon, in warding off the necessity for an operation, are the vapor bath followed by brisk friction, gentle and repeated emetics, followed by the strongest tonics, and nourishing food, and vegetable diuretics. Inhaling tubes for the purpose of expanding the compressed lung, are by some highly recommended. When the effusion has a purulent character, the hydriodate of potassa in the dose of two or three grains, three times a day is often useful; in more asthenic cases, the iodide of iron, in rather small doses may be given. For a diuretic, when the vegetable diuretics before mentioned, fail to give relief, the tartrate of iron is serviceable, especially where a dropsical diathesis prevails.

SECTION IV.

LATENT PLEURITIS.

This variety differs from others mainly in the absence of the more common rational symptoms, such as dyspnoea, cough and pain. These are either entirely wanting or are so imperfectly developed as to make it impossible to found upon them an accurate diagnosis. The disease passes so insidiously through its different stages, that the patient is seldom aware of the nature of the malady with which he is affected. After recovery he often forgets the trifling indisposition which he felt during its progress. In this form of pleuritis adhesions of the lungs to the costal pleura often become extensive. In rare cases the general symptoms are more marked, attended with a gradual wasting of the vital forces. In general such cases are complicated with phthisis.

PATHOLOGY.-The anatomical lesions in latent pleuritis differ so little from those already described, that their consideration in this place would be but a useless repetition.

DIAGNOSIS.-The absence of the rational symptoms, makes the diagnosis dependent almost wholly upon the physical signs. In case there is considerable effusion, we have dulluess on percussion, feeble respiration and egophony.

Additional evidence of the pleuritic character of the disease is afforded by the existence of the friction sound. In case this is absent and the other signs above referred to are but imperfectly developed, there is danger of confounding the disease with enlargement of the liver, or with consolidation of the lung. In the majority of cases, however, the physical signs are so well marked that a correct diagnosis may be made. With tuberculous disease it is often so intimately connected that it is difficult to determine how many of the morbid phenomena proceed from the tubercular deposits, and how many from the pleuritic inflammation. Almost always in those of a scrofulous diathesis, these two diseases are more or less mingled together; and hence, in such persons, the slightest symptoms of phthisis occurring in pleuritis should be closely observed.

PROGNOSIS. The prognosis is favorable or unfavorable according to the nature of its complicating diseases, and the condition of the constitution. When associated with phthisis there is but little reason to hope for recovery; when isolated and occurring in a healthy constitution, it generally, under proper treatment, terminates favorably.

TREATMENT. The treatment does not materially differ from that of other chronic forms of the disease. There is, therefore, no need of any repetition in this place, of that which, under the head of Chronic Pleurisy, is fully described. The remedies should, of course, be continued until all physical signs of the disease disappear, and the general healthy appearance of the patient is indicative of complete recovery.

SECTION V.

SECONDARY AND COMPLICATED PLEURITIS.

PATHOLOGY.-Pleuritis is often associated with inflammation of an adjoining tissue or organ, or with some other lesion or malady. It may be either primary or secondary. With inflammation of the parenchyma of the lung it is frequently complicated; the disease sometimes beginning in the pleura and extending to the substance of the lung; at other times, on the contrary, beginning in the lung and extending to the pleura. This complication is usually termed pleuro-pneumonia, and by older writers was known by the name peripneumonia. In such cases the inflammation usually assumes a sthenic character. The pleuritic and the pulmonic inflammation may be coetaneous. More often, however, the pulmonic, is antecedent to the pleuritic than the reverse.

Some writers assert that the complication of pneumonitis with pleuritis lessens instead of increasing the danger. The reason given is derived from the idea that the pneumonia is lessened by the pressure of the effused fluids of pleuritis. The lung also by its increased size, in consequence of the engorgement of its vessels, presses upon the fluids, and this excites a degree of activity in the absorbents, which under other circumstances would not exist. There is, then, according to this theory, a reciprocity of action, whose tendency is to the cure of the disease.

Pleurisy is sometimes complicated with exanthematous and continued fevers. Unless it occurs in the period of convalescence from these maladies, it is prone to assume the sthenic form, but when during recovery the fluids of the body are contaminated, and the vitality of the system depressed, the asthenic form is most common. Whenever, in fevers, the breathing becomes very short and frequent, whether or not accompanied with pain in the side and cough, then pleuritic inflammation may be suspected, and an examination should be immediately made in order to arrive at a correct diagnosis, and predict with certainty the nature of the termination.

Another very frequent complication of pleurisy is with phthisis and chronic tubercular pneumonitis. Tubercles existing near the surface of the lung, often excite inflammation in the circumjacent tissues, which is readily extended to the pleura pulmonalis. On its free surface lymph is effused, which, coming in contact with the pleura costalis, excites on it inflammation. Adhesion usually is the result. Sometimes, however, a different state of things takes place. A cavity, by the softening of tubercular deposits, is formed near the surface of the lung before adhesion is effected. This, in some cases, producing a perforation of the pleura pulmonalis, and at the same time communicating with the bronchial tubes, admits into the cavity of the pleural sac, the atmosphere. This kind of lesion is called pneumothorax, which, in another place, will be more fully considered.

Tuberculous pleurisy may be consecutive to tubercular deposits in the parenchyma of the lungs, and then it is strictly secondary. Again, in the second place, it may arise from the deposit of tubercles in the pleura itself; and, lastly, the inflammation of the pleura is antecedent to the tubercular deposit, the pleuritis thus becoming an exciting cause of phthisis. The latter effect of pleuritic inflammation should then be considered in this connection. Why is pleuritis more prone to produce tubercular disease, than pneumonitis? To answer this may be difficult; and yet such is the fact. May not the absorption of pus into the blood be one prominent cause? This, like all other impure matter in the blood, must tend to produce more or less debility, must excite an irritative fever simulating the hectic of phthisis.

That febrile action which most nearly resembles the hectic of phthisis, should cæteris paribus be most likely to afford conditions most favorable to the development of tubercles. This may be one cause of the tendency of pleuritis to generate phthisis.

Pleuritis is also complicated with many other diseases, with pericarditis, hepatitis, peritonitis, and rheumatism. These complications, however, are not sufficiently common to be made subjects of separate consideration.

DIAGNOSIS. The diagnosis in complicated pleuritis, must depend upon that accurate discrimination in the balance of symp

toms, which is the possession of every close observer of disease. Each symptom is often a complex phenomenon, divisible into a number of separate signs. If in the course of pneumonitis, the friction sound occurs, if there is great dullness on percussion, the limits of which change on every change of posture, if there is egophony, if either one or all of these physical signs, are combined with those of pneumonitis, the diagnosis will be evident. Complications with phthisis will of course, give the signs of both diseases; with pericarditis, will give the friction sound of pleuritis heard only during respiration; while the friction sound of pericarditis is heard during the suspension of respiration. The effusion, and consequent dullness of pericarditis is confined to a small space-the præcordia; that of pleuritis extends over the base and sides of the lung and is in general changed by any change of posture. When both these trains of symptoms are coetaneous, the nature of the complication will be evident. The diagnosis of other complications must depend upon principles similar to those already suggested.

The PROGNOSIS will depend upon three conditions, the nature of the complicating disease, the extent of the pleuritis and the constitutional state of the patient. Pleuro-pneumonitis, has already been referred to. Pleuritis complicated with phthisis is always very dangerous; with pericarditis it is unfavorable.

TREATMENT. The complications of pleuritis necessarily involve the same principles of treatment as the more distinct forms of the disease. Regard must be had to the nature of the malady with which the pleuritis is associated. If its complication be with some other sthenic inflammatory disease, the anti-inflammatory means must be used in the process of cure. If associated with pneumonitis, all narcotics should be used with more caution. than in its simple form. When arising from the retrocession. of eruptions from the surface, warm bathing with stimulants and diaphoretics should be used. When complicated with phthisis, the treatment for the latter disease is most appropriate.

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