factory effects of absorption, in cases where the dyspnoea and faintness seemed to me most urgent and dangerous. It was quite common, and, in fact, occurred in the majority of cases, that the fluid descended one third, and still oftener one half, down the chest, within the space of forty-eight to sixty hours, carrying with it the extreme dyspnoea and faintness, to the great relief of the patient.

Say that blisters were used from the first, and that the following became my settled plan of managing them. One blister six inches long and three and a half broad, exclusive of margin, was placed longitudinally over, and a little to the outside of the angles of the ribs, leaving space for another of similar size between the first and the spine. Great care was taken not to remove the cuticle, (one means of which was to cover the surface of the blister with silver paper,) as this forms by far the quickest healing plaster; but after about forty-eight hours, during which the running was absorbed by dry napkins, carefully prevented from adhering, it became requisite to cover the whole with the mildest soap-plaster, spread on soft calico, to prevent the cuticle from being accidentally abraded. In this way all irritation promptly subsided, that is, in the course of from two to three days, and the patient was ready for the second blister, which was placed between the first and the spine. It was similarly treated; and, at an equal interval, a third was placed in front of the original one; that is, rather forward in the axilla. When pain indicated the possibility of a pleuritic stitch in any part of the side, it is needless to say that the first blister was placed over that.-Say that diuretics are conjoined: viz. squill; sp. æth. nit.; juniper; iodide of potassium, and, when there is no irritation of the mucous membrane, the various other preparations of potass. Digitalis, by creating faintness, is apt to confuse the symptoms; I do not, therefore, use it till later. When all these remedies had failed for two or three days, and dyspnea continued as urgent as ever, I have occasionally used a powerful hydragogue, as half a grain to a grain of elaterium, combined with calomel and capsicum to prevent nausea; or the pulv. jalap comp. 3j.; so as to produce ten or twelve copious watery evacuations per day, stimulants being at hand in case of any sinking tendency. The effect of this has on several occasions been perfectly satisfactory, absorption in the chest having now made rapid progress. I derived this idea from a case already alluded to, in which a patient had an accidental hypercatharsis to the amount of sixty stools in two days, which emptied the chest in the same space of time. The patient is better in bed, both because it favours gentle transpiration, and obviates faintness.

Remind that, hitherto, I have been treating a case in which the dyspnœa seemed eminently dangerous, and the most vigorous use of remedies consequently indispensable; but now explain that inconvenience sometimes resulted from hypersalivation; for, notwithstanding an immediate suspension of the mercury either on the first appearance of tenderness of the gums, or of amelioration of the symptoms-especially the dyspnoea and obvious commencement of absorption-untoward salivation would occasionally occur, and greatly retard the convalescence. Explain that, on several times observing this, and having reason to believe that the patient could bear the dyspnoea with safety for some hours longer, provided he were prevented from rising, which creates faintness, (case of Mr. Smith, barrister,) I used more moderate quantities of mercury, being content to affect the gums within three or four days. In this way, the action of the remedy was easily controlled, either by omitting the mercury for two or three days, if its action threatened to be considerable, or by merely diminishing it according to the evidence of the mouth and of the symptoms. I found, however, that it did not answer to suspend it altogether, but that a continuation of it daily in a mild form, as a blue pill night and morning, or at night only, for the purpose of maintaining the first impression for a period of two or three weeks, or, in short, until all the disagreeable symptoms had disappeared-was attended with far better success. Explain, further, that the great acceleration of pulse, which

rises commonly to 120 or 130, and in young persons even to 150 or 160, and which is attended with what the patient calls "internal fever," thirst, craving for cold drinks, and dryness and heat of skin, is not necessarily a result of fever, but it is necessarily a result of anæmia, occasioned by the deficiency of oxygenation from the total incapacity of one lung at least. Here was the error made by Broussais, who supposed this to be fever, and put his patient on the lowest diet. On the contrary, acting on the opposite principle, I always supply my patients with at least one or two pints of concentrated beef tea, or plain ox-tail soup; and if the state of the tongue and the alimentary canal fully authorises it, I permit them tender old mutton or beef for dinner. On this treatment, the pulse and "internal fever" rapidly fall in proportion as the anæmia disappears.

Next proceed to those cases in which hectic is established, resulting for the most part, I should imagine, from the fluids being of a puriform character-for after a month or six weeks, and sometimes much earlier, if the inflammation have been very intense, it assumes this character. Allude to the opinion pretty prevalent that mercury is injurious in such cases, and say that I have not found it so, but that its use was still indispensable: for I have noticed that where it has been omitted, contrary to my wishes and instructions, a recurrence of the effusion has taken place, notwithstanding the use of mineral acids and the various other remedies usually considered available against hectic; whereas, on resuming mercury with opium, and giving the mineral acids for hectic, I have been enabled to restore matters to their former condition, though not without an extra shake to the patient. One of the best instances of this was presented by Sir Clifford Constable's coachman. Dwell on this case; say that, after acute pleurisy of three weeks I saw him, and the chest was emptied in a week, but the mercury ordered to be continued. This, on my taking my leave, was omitted; and as he seemed weak, (viz. merely from anæmia,) he was ordered ammonia, brandy, and other stimulants. In ten days, when I was again called in, his chest had refilled, and he now had a most violent hectic paroxysm at eleven o'clock, A. M., and again at 11 P. M. Each of these thoroughly drenched him, and during the extreme heat the pulse would rise to 150, being also barely perceptible. In this, I saw nothing but a large quantity of pus in the circulation, which nature was endeavouring to throw off in her usual manner. I believed, in short, that the fluid in the chest was wholly purulent. I therefore continued the mercury and blisters in moderation, and made free use of the mineral acids, which, fortunately, he bore perfectly well. During the brief intervals of the hectic paroxysms, he exhibited that marked relief which we habitually see, and had always a keen appetite for his meals. He accordingly took as much mutton-chop, beef-steak, or roast or boiled mutton, as he was inclined to take. Under this treatment, the chest was again emptied within the space of ten days; the hectic symptoms slowly gave way during a period of a month or six weeks, and I dismissed him convalescent to go to the country. I may add, however, that when the hectic was nearly gone, sulphate of iron was added to his sulphuric acid, in order to co-operate with the animal food in removing all remains of anæmia. Dwell likewise on the case of Mr. Morgan, æt. about 20, who was not only highly hectic, but had also slight gastro-enteritis. I continued the gentle external use of mercury, allayed the irritation of the mucous membrane by mild antiphlogistic means, &c., but allowed him plain veal and chicken broth, then beef tea and mutton broth, in such quantities as I found he could bear. The gastro-enteritis having been thus pretty well subdued, he became tolerant of the mineral acids and sulphate of iron, well guarded with laudanum. His youth rendered the progress of absorption more rapid than in the preceding case, for the fluid all disappeared within ten days, with entire relief to his dyspnoea; and so great a restoration resulted from the new supply of oxygen and removal of anæmia, that a week afterwards he came in a cab from the city to the West-end to call upon me.

Auscultators should be careful not to throw away their chances by neglecting to use the stethoscope. In one instance, an accomplished physician, having examined the top of the lung and found it dull, with the other usual signs of induration, without following up his examination down the whole side, took the case for phthisis, and ordered the patient to the southern coast. A common friend having mimicked to me the mode of breathing of the patient, I declared at once, (for his imitations were most graphic,) that such was not the dyspnoea of phthisis; and as I knew him not to be a phthisical subject, and to have been in robust health two months before, I entreated of our friend to go down to the patient in the country the same afternoon, and not to let him stir (for he was to start two days after) without a consultation of physicians. Ì declined going myself, as having suggested the measure. Answer was returned that if I would not go, he would see no one else, as he had originally intended to have consulted me. I saw him, and found what I was before sure of: namely, that the whole side was full of fluid, indicated by the usual symptoms, including anæmia and the physical signs. I flattered him that we should empty the chest within a week or ten days, and that he would be convalescent, deo volente, in a month. So it happened, though mercury could only be borne externally, and that with great reluctance on the part of the patient. His convalescence was somewhat protracted, in consequence of the irritable state of the mucous membranes rendering them incapable of bearing the animal diet, and ferruginous preparations suitable for the removal of the anæmia. He had flying pains principally below the region of the heart, but these ceased under the use of plasters, especially belladonna; and he has enjoyed perfect health for the past year.

In the great majority of cases, an attrition murmur, (always most perceptible along the line of the margin of the lungs from the heart, curling backwards to the bottom of the lower lobe; in other words, below the axilla,) was found to appear as the fluid disappeared by absorption. I have noticed that the longer this attrition murmur lasts, the better; as the adhesions are more apt to be of a loose and elongated character, which I infer from the patient's recovering complete resonance on percussion, and complete restoration of respiratory murmur sooner than in other cases where the attrition murmur lasts but a few days, in consequence, probably, of the adhesions becoming universal and close. Whenever the latter is the case, the patient may lay his account to being more or less delicate for a year and a half or so, because the lung requires fully this time slowly to stretch the adhesions, to reacquire her natural respiratory murmur; or, if this should never occur, for the patient to gain a compensation by hypertrophy of the opposite lung, which, meanwhile, has constantly been doing vicarious duty; namely, breathing in an exaggerated or puerile manner. These exquisite arrangements of Providence cannot be sufficiently admired. The more we look into them, the more complete we find them.

The lung sometimes remains permanently condensed, from the thickness and utter inexpansibility of the side; and dilatation of the bronchi may result from this cause, of which I have met with and detected four or more instances. Condensation of this kind is less frequently attended with falling in of the side than in cases of pleurisy; for the opposite lung slowly becomes hypertrophous and fills up the vacant space, advancing, however, into the opposite side of the chest, and carrrying the heart with it in either direction. Thus, in Peter Parker, an out-patient of St. George's, the heart is protruded almost into the right axilla, and the aorta pulsates an inch to the right of the sternum. Lung condensed by adhesion, is rarely healthy. There is almost invariably a slow, wearing, chronic bronchitis, which harasses and reduces the patient, and generally curtails his existence. Parker had had his cough for ten years, and he was an emaciated and decrepid subject.

Here introduce a number of detached observations, more or less original,

on various subjects. Thus, for eight or ten years, I have been in the habit of asking the question of all respectable patients of robust constitutions, who had been attacked with pleurisy, peripneumony, acute rheumatism, whether they were in the habit of wearing flannel, or not; to which they generally answered in the negative-the common reason assigned being, that they were so much exposed, that they could not venture to pamper themselves. I recently put the same question to a London physician, and he gave the same answer with a smile, and "my dear friend, it is impossible," &c. He was attacked with rigors the same night, and had a severe rheumatic fever. I do not quote the poorer classes, for they, almost universally, are deterred from wearing flannel by the expense, and it is notorious that they are subject to acute inflammations of all kinds, in a much greater proportion than the higher classes. Flannel is also highly beneficial to chronic affections of the mucous membrane of the lungs.

Pleurisy is, after rheumatic fever, one of the most frequent causes of pericarditis-not endocarditis, at first-the inflammation being propagated to the pericardium by contiguity of tissue: if endocarditis supervene, it is by propagation from the peri to the endo-cardium.

Diaphragmatic pleurisy may occasion agonising pain by interfering with the action of so great a muscle as the diaphragm. It is in such cases that we occasionally see the patient put on what is called the sardonic grin-a species of sympathetic spasm dependent on the excito-motory system and

nerves.

In some convenient part of the paper, give a brief and compact, but very clear synopsis of the signs of a chest full of fluid. For I repeat that, well as these are known to systematic writers, they are singularly forgotten and overlooked by practitioners. They ought, therefore, to be pushed prominently forward on every occasion. Refer likewise to a synopsis of the signs of anæmia in the essay on that subject; by which the practitioner will readily distinguish this condition from that of fever, for which it has been mistaken by Broussais and others.

Wind up by a general statement, that, if Dr. Stokes has cured twenty cases running by Mons. Lugol's solution and ointment of iodine, together with blisters and other means; and I have cured thirty-three consecutive cases by other means; fifty-three cases cured successively, without selection, afford a strong presumption that all really curable cases are curable without paracentesis. It remains to be proved by experience whether iodine or mercury be the less injurious to the constitution. I have myself the most favourable opinion of the harmlessness of the iodide of potassium when protected by starch-that is, a little bread with each dose; for I made the experiment of giving eight-grain doses against three-grain doses, in two hundred cases, for the purpose of ascertaining which dose was the most efficacious. The larger, both being given thrice a day, succeeded incomparably the better, and I now rarely give the smaller.

I have met with seven or eight cases of circumscribed pleurisy, and whenever a chronic pleurisy becomes very protracted, I am not sorry to see a purulo-sanguineous discharge take place periodically, as it generally does, into the bronchial tubes; for in this case a slow process of healing generally occurs, and the patient, in a fair proportion of cases, recovers. I have recently discharged one, Henry Wade, who appeared to me to have had a chronic pleurisy engrafted on a previous circumscribed or sacculated one. The history of the chronic one is developed in my journal in the utmost detail; but the patient also informed me that some months before he had been under the care of a physician in Norfolk, who had treated him for six months previously for a discharge of half a pint of pus, mixed with blood, expectorated once a day from the bronchial passages. After this time, he sent him to London to consult me, and I found him with a very circumscribed empyæma that he might have had, obscured by general empyæma. This having been removed, the original circumscribed empyema pointed at

the chest, and discharged by two or three apertures. When the discharge was free by the apertures, it was correspondingly diminished by the bronchial tubes. Both slowly decreased. The circumscribed empyæma seemed to descend very low in the splenic region, and after nine months of hospital attendance as an in-patient, he was dismissed without discharge, with slight cough and in general good health, his weight being at least twelve stone, though a moderate-sized man.

I discharged a patient from the Mary-le-bone Infirmary, cured six times of circumscribed empyæma above the left mamma, and opening into the bronchi. At the end of six months he was completely well.

In another, in the Mary-le-bone Infirmary, the whole length of a probe could be passed directly into the chest. He recovered, but with much collapse of one side.

A third, in the Mary-le-bone Infirmary, a boy of eighteen, had effusion for six months. My colleagues, in consultation, had given their opinion that he was tubercular. The operation of paracentesis, therefore, was negatived. The opposite lung was soon after attacked with peripneumony, and he died, when the exemption from tubercles was proved. I did not then understand an efficient treatment for fluid in the chest; and was therefore an advocate for the early operation on the principle of the late Dr. Thomas Davies, of Broad street. I had much regret, therefore, respecting this case, that the operation had not been performed. One feature was remarkable. Andral, Broussais, and others, recommend that patients in chronic pleuritis should be kept on light diet. This youth ate twelve ounces of dressed meat at dinner; eight ounces at breakfast, with two eggs; tea and milk ad libitum; sixteen ounces of bread daily.

Numerous similar cases show that nature's mode of performing the operation is incomparably more safe than paracentesis.

ART. II.-ON THE PATHOLOGY, PHYSICAL SIGNS, AND TREATMENT OF VALVULAR DISEASES OF THE HEART, IN CONNECTION WITH THE SOUNDS OF THIS ORGAN.'

BY T. H. MOORE, M. R. c. s.

Late Secretary to the Dublin Medico-Chirurgical Society.

The following case, which has lately come within the range of my observation, I have been induced to give, not merely from the intrinsic value it possesses as being linked with the others, by the symptoms, physical signs, and morbid appearances, but also on account of other particulars, which cannot fail to sanction its introduction here.

A woman, advanced in years, the mother of four children, was brought into the hospital, on the morning of the 16th of May, with both legs, feet, and thighs immensely swollen, presenting a florid red, glossy, erysipelatous hue, nearly as high up as the knees; pitting on pressure; of such weight that it was with pain and much difficulty they could be moved. There was an expression of great distress and anxiety in her countenance; lividity of the lips and cheeks; a tinge of bile on the conjunctiva; turgescence of the jugular veins, with distinct undulatory or pulsatory motions, very remarkable for the regularity of their succession in those of the right side of the neck. No degree of uniformity between them, the cardiac impulses, and the arterial pulsations, could be ascertained with precision, or in a satisfactory manner; their persistence, whether in erect or recumbent posture, was noted;

London Medical Gazette, June, 1841, p. 542.