must be supported with wine-whey, wine, &c. We cannot detract blood from such patients, but dry cupping will often be of servicethe mustard poultice should be applied, and here, also, blisters will be found well adapted.

Chronic bronchitis is usually a consequence of the acute form, but may occur as a primary affection, in which case it is developed slowly and insidiously. There is cough, with slight soreness of the trachea and thorax, a sense of stricture and tightness, increased on drawing a deep breath; the voice is somewhat hoarse. The cough becomes more harassing and severe; the expectoration, at first scanty, increases in amount, and changes from mere mucus to muco-purulent consistence, sometimes colored with a little blood. In a few cases hæmoptysis may happen, but this is not frequent. Respiration is hurried, and panting attends any muscular exertion, or the ascent of a stair. The pulse is tense and frequent, and a febrile exacerbation shows itself at first in the evening, going on to a full development of hectic, with nightsweats, emaciation, and great loss of strength, diarrhoea, &c.

Autopsy. The bronchial mucous membrane is high colored and thickened, and occasionally eroded with ulcers. The lungs are found hepatized or solidified, the air-cells and tubes filled with muco-purulent matter, mingled with a frothy and bloody serum.

Prognosis. The unfavorable indications are chiefly drawn from the degree of dyspnoea in the early stages, and at a late period from the atrophy and emaciation which waste the patient. An extreme frequency of pulse is unfavorable. Panting also, and paleness or lividity. Diagnosis.-The distinction between chronic bronchitis and tuber. cular phthisis is sometimes difficult. In the latter, there is more dulness, less râle, less soreness of the trachea and thorax, more tendency generally to hæmoptysis, and less expectoration in the early stages. In their advanced progress, we can draw no line between them, except from their previous history. Hence the phrase "Catarrhal Phthisis."

Treatment. The lancet is rarely required. Leeches may be applied to the throat, and cups to the chest, with benefit. Dry cupping the thorax is useful, as a revulsive. Emetics are much confided in, and great stress laid on preference due to particular articles. Ipecac. is generally chosen; some combine it with tart. antimon., and others with the sulph. cupri. The utility of emetics is unquestionable; they are expectorant, diaphoretic, and, in most instances, move the bowels sufficiently. To soothe pulmonary irritation, and keep up a constant determination to the skin, we may exhibit a combination of the nitrate potass. with Dover's powder, allowing a full dose of anodyne nightly, at bedtime. A choice of the numerous preparations from opium may be made to suit each particular case. I do not think any other of the narcotics, as the lactucarium, hyoscyamus, &c., entitled to our confidence. The digitalis or the veratrum viride may do service when the pulse is particularly frequent. Squill is highly prized by some as an expectorant.

The infusions of serpentaria and seneka afford good bases for the mucilaginous, demulcent, and anodyne solutions, administered to re

lieve the troublesome cough. In threatening cases, I would advise an alterative mercurial course. Calomel, in small doses, or the blue pill, may be so given as to produce highly beneficial results, while it should not interfere with the proper employment of such other remedies as may be demanded. Inhalation of various airs and gases, the vapor of ether, in which conium has been macerated, that of burning tar and of resin, iodine and chlorine, have been extolled.

The several balsamics were formerly much in vogue. Myrrh, tolu, and copaiba, are the best of them. "Pine-gum pills," and "lightwood rum," are common domestic prescriptions, in the south and southwestern States. Naphtha is advised. Cod-liver oil is still in repute.

Tonics may be made of great benefit, by a proper selection of the period for their exhibition, and the cases to which they are adapted. I would use them when the tokens of muscular debility and general relaxation were more prominent than those of local irritation, or febrile excitement. The infusion of cinchona with mucilage, is lauded by Broussais and Hastings. The elixir vitriol and tinct. mur. ferri are prescribed as serviceable in restraining nocturnal sweats.

The persevering application of counter-irritants to the chest and arms will be of great advantage. I prefer to blister successively one and another portion of the surface. The tartar emetic is a favorite irritant with many physicians, while others still prefer setons and caustic issues.

The convalescent must take as much exercise in the open air as he can undergo, without fatigue. A long journey, or a sea voyage should be advised, and an equable climate chosen.

PLEURITIS.-Inflammation of the serous investing membrane of the lungs is a common and well known disease, usually met with in winter and spring, and frequent in occurrence in proportion to the abruptness of the changes of the weather in these unsettled seasons. It comes on with sharp pain in the thorax, at the side, and most often, perhaps, on the right side; the pain is fixed and circumscribed, constant, but increased by a full inspiration; the breathing is short and restrained, and the patient assumes a bent posture, leaning to the affected side. Fever soon supervenes, with quick, frequent, hard, and full pulse; the skin is hot and dry, and a cough comes on, aggravating intolerably the keen lancinating pain.

If not soon relieved, the dyspnoea increases, and the symptoms of pulmonic inflammation are added, and become prominent; or the case is protracted into a chronic stage, in which the results of the inflammation of the pleura vary somewhat. Effusion takes place within the cavity of this membrane, which exhibits itself by the continuance of dyspnoea after the earlier acute symptoms have subsided; it is aggravated into orthopnoea, more annoying when the patient sleeps, and during the night. The affected side becomes fuller to the eye, and does not follow the ordinary movements of respiration; there is not only a total absence of resonance on percussion and respiratory murmur, but the heart itself is sometimes displaced by the accumulated fluid, if on the left side, and pressed over to the sternum and upwards;

and all the phenomena detailed in the description of hydrothorax

supervene.

The causes of pleurisy are already pointed out; exposure to cold and moisture, and sudden changes of temperature. External violence too may give rise to it; puncture by the spicule of a fractured rib has occasioned it; and a fatal case is on record where the pleura was wounded by a needle employed in passing a ligature round the subclavian

artery.

The diagnosis of pleurisy is not difficult. The pain in the side is attended at first, if the case be uncomplicated, with little impairment of resonance on percussion; the respiratory murmur is only deficient because the patient does not inspire freely. After a short time, the "frottement" sound is heard, produced by the rubbing together of the opposite surfaces of the pleura, roughened somewhat by the exudation of plastic lymph, or fibrinous shreds. The case still advancing, effusion of serum gives a brief ægophony; this is followed by great dulness of resonance, varying somewhat with the posture of the patient, and corresponding loss of respiratory murmur, owing to the still increasing amount of fluid only, if the case continue a simple one. But in fact it is apt to complicate itself into pleuro-pneumonia, the superficial inflammation extending to the tissues beneath; when we shall have of necessity the symptoms of pneumonia vera added to those above enumerated.

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Prognosis. In general, pleurisy may be regarded as a manageable disease, attended with little danger, if the patient is seen early. In the first stage, the danger of risk may be inferred from the extent of the inflamed surface, the violence of access, the severity of the constitutional excitement supervening, and the apparent ability of the patient to bear the requisite remedial measures. As the case progresses, the increase of dyspnoea into orthopnoea is unfavorable. All tokens of effusion are of course to be dreaded. This is shown by dilatation of the side of the chest affected and protrusion of the intercostal spaces. Adhesions of the pleura, on the contrary, give rise to contraction, flattening, immobility, and lateral curvature.

Autopsy. The most common result of inflammation of the pleura, often indeed observed in bodies dead of other forms of disease, is the adhesion of the opposite surfaces of the pleural sac, or their connec tion, by layers or strips of organized membrane. Effusion of pus, empyema, is occasionally met with; that of serum is far more fre quent.

Treatment. The lancet, used promptly and boldly at the outset of the disease, will often put an end to it at once. It is to be resorted to at all stages while the breathing is sharply painful and difficult, unless the pulse is feeble, and the strength of the patient obviously failing.

Topical depletion by cups, which should be applied on and near the seat of pain, is next proper; after which, large warm poultices should be assiduously laid about the side. A full and free dose of an anodyne diaphoretic will now complete the relief of the patient, who sleeps soundly, breathes quietly, and wakes restored to comfort. Dover's powder is perhaps preferable here to any other formula.

If the attack be protracted, cathartics will be found useful, and the drastic and somewhat irritating should be chosen as most revulsive. No prejudices have less foundation than those which oppose the employment of purgatives in thoracic inflammation. They are adapted, however, only to the early stages of febrile character in young and robust subjects. It is advantageous to combine them with an antimonial or other diaphoretic, as in the common formula of nitrate potass., pulv. jalap. et tart. antimon. I have seen little or no benefit from the exhibition of emetics, so highly recommended by some prac titioners. Among the vegetable diaphoretics, the infusions of seneka and serpentaria, and of the asclepias decumbens (vulgarly called "pleurisy root"), are deservedly extolled. The combination of ipecac. with opium in the pulv. Doveri is an invaluable remedy; a full dose of it, twelve to twenty grains, should be given nightly, and it may be usefully added at regular intervals to such other medicines as are prescribed during the day. Demulcent drinks, rendered more efficient by the addition of tinct. op. camph., tinct. tolut., and nitrous or chloric ether, may be taken to palliate cough.

Epispastics should be applied over the affected part of the chest, if any pain should continue after the febrile excitement has been subdued, and the pulse has lost somewhat of its force and tension. This abatement of inflammatory irritation constitutes the "blistering point" of English writers. Empyema or hydropleura may demand the operation of paracentesis, to relieve the patient of the otherwise fatal accumulation of serum or pus.

Some recent writers recommend an early resort to the operation of paracentesis, even in acute pleurisy, and as soon as effusion in any considerable amount has taken place. The suggestion appears to me to be reasonable and promising, and many cases have already been reported in favor of it.

BILIOUS PLEURISY.-In all low miasmatic regions, the thoracic affections of spring and early winter are apt to be combined with, and modified by, notable symptoms of gastric and hepatic disorder. This complication, known familiarly by the title just given, I am disposed to attribute to the persistent effect of malaria upon constitutions imbued with that poison; an English writer of some authority speaks of it as owing to an undefined atmospheric and epidemic influence still present and acting.

In this form of the disease, which is by no means rare in the southern country, less vigorous depletion by the lancet is required or admitted of, than in simple pleurisy. Emetics are more beneficial; cathartics indispensable; and mercurials more applicable. The sulph. quinine is used with advantage, after the very first stage has passed. Vesicatories are well adapted, and may be applied early.

Convalescence requires great care and prudence. The clothing should be warm, and all exposure avoided.

PNEUMONIA-PNEUMONITIS-PULMONITIS-is the inflammation of the substance of the lung-its parenchymatous and cellular tissue.

Recent pathologists have made some difficulty about its ultimate seat, and showed a disposition to confound it with bronchitis. But the interstitial or intervesicular tissue, though it does not absolutely escape either in pleurisy or bronchitis proper, either in inflammation of the investing serous tunic or that of the internal lining mucous membrane, is subject to its own special affection, which we now proceed to treat of. They, in turn, participate in its inflammation, and we have few cases of pneumonia so exclusive as, on the one hand, to evade some complication with bronchitis, an extension indeed almost unavoidable, in greater or less degree, and on the other with pleurisy, constituting a pleuro-pneumonia. Here the whole mass of lung substance is involved. The right lung is the one most frequently attacked; the lower portion of the middle, or the upper half of the lower lobe, the special locality; in about one-fourth or one-fifth of the cases, both lungs are attacked-double pneumonia.

This is one of the most frequent of our diseases, a large and familiar outlet of life. It is oftenest met with in winter and spring, but occurs in all seasons of the year. It assails all ages-infancy, maturity, and the decline of years. When it affects the whole lobe of a lung diffu sedly, it is spoken of as lobar; thus it appears in the adolescent and adult. In children below six or seven years of age, it is less extensive in the parts it attacks, though it may show itself in several spots in the lung, and this circumscription is intended when we speak of lobular pneumonia. In the adult it is often primary, but not unfrequently secondary, supervening in the course of other diseases, as in typhous and other fevers, in smallpox often. Children of tender years are very liable to this secondary pneumonia, which is often latent or masked by the original malady. In all febrile attacks to which young children are subject, in winter and early spring, it will be well to examine and guard against this secondary annoyance. It follows croup, catarrh, bronchitis, hooping-cough, and many other ailments, belonging, indeed, to the history of the exanthemata.

Pneumonia is essentially pyrectic, and the fever may be either of open and high excitement, or of low type, either inflammatory or typhous. In all malarial regions we are familiar with the complication known as bilious pneumonia or bilious pleurisy, in which the fever exhibits periodical form, and the other characteristics which mark our autumnal remittent.

Cause. It seems to be among the most direct and usual effects of exposure to cold; moisture aids this effect. It follows, also, the impression of marked alternations with prevailing low temperature.

Symptoms.-Pneumonia comes on often with a formed rigor or chill, which soon passes away, leaving the patient hot and flushed, with some dyspnoea, and a sense of uneasiness and oppression in some part of the chest. This soon increases to pain, which is usually dull rather than sharp, with augmenting difficulty of breathing, oppressive rather than severe. It is not easy to draw a long breath, but the attempt is not suddenly checked by a keen pang, as in pleurisy, nor restrained by an extended feeling of soreness, as in bronchitis. The pulse becomes frequent, full and hard; and in proportion to the degree of attendant