mouth. The patient may smoke stramonium cigarettes or inhale the fumes. of burning stramonium or nitre paper or asthma powder before drowsiness sets in and the patient forgets his misery in sleep.

Powder for asthma, a teaspoonful to be burned under an improvised tent.

When dyspnoea is urgent despite these measures, the inhalation of chloroform or chloroform internally often gives relief:

M., ft. emulsio. S.: A teaspoonful every hour.

In children the potassium iodide mixture No. 1 may be given in one half teaspoonful doses. Sulphate of atropine, gr. To to gr. 1 in adults, is used hypodermically to control the attacks. As soon as the acute attack is over, a careful and complete clinical examination must be made in order to ascertain if possible any underlying cause or source of irritation. The nasopharynx is a common irritation centre for asthmatic attacks. Nasal obstruction of whatsoever nature (hypertrophies, polyps, deviations, and spurs) must be removed (see Nasopharynx). Hypertrophic tonsils must be reduced and granulations in the pharynx are to be destroyed. After all this is accomplished, the nasopharynx may be kept clean and moist by means of a saline or albolene spray. Attacks of hay fever and sneezing are to be treated locally with cocaine and suprarenal decoction and with Dunbar's pollantin (see Hay Fever). The nasopharynx should be examined several times a year for polyps, which are apt to recur.

The digestive tract must receive every attention. The bowels should move once a day (abdominal massage, aloin pills, enemata). Five to ten drops of hydrochloric acid in water may be taken after each meal. Heavy meals are to be avoided because overloading the stomach may bring on an attack, but the diet may be liberal as to variety. Beans, peas, cabbage, pork, mayonnaise, and pastry are to be avoided, including such other articles of diet as are found to disagree. There is no special diet for asthmatics. Alcoholic stimulants may be taken in moderation.

THE UROGENITAL TRACT IN ASTHMA.-After a severe attack of asthma albumin is frequently found in the urine, but it usually disappears when the sufferer is comfortable and the circulation is not embarrassed. Excessive menstrual flow and endometritis may call for curettage. Frequent pregnancies as a rule have an unfavorable influence on asthmatic women by favoring emphysematous changes in the lungs.

NEUROTIC TROUBLE. The neurotic element in asthma must not be overlooked. Cold sponging or a rest cure with massage and passive exercise is helpful, and all fatiguing social duties are to be laid aside. Mental occupation is desirable for persons apt to become self-centred and morbid. Nearly all cases of asthma show evidences of a psychic element.

Suggestion therapy is decidedly indicated in such cases, and occasionally hypnotism is of real benefit. Eye strain, when present, must be corrected. Hygiene of the skin in the shape of baths and friction must not be neglected. Very thin flannel or linen underwear should be worn all the year round, and in cold weather the outer garments should be heavy enough to protect against chill. The feet must be kept warm by means of thick stockings.

CHANGE OF CLIMATE FOR ASTHMATICS.-There are no fixed rules to guide us in suggesting a change of climate for asthmatics, but it is a positive fact that they enjoy a prolonged freedom from attacks in some places and not in others. Some of the writer's patients have done very well in Colorado, New Mexico, southern California, Florida, or the level of the sea at Nantucket and in other maritime districts. A trial sojourn is the only way to settle this question. Under no circumstances should asthmatics be in frequent contact with tuberculous subjects, on account of the special danger of becoming infected. As to the value of the pneumatic cabinet in the treatment of asthma, the writer can state that he has not observed favorable results and does not advise such treatment.

Bronchitis and bronchopneumonia are frequent sequela of asthmatic attacks, and will require the treatment which is laid down for such conditions. Asthmatic patients frequently acquire chronic emphysema, which is practically incurable and requires symptomatic management.

ACUTE AND CHRONIC PLEURISY

General Remarks

The pleural sacs extend from two to three inches below the lower border of the lungs. This so called complementary pleural space extends posteriorly from the ninth to the eleventh rib, and the surfaces of the reflected pleura are in contact except when filled with fluid or separated by the border of the lung, which advances and retreats during respiration.

Pleurisy, or inflammation of the pleura, is brought about by infection. Exposure and traumatism are predisposing factors. It may be primary or secondary, unilateral or bilateral. It is often associated with tuberculosis, pneumonia, rheumatism, syphilis, pulmonary infarction, pericarditis, typhoid fever, scarlatina, malarial disease, and other infections or with renal, hepatic, and cancerous disease and arteriosclerosis and gout. The three principal bacteriological forms of pleurisy are: The tuberculous, the pneumococcic, and the streptococcic.

The onset may be insidious or sudden. Clinically we distinguish the following forms: Dry pleurisy (acute or chronic, proliferative or calcified); effusive pleurisy (serous, hæmorrhagic, purulent, chylous, encysted, interlobular, and pulsating); and diaphragmatic pleurisy (which may be dry or wet).

DRY AND WET PLEURISY

461

Dry, Fibrinous, or Plastic Pleurisy

occurs as an independent affection, with pain in the side, slight fever, and friction sounds as symptoms. There may be jerky, cog wheel, or suppressed breathing. As a secondary process, we find it in all inflammatory conditions of the lung, and we suspect its presence whenever a cough is very painful. In diaphragmatic pleurisy the pain is usually referred to the region of the liver or stomach, and the friction sounds are heard at the base. A dry pleurisy is often the first symptom of a tuberculous infection, with friction sounds at the base or apex. After persisting for a short time, the characteristic friction sounds disappear and no exudation takes place. Adhesions between the lung and costal pleura may take place, such adhesions giving rise to crackling friction sounds.

The prognosis depends upon the underlying cause. A simple dry pleurisy admits of a favorable prognosis.

Effusive Pleurisy, Wet Pleurisy

This form of pleurisy may come on insidiously and is frequently overlooked. On examining a patient with moderate dyspnoea and accelerated pulse and normal or slightly elevated temperature, we are frequently surprised at finding the chest filled with fluid.

Symptoms. In other instances the patient complains of a chilly feeling for several days with an early sharp pain in the side. The pulse is quickened and the temperature may be 102° to 104°, its curve not being characteristic. Cough and expectoration may be absent. The breathing may be free or embarrassed. In some instances there are vomiting and delirium. There is no expectoration at first. In the event of an associated pulmonary inflammation, the sputum may be blood streaked or purulent if an empyema or purulent pleurisy has perforated into a bronchus.

Physical Signs.-An effusion is recognized by the physical signs: Dulness on percussion, absence of vocal fremitus, and bulging of the intercostal spaces on deep inspiration. In many instances the physical signs are indefinite and a probatory puncture will be necessary to determine the presence or absence of fluid and its character. All these matters are discussed in detail in the section on Pædiatrics. An effusion of more than 400 c.c. in adults or 120 c.c. in children may cause discomfort, but gives no very definite physical signs. When a puncture reveals fluid in the chest, it shows

us at the same time its character and enables us to further look into the underlying pathological process by a laboratory examination of the fluid.

Prognosis. Acute non-purulent pleurisy may terminate as such in two or three weeks, with complete restitution to the normal, or may become more or less chronic and finally dry up, leaving dulness due to adhesions, or may turn into an empyema which requires an operation.

In serofibrinous pleurisy the fluid is yellowish and clear or slightly turbid. It may be dark brown, particularly if the fluid is partly inspissated or has been in the pleural cavity a long time. It is rich in albumin and may coagulate spontaneously within and without the thorax. A coagulated exudate will not pass through an aspirating needle. Under the microscope

the cells pertaining to local inflammation are seen in the exudate. When the fluid in the right thorax is thick and dark brown, it may be of importance to look for liver cells. When the exudate is large, the lung is pushed into the apex, and apical dulness on percussion, with increased fremitus, will be evident. Large exudates displace adjacent organs, and on the right side depress the liver.

Purulent pleurisy, or empyema, may begin abruptly or come on insidiously in the course of other disease, or it may be evolved from a serous pleurisy. Septic symptoms are rarely wanting in purulent pleurisy. For physical signs and termination, see the Pædiatric Section of this book

Hæmorrhagic pleurisy is met with in malignant fevers, cancer, tuberculosis, Bright's disease, and hepatic cirrhosis, and it may be produced artificially by puncture for diagnostic or therapeutic purposes. It is occasionally difficult to distinguish this form from hæmothorax which is the result of rupture of an aneurysm or pressure on the thoracic veins. A sanguineous. exudate shows blood clot formation within and without the thorax. aspirating needle entering a blood clot would not draw fluid. When a bloody fluid remains a long time in the thorax, the blood clot becomes disintegrated and dissolved. A puncture made at such a time shows a fluid resembling blood which does not coagulate on standing.

An

Diaphragmatic pleurisy may be dry or wet. In such cases the pain is low down, and the diaphragm appears to be fixed. Litten's diaphragm phenomenon is a "visible descending and ascending wave associated with the respiratory movements of the diaphragm in the lower zone of the thorax." It is of very little practical value in diagnosis.

Encysted pleurisy is that condition in which adhesions separate the fluid into pockets, which may or may not communicate with one another. An interlobar encysted pleurisy is sometimes observed.

Chylous pleurisy may result from injury to the thoracic duct, from a parasitic disease called filariasis, or from fatty metamorphosis of the epithelium.

Pulsating pleurisy derives its name from the transmitted pulsations of blood vessels or the heart.

Differential Diagnosis. The important diagnostic points regarding pleural exudates, and particularly with reference to the conditions found in children, are discussed in Pædiatrics, to which the reader is referred. Treatment of Dry Pleurisy.-A brisk purge should be given.

Quinine is given to counteract any malarial factor should it be present. Dry cups may be applied over the seat of pain, or a cold compress, an ice bag, or a hot water bag to the chest. Should this fail to give relief, ten grains of sodium salicylate and two grains of potassium iodide may be given every two to three hours, in lemonade. The pain may be so severe as to warrant a hypodermic injection of morphine (gr. to 3) for an adult.

TREATMENT IN PLEURISY

463

Treatment of Pleurisy with Effusion. In the beginning the treatment is precisely as in dry pleurisy, but the patient should rest in bed and have liquid diet. When the temperature is high, hydrotherapeutic measures are indicated. As soon as effusion is evident, its nature may be ascertained, and if necessary a probatory puncture should be done, as there are no physical signs which will enable us to distinguish between serous and purulent effusion.

In the absence of severe and septic phenomena, we may assume that the fluid is not purulent, but the needle alone will prove the case. In the event of a purulent or seropurulent fluid, its immediate removal by incision

and drainage is indicated. To facilitate drainage a portion of a rib should be resected. A serous fluid should not be removed immediately unless there is a vital indication for so doing. Very urgent dyspnoea which very greatly embarrasses the action of the heart, as in cases in which the fluid. reaches to the clavicle, is one of the indications for removing by aspiration all or part of the fluid accumulation. The removal of a few ounces of fluid sometimes appears to start the absorption process.

At this stage a somewhat dry diet is indicated, and a brisk purge every second day is beneficial. It is also advisable to act upon the skin and kidneys by means of warm baths and enteroclysis at 110° F. Large exudates gradually disappear under such management. In some cases the wearing