maturely to the use of these means after an attack of Pneumonia. A far safer practice, on the whole, is to continue the use of such medicines as nitre, sal ammoniac, and sulphur. aurat. until all the dregs of the disease are entirely got rid of.

The seat of the pain in Pneumonia cannot be trusted to, by itself, as a sure guide as to the seat of the inflammation. Stoll and other writers record many cases in which dissection proved that the inflammation was on the opposite side from that on which the pain was felt during life. It is only by the use of the Stethoscope that we can attain to any exactitude in our diagnosis as to the seat of a Pneumonic attack.

In a former part of this article, we have alluded to the modifying influence of an Agueish principle on the course of Typhus fever. A somewhat similar change is observed to result from the operation of this principle on the symptoms and general character of several thoracic diseases. In one of the cases of Pneumonia recorded in these Reports, the patient had been long subject to Ague. Dr. Schoenlein availed himself of the opportunity, thus presented to him, of pointing out the peculiar idiosyncrasy of constitution which this circumstance is apt to engender :-but first let us notice his remarks on a question that has been much occupying the attention of some French physicians of late, the Antagonism between Intermittent Fevers and Phthisis.

"Although it would seem that these diseases exclude each other (at least, in a very great measure) so that the latter is seldom met with in those places where the former prevails, it is unquestionably true that persons-who, after having long suffered from Ague, have left the malarious district and have gone, seemingly quite cured, into another region-are exceedingly liable to being attacked with catarrhs; and these catarrhs not unfrequently terminate in confirmed, and often galloping, consumption, although there be no hereditary or constitutional predisposition to the disease. I first observed this fact in those Swiss, who had returned from the ague-districts of Holland. In cases of this sort, according to my experience, the tuberculous disease is generally most developed in the left lungcorresponding therefore with the side on which the Spleen is situated—and most frequently too, in its lower lobe. There was always more or less splenic enlargement present at the same time, in the patients affected in this way. A striking illustration of the antagonism, that exists between Intermittent fever and Phthisis, will be found in the medical geography of Gasterland (situated between the lakes of Zurich and Wallenstadt). This district used to be the constant seat of agues, in consequence of the land being frequently overflowed; subsequently it has become quite dry. The Agues have left it, but their place is taken by Phthisis, a disease which was formerly almost quite unknown,"

In reference to the case of Pneumonia, to which allusion was made above, the following observations are introduced by our author.

"In such persons, various diseases, with which they may happen to be affected, are usually more or less decidedly modified, so that their course in reference to symptoms and crises is considerably altered from that which we generally observe them to pursue. This is a point which is of the highest importance in the practice of medicine, although it has not met with the attention which it deserves. A somewhat analogous change is observed in respect of Plants; which, it is well known, undergo such considerable modifications from variety of soil, difference of exposure to the sun and so forth, that mere varieties are not unfrequently apt to be mistaken for different species. In the same manner, the characters of

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diseases may be very materially modified, according to the nature of the patient's constitution in which they become developed. How difficult, for example, it is to eradicate a syphilitic taint from a scrofulous habit of body! and who does not know the extreme tendency of gonorrhoea, and other mucous discharges, to become chronic in strumous persons. In Ophthalmia too, how much does the obstinacy and intractableness of the symptoms depend upon the idiosyncrasy, natural or acquired, of the invalid! Now, if this remark be true of the eye, there is every reason to believe that it is equally applicable to every other organ of the body, although in none can the progress of the disease be so well observed as in it. We might allude also to the difference in the nature of morbid formations and secretions observable in different constitutions. The coagulable lymph, that is effused during an attack of Pleuritis or Peritonitis in a scrofulous patient, becomes very often the seat of tuberculous matter deposited in its interstices."

But to return to the complication which suggested these remarks-viz. that of an Agueish tendency with an Inflammatory disease,-let us briefly notice some circumstances which may suggest to the mind of the physi cian the suspicion of such being the case. During the full activity of the phlogistic symptoms, nothing unusual may be observed; it is when these have begun to subside, that the peculiarity is usually discernible. Perhaps everything may be promising that the severity of the inflammatory attack is past, and that the disease is fairly subdued, when the patient becomes hot and feverish (with, or without a previous chill) in the afternoon, complains of headache, and may even be delirious, the pulse being much accelerated all the while. These symptoms continue more or less severely until about midnight, when they subside; the patient then probably falling asleep, and awaking in the morning much better. Now such a febrile invasion and remission may be repeated day after day, for some time; and, unless the physician forms a correct diagnosis as to the real nature of the case, he may unfortunately persevere in the use of those very means which will inevitably render the Intermittent type more and more difficult of removal. The sooner, as a matter of course, that Bark is administered in such cases, the better. There may, indeed, still remain the dregs, so to speak, of the inflammation; and therefore the administration of this remedy may require to be accompanied with the cotemporaneous use of appropriate antiphlogistic and derivative means, as cupping, blisters, and so forth.

P. Frank has some useful remarks on this subject in his Interpretationibus Clinicis. This writer remarks that, whenever the paroxysm of an Intermittent fever is in the habit of daily coming on sometime after noon, we have reason to suspect that it is not a genuine and simple Quotidian that we have to deal with, but that there is some other morbid action coexisting at the same time. In cases of complicated Intermittent, the paroxysm also very frequently takes place without any cold stage; and the occurrence of any distinct crises by the skin or kidneys, under such circumstances, is always more rare and imperfect than in simple Agues. Thus the Urine may remain of a deep colour, without any change taking place, when the febrile paroxysm is not present; and if a critical evacuation does really occur, this will perhaps be the genuine crisis of Inflammation, as a hæmorrhage from the nose or some other part of the body.

Before passing on to the subject of Pleuritis, it may be as well to find a place here for the following remarks on two practical points, viz. 1, the em

ployment of Tartar Emetic in Pneumonia; and 2, the treatment of a peculiar status nervosus, which is apt to occur in some cases of this disease.

With respect to the effects of the Tartrate of Antimony in thoracic inflammation, M. Schoenlein is by no means inclined to go nearly so far in its praise as some recent writers, who pretend that it may almost supersede the use of blood-letting. That it is indeed a most powerful auxiliary, no experienced physician will deny; but it should rarely be trusted to alone. When a Pneumonia has already lasted for some days, and still continues in spite of active depletion, the exhibition of the tartar emetic cannot be too highly praised; but then only after Venæsection has been duly practised. Again, whenever the biliary organs are much deranged at the same time, great benefit may reasonably be expected from the judicious employment of this potent remedy. The contra-indications to its use are the existence of any symptoms of an inflammatory or irritated condition of the gastro-intestinal membrane (inflammation of the cardiac orifice of the stomach is a not unfrequent accompaniment of Pneumonia), or any tendency to Diarrhoea. In old people more especially, it requires to be used with caution, as in them it is apt to induce a Marasmus of the digestive organs. M. Schoenlein is not friendly to the exhibition of the very large doses recommended by some writters. His usual formula is a solution of from two to six grains in as many ounces of water; of this mixture, one-half is to be taken at once, and then a table-spoonful of the remainder every half-hour or so.

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The nervous condition, which not unfrequently comes on in cases of severe Pneumonia, in consequence of some disturbance of the circulation, —and which is indicated by a frequent, small, and oppressed (unterdruckten) pulse, a blueishness of the countenance, coldness of the extremities, delirium, &c.-should always be cafefully distinguished from that state wherein the attendant fever is of a torpid or typhoid character from the very beginning, as is the case in genuine Pneumonia typhosa. Unfortunately both of these conditions have been at different times described under the general appellation of nervous. The physician must be on his guard that he is not deceived by the symptoms in the first of these cases, and thereby be led prematurely to suspend the use of antiphlogistic, and have recourse to that of stimulant, remedies. We should steadily persevere in the employment of the former, although certainly it may be wise to modify them according to individual symptoms.

One of the best remedies under such circumstances is Digitalis, in the form of infusion, to be given in frequently-repeated doses: some of the Aqua lauro-cerasi may often be added to it with advantage. It lowers the action of the heart, and at the same time serves to stimulate the urinary secretion. Small doses of Calomel and Sulphur. aurat. night and morning, may also be of great service, at the same time.

III. The class of cases, which next attracts our notice, is that of Pleuritis, and its not unfrequent consequence-the effusion of a serous or sero-purulent fluid into the cavity of the chest. In the remarks which immediately follow, the attention of the reader is drawn to a peculiar symptom which may perplex his diagnosis in some instances.

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Complication of Spinitis with Pleurisy.

We occasionally meet with cases of Pleuritis, which are accompanied with severe pain in the back, and stiffness of the vertebral column: these phenomena may depend upon an extension of the inflammation to the investing sheath of the spinal-marrow. Allan has described this form of the disease, in his Synopsis Medicinæ Practicæ, under the name of Pleuritis Postica. A case of this sort occurred in Schoenlein's clinical practice a few years ago. A labouring man was admitted with all the symptoms of Pleuro-pneumonia on the left side: there was reason to believe that the inflammation extended to the diaphragmatic pleura. At the same time, the patient complained of a severe dragging pain in the sacral region, much increased on pressure and motion, along with a feeling of tension around the abdomen, and a sense of formication along the left lower extremity. The patient was freely bled from the arm, and also by means of cupping over the loins, and ultimately recovered. In reference to that case, Dr. Schoenlein made the following remarks at the time.

"These severe pains in the spine are not unfrequently mistaken and treated as if they were of a Rheumatic origin; and perhaps, before their real nature is discovered, paralysis has already set in. Exposure to cold and wet is the most frequent cause of this dangerous lesion. I had repeatedly occasion to witness cases of this complication at Wurtzburg among the soldiers who kept sentry upon the walls at night, exposed to the cold sharp winds: in some instances, the attack assumed a tetanic character from the commencement. I have also met with cases among persons who were travelling on foot through Switzerland, and who perhaps had remained all night upon the summit of Mont Rigi, in order to witness the rising of the sun in the morning. One of these cases proved fatal. "We need not say how very important it is to distinguish any case of Spinitis from one of mere Rheumatism. The pain will be found to be seated not in the muscles, but fixed at some part of the spinal column; and it is always much aggravated by pressure and motion. A feeling of constriction in the abdomen, as if a band was drawn tightly around it, is a symptom that is generally present; and likewise that of numbness or perhaps of formication in one or both of the lower extremities. The act of walking is always more or less painful and difficult; and there is very generally some disturbance in the excretion of the urine. If the cervical portion of the spine be the seat of the disease, then there is usually a sense of constriction in the chest ; perhaps also a spasmodic cough, or, it may be, nausea and vomiting; in many instances, too, a greater or less degree of paralytic weakness of the upper extremities. As to the treatment of all such cases, we should have recourse to blood-letting (especially local), the inunction of mercurial ointment over the affected part, and the exhibition of large doses of calomel, to which some jalap should be added: subsequently, the use of warmbaths is of the greatest service."

CASE.-Pleuritis mistaken for Rheumatism— Effusion into the right Sac of the Pleura-Indications for having recourse to Paracentesis—Stimulation of the Normal Secretions—Narcotism from Digitalis—Recrudescence of the Pleuritis-Recovery.

A man, 26 years of age, had been seized, three weeks before his admission into the hospital, with shivering followed by heat, and with sharp pain on the right side of the chest, increased by deep inspiration, and by any movement of the arms. The case had been mistaken for one of Pleurodyny—a mistake, by-the-bye, that is not very unfrequent-and treated

with tartrate of antimony, cupping and blisters; remedies, however useful in themselves, not potent enough for the dangerous disease that was actually present. When admitted, the breathing of the patient was not much distressed, except when he attempted to lie on his left, or sound, side. The right side of the thorax appeared to the eye somewhat fuller and more arched out than the other. The whole of this (the right) side, with the exception of the space between the clavicle and second rib, was dull on percussion, and no distinct respiratory murmur was to be heard over it. There was a slight cough, which (pressure had the same effect) caused pain between the fifth and sixth ribs. The liver was to be felt lower down than usual: in some cases of effusion into the right pleura, this viscus has been known to be thrust down as low as the ilium.

The nature of the present case was obvious: a pleuritic attack had terminated, by a pseudo-crisis, in a serous effusion. As there was still a feverish frequency of the pulse, and the urine was also deep-coloured, it was deemed not unlikely that the inflammatory action had not entirely subsided. Accordingly, a small quantity of blood (which proved to have the buffy coat) was taken from the arm, and the cupping-instruments were applied over the spot where the pain was felt. At the same time, a mixture-composed of infus. Digitalis (Əj.) živ., Mucilag. Salep. 3j., Nitri 3ij. (the liquor kali acetici was subsequently added), and syrup 3j., was ordered to be taken in frequently-repeated doses; and the right side of the thorax was well rubbed with an ointment, consisting of ung. hydrarg. and ung. pot. hydriod., to which some oleum hyosciami and oleum juniperi were added. As the medicine did not act sufficiently upon the bowels, the tartarus boraxatus (3ss.) was substituted for the nitre.*

It is certainly very surprising how little the breathing is distressed in some cases of extensive pleuritic effusion. Instances have been known where the patient has scarcely suspected that any thing was amiss in his chest, until he happened to observe that his heart was beating on the wrong side, to the right of the sternum. Perhaps the only inconvenience that he had hitherto experienced, might be a slight oppression in his breathing upon going up stairs, or in the evening after a full dinner.

It is sometimes not very easy to determine which is the best emunctory -the bowels or the kidneys-by which the evacuation of the effused fluid should be sought to be promoted. Much must depend upon what seems to be the tendency of Nature in each individual case. Most frequently, certainly, the effort is made by the kidneys; and here it deserves to be noticed, that the character of the urinary secretion is found to vary much in different instances-according, it would seem, to that of the effused fluid. When this is serous, the Urine is usually merely increased in quantity, and but little altered in its qualities; while, in other cases, it is found to contain a quantity of mucus, or even of pus, when the pleural effusion is of a purulent character. In this manner, therefore, we may often be enabled to predict the nature of the fluid effused into the cavity

Upon a previous occasion, Schoenlein remarks that he has often found the milder aperients, and especially the Syrupus Rhamni, answer a great deal better in dropsical cases than many of the drastic purgatives in ordinary use, such as Gamboge, Elaterium, &c.