292 PLEURISY. 



crackKng noise as when congestion is going on — not tlie febler murmur as» 

 congestion advances, but the absence of it, beginning from the bottom of 

 the chest. 



It is painfully interesting to watch the pi'ogress of the efiusion — how 

 the stillness creeps up, and the murmur gets louder above, and the grating 

 sound louder too, until at length there is no longer room for the lungs to 

 play, and suffocation ensues. 



The fluid contained in the chest varies in quantity as well as appearance 

 and consistence. Many gallons have been found in the two sacs, jjale or 

 yellow or bloody, often differing in the two sides or the thorax — occa- 

 sionally a thick adventitious coat covering the costal or the pulmonaiy 

 pleura — rarely much adhesion, but the lungs purple-coloured, flaccid, 

 compressed, not one-fourth of theii' usual size, immersed in the fluid, and 

 rendered mcapable of expanding by its pressure. 



Here, as in pneumonia, the bleeding should be prompt and copious. 

 Next, and of great importance, aperient medicine should be administered 

 — that, the effect of which is so desirable, but which we do not dare to 

 give when the mucous membrane of the respiratory passages is the seat of 

 disease. Here we have to do with a serous membrane, and there is less 

 sympathy with the mucous membranes of either cavity. Small doses of 

 aloes should be given with the usual fever-medicine, and repeated morning 

 and night until the dung becomes pultaceous, when it will always be 

 prudent to stop. The sedative medicine is that which has been recom- 

 mended in pneumonia, and in the same doses. Next should follow a blister 

 on the chest and sides. It is far preferable to setons, for it can be brought 

 almost into contact with the inflamed sui'face, and extended over the ^vhole 

 of that surface. An airy, but a comfoi'table box, is likewise even more 

 necessary than in pneumonia, but the practice of exposure, uncovered, to 

 the cold is both absurd and destructive. The blood, repelled from the 

 skin by the contractile, depressing influence of the cold, would rush with 

 fatal impetus to the neighbouring membrane, to which it was before 

 dangerously determined. Warm and comfortable clotliing cannot be 

 dispensed with in pleurisy. 



The sedative medicines, however, should be oixutted much sooner than 

 in pneumonia, and succeeded by diuretics. The common turpentine is as 

 good as any, made into a ball with linseed-meal, and given in doses of two 

 or tlu^ee drachms twice in the day. If the constitution is much impaired, 

 tonics may be cautiously given, as soon as the violence of the disease is 

 abated. The spirit of nitrous ether is a mild stimulant and a diui-etic. 

 Small quantities of gentian and ginger may be added, but the turpentine 

 must not be omitted. 



There is in pleurisy a far greater tendency to relapse than in pneumonia. 

 The lungs do not perfectly recover from their state of collapse, nor the 

 serous membra,ne from its long maceration in the effused fluid : oedema, 

 cough, disinclination to work, incapability of rapid progression, colicky 

 pains, as the unobservant practitioner would call them, but in truth 

 pleuritic stitches — these are the frequent sequelte of pleurisy. This will 

 afford another reason why the important operation of pai*acentesis should 

 not be deferred too long. 



There is much greater disposition to metastasis than in pneumonia : in- 

 deed, it is easy to imagine that the inflammation of a mere membrane may 

 more readily and oftener shift than that of the substance of so large a viscus 

 as the lungs. The inflammation, sliifting its fiz'st ground, attacks almost 

 every part indiscriminately, and appears under a strangely puzzling variety 

 of forms. Dropsy is the most frequent change. Efl'usion in the abdomen 

 is substituted for that of the chest, or rather the exluilant or absorbent 



