is a stimulation of the surrounding tissues. Now suppose that a part in the vicinity of the artificial irritation is in the first stage of inflammation; it is evident that the disease may be aggravated by the slight additional stimulation. But this does not always happen. It is possible that under certain circumstances the little additional excitement may cause what is termed effusion, and the second stage of the disease to be developed. In the first stage of pleurisy, for instance, a blister on the chest soon relieves the pain; but relief is obtained not because the disease is "allayed" or "controlled," but because the pleuræ become separated by a layer of fluid; in short, the counterirritant has not checked the diseased lung, but merely assisted it through its natural progress. In the second stage of inflammation a great many of the capillaries are occluded, and the proper parenchyma of the part must necessarily suffer from insufficiency of nourishment; hence a gentle stimulus is necessary in order to deflect the nutrition towards health. If, however, the proper structure of the part is on the eve of breaking down into pus, the additional stimulus of a counter-irritant may accelerate the event; and this may or may not be desirable in the treatment of a case according to circumstances. It is very evident that a stimulant action is very likely to do good in cases of chronic inflammation and of local debility; while it is scarcely necessary to add that this theory will account for the quantitative differences which occur in the effects of counterirritants according to their distance from the primary disease, and according to the degree of irritation produced. This theory, therefore, gives complete unity to our conceptions of the mode of action of counter-irritants, and the practical precepts which guide us at the bedside may be readily deduced from it. This is the highest verification which is possible to be given to the theory.



BY FREDERICK T. ROBERTS, M.D., B.SC., M.R.C.P. Assistant Physician to University College Hospital, and to the Brompton Consumption Hospital.

THE attention of the profession has been recently drawn to the question of the advantages to be derived from the employment of rest in the treatment of pulmonary phthisis, by some papers published in the medical journals, particularly one from the pen of Dr. Berkart in the Lancet of October 18th, 1873. I propose in the following remarks to take a more comprehensive view of the subject, first offering a few general observations upon it, and then considering the matter with reference to particular chest affections, phthisis among the number. My reasons for taking part in the discussion are, that for several years I have studied the question with some care, and have made rest a prominent element in the treatment of pulmonary affections; that the majority of the profession certainly do not at present recognise in a practical manner the benefits which it is capable of affording, and therefore cannot be too often reminded of them; and that certain of the statements made in some of the communications already alluded to seem to me to call for further comment and consideration.

Beginning, then, with the general principle of rest as applied to the treatment of diseases of the respiratory organs, and of the other structures engaged in the performance of the respiratory functions, it will be well to point out briefly, first, the objects to be aimed at in attempting to carry out this principle;

and secondly, the methods by which the desired rest may be secured. One of the most important and most obvious ends to be sought after is to maintain structures, which are either actually diseased or in danger of becoming so, in as quiescent a state as possible; in short, to try to procure mechanical rest, just as is ordinarily done in the case of a diseased joint. This applies to the structures forming the chest-walls, to the pleuræ, and to the lungs themselves. A further object, also of importance, in restraining the respiratory functions, is to prevent, so far as is practicable, the contact with diseased pulmonary tissue of air, which, either from its own physical conditions or from being contaminated with abnormal and injurious gaseous or floating solid elements, may prove a source of irritation, and thus tend to increase the mischief. Again, bearing in mind the influence which the movements of the lungs during breathing exercise over the circulation of the blood through these organs, it is not improbable that by limiting these movements, either generally or locally, and thus rendering the circulation less active, some effect may be produced in the way of checking certain morbid processes, which an over-active circulation tends to promote. Lastly, some writers have attached much importance in certain cases to the diminution in the oxygenation of the blood and tissues, which necessarily follows any restriction in the performance of the respiratory functions, considering that undue oxidation is injurious, and that it hastens the progress of disease. Upon this question I shall have more to say hereafter.

Coming now to the methods which are open to us for procuring rest in connection with the respiratory organs, it may be remarked generally that the immediate objects which these have in view are either the limitation of the respiratory functions as a whole; the checking of certain acts in which the lungs are called into violent play; or the interference with the movements of limited portions of these organs or of the chest-walls. At present it will suffice merely to indicate what these methods are, as they will call for further consideration when treating of individual diseases. 1. The activity of the respiratory functions will of course depend upon the degree in which the body is exercised, and the amount of muscular effort which is put forth. Hence, by diminishing this, and especially avoiding all kinds of

violent exertion, breathing may be kept within proper limits, and it may be desirable to keep patients completely at rest, so as to reduce to the minimum the call made upon the lungs. 2. By voluntary effort on the part of the patient, the respirations may be considerably reduced in number, and limited in depth; and further, it is possible to breathe in such a manner as to use only certain portions of the lungs, leaving other portions in a state of repose. In some cases it is advantageous to draw the attention of patients to this matter, who can thus assist in the treatment when rest is required. 3. Unquestionably much harm often results, both in the way of originating morbid conditions and aiding their progress, from certain actions which call the respiratory organs into more or less violent play, and exercise a strain upon them, especially coughing, excessive use of the voice (as in public speaking, street-crying, singing, &c.), and blowing wind-instruments. Therefore it frequently becomes a matter of much importance in treatment to use every means for checking cough, and to forbid imperatively any indulgence in the violent exercises above alluded to. Indeed it is sometimes advantageous to prevent a patient from using the voice at all, quite independently of any implication of the larynx. 4. In order to avoid irritation of the lung-tissue by unhealthy air, of course the obvious duty of the practitioner is to take every precaution against the inhalation of such an atmosphere. It is clear, for instance, that if a person is, in connection with his occupation, habitually inhaling air loaded with irritating solid particles, he should at once be advised to give up such occupation, though unfortunately this advice very often cannot be followed out. In all cases of pulmonary disease, it is incumbent upon the physician to inquire into the conditions of the air which the patient habitually breathes, and to endeavour to make this as satisfactory as circumstances will permit. 5. It has been found that inhalation of compressed air has an influence in diminishing the number of respirations, both during the inhalation and subsequently; and Dr. Berkart expresses his opinion, "that the value of compressed air in the treatment of phthisis principally consists in the rest which the lungs derive from it." Finally, by the application of different kinds of apparatus over the chestwalls externally, such as plasters, bandages, &c., we possess the

power of diminishing or even completely preventing the movements of respiration, either generally, on one side, or over limited regions. This mode of procuring mechanical rest has received remarkably little attention, and though of the utmost value in many cases, has been practically overlooked by the great bulk of the profession.

I now pass on to the consideration of special diseases, in order to determine to what extent the principle of rest can be applied in the treatment of each, and how it can be realised under different circumstances.

PLEURISY.—To anyone who is acquainted with the pathological conditions resulting from this disease, it must be evident that to restrain the movements of the affected structure, to prevent the friction of the inflamed surfaces against each other, and keep the parts as much at rest as possible, ought to be the first principle to be followed in its treatment. The state of things is very similar to that observed in connection with an inflamed synovial membrane in a joint, and in this condition the first thing the surgeon attends to is to maintain the joint perfectly motionless. I have never seen this principle definitely advocated for the treatment of pleurisy in the published writings on this affection, and, with the exception of two or three suggestions on the subject, it does not seem to have received any particular notice. In the course of my hospital practice during the last ten years, a large number of cases of this complaint have, as a matter of course, come under my care. In the year 1864 I, quite independently, arrived at the conclusion, from certain observations, that the primary object to be arrived at in treating pleurisy should be to endeavour to procure rest; and since that time experience has fully convinced me that I was not mistaken in my opinion. I have on previous occasions brought the subject before the profession, among others in a paper on "Rest and Position in the Treatment of Medical Diseases," published in vol. ii. of the "Liverpool Medical and Surgical Reports," 1868. In my "Handbook of Medicine," lately published, the principle has been definitely laid down and advocated, and an indication given of the mode which I usually adopt in order to procure the needed rest. Now I

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