propose to present a more detailed account of my experience of this treatment, and of the manner in which it is carried out.

With regard to the methods employed for procuring rest in the treatment of pleurisy, that which is of special importance is the use of certain appliances fixed round the affected side. more or less extensively, so as to limit or prevent its movements. As subordinate aids, it is advantageous in severe cases to keep the patient quiet; to give instructions to restrain the breathing as much as possible (though this is generally done instinctively, on account of the pain the act induces); and to forbid all conversation. In a pathological point of view the results which might be fairly anticipated from this mode of treatment are, that the inflammation would be limited and subdued; that the effusion of lymph and fluid would be checked; and that whatever morbid exudations had been poured out would be more readily absorbed, followed by organisation of the remaining lymph, with the formation of adhesions.

In actual practice cases of pleurisy present very considerable differences when they come under observation, and it will be necessary to point out to what extent the treatment by rest is applicable to the different classes. In one group of cases, of very common occurrence in hospital practice, the inflammation. is localised to a small patch, and appears to have but little tendency to spread. There is generally a good deal of pain, especially on breathing or coughing, but there are no constitutional symptoms. Physical examination reveals limited frictionsound. In these instances the firm application of three or four strips of plaster round the side, in the manner to be presently described, almost invariably gives complete relief, and even allows the patient to continue his occupation. Nothing more is needed, and in a week or two the plasters may be removed. In another class of cases, a patient comes under notice who is evidently in the early stage of a severe and extensive attack of pleurisy, judging by the local and general symptoms and physical signs. It is an unfortunate fact, however, that in many instances the symptoms are not very prominent at first; and it is by no means uncommon to find that abundant effusion has taken place before the patient is aware that there is anything particularly wrong. Should a case come under treatment in

this early stage, I would strongly recommend that a trial should be given to the plan of mechanically fixing the entire side by one of the methods to be now described. In order to be of any use it should be done effectually, so as to restrain the movements as much as possible, and the sooner the application is made, the more likely is it to be of service. The plan I originally adopted was the following:-Strips of adhesive plaster, from four to five inches wide, were fixed at one end close to the spine, and then drawn tightly round the side as far as the middle line in front, the patient being directed to expire deeply. In this manner the whole side was included, commencing from below and proceeding upwards, each succeeding strip partially overlapping the one below. One was also fixed over the shoulder. Over this layer of plaster strips of bandage of the same width were fixed in like manner, having been previously dipped in a mixture of mucilage and chalk, such as is used in the treatment of fractures. Two or three layers of these were laid on, and then heated sand-bags applied, in order to dry the application as soon as possible. This is a most effectual mode of fixing one side of the chest, while it leaves the other quite free to act; and I would, by the way, commend it to those who are called upon to treat fractured ribs. The plaster adheres firmly to the skin, and the bandages adhere to the plaster, a firm casing being formed which will remain on any length of time. With regard to pleurisy, however, I have since then adopted another plan, which, so far as this disease is concerned, seems sufficiently efficacious. It is merely to use strips of plaster, putting on two or three layers in the following manner:-The first strip is laid on obliquely in the direction of the ribs, the second across the course of the ribs, the third in the direction of the first, about half overlapping it, the fourth as the second, and so on until the entire side is covered. A strip is also passed over the shoulder, which is kept down by another fixed round the side across its ends. Now it is difficult positively to prove that this treatment actually checks the course of pleurisy; but, taking a common-sense view of the matter, it is not improbable that such a result might be anticipated; and, from my own experience, I have not the slightest doubt but that it is brought about. I have carried it out now in a good number of

188 ON" REST" IN THE TREATMENT OF CHEST AFFECTIONS.

cases, and in all the course and termination have been most satisfactory, while relief to the pain and other distressing symptoms has been generally immediate. I feel convinced, also, that in many of those cases of extensive pleuritic effusion which come under observation, the accumulation might have been prevented or moderated had this plan of treatment been adopted at an early period.

In another set of cases of pleurisy there is found to be a moderate amount of effusion when the patient first comes under treatment. Here, too, I would recommend efficient fixing of the side. In those cases in which I have carried it out, I have almost always had satisfactory results, whereas I have more than once regretted the neglect of this plan of treatment. Where the effusion is very abundant, but little can be expected from it, though I think that occasionally it has appeared to aid absorption. Now and then cases present themselves in which there is extensive exudation of lymph over the surfaces of the pleura, with but little fluid. Here the only object to be desired is to bring about adhesion of the surfaces as soon as possible, and strapping the side firmly aids this most certainly. In bilateral pleurisy of course this mode of treatment can scarcely be practised; and where this disease complicates others it will be of less service.

(To be continued.)

PLEURITIC EFFUSION WITH ACUTE MANIA CURED

BY PARACENTESIS THORACIS.

BY RICHARD GREENE,

Senior Assistant Medical Officer, Sussex Lunatic Asylum, Hayward's Heath.

IT is to be feared that paracentesis thoracis for the removal of fluid effused consequent on acute pleurisy is not yet so common as to prevent the following case being interesting to most readers of the Practitioner. It is still too much the custom to regard this simple operation as a dernier ressort, and not as the ordinary treatment for pleuritic effusion, when we feel satisfied that the fluid is not being rapidly absorbed, or when there is much disturbance of the circulation or of the respiratory movements. The longer the fluid is allowed to remain in the pleura, the greater is the danger of irremediable lung-mischief supervening; and the risk of the operation being very slight, it is certainly better to err on the safe side, performing it too soon rather than leaving it until the lung, or part of it, has become so carnified that resumption of its function is impossible.

Those old true-blue practitioners who object to make a tiny wound in the thoracic wall should remember that they never hesitate to ruin their patient's constitution by the "judicious use of mercury," drift him into phthisis by blood-letting, inflict horrible torture by repeated blistering, or drench him with nauseous drugs, named diuretics by courtesy.

No operation could have been undertaken under more unfavourable conditions than in the following case, and yet the result was perfectly satisfactory. The patient's disease had been mistaken by his medical attendant: he was exhausted

from want of nourishment and from a long railway journey, and he was in a state of raving madness, having no knowledge of his surroundings or of his own weakness. Moreover, having no Bowditch's syringe at hand, I had to use an ordinary trocar and canula, conducting the fluid under water by means of a few feet of indiarubber tubing. I am satisfied, however, that no air entered the pleural cavity.

A. B., aged 28 (No. on Register, 2,228), was admitted into this asylum on the 8th of March, 1873, suffering from acute mania. It was stated by the medical practitioner who certified to his insanity that he was then suffering from pneumonia, but that the thoracic disease had supervened on the insanity, and that they were not related to each other as cause and effect. On admission, mentally he was almost as ill as it was possible for him to have been, and his incoherent ravings were, as is so often the case, divided between perverted religious ideas and the most disgusting obscenities; while, physically, he was found to be in a very exhausted state. His pulse 136, weak and compressible, respirations 33, and temperature in the axilla 100°.3. There was little or no respiratory murmur audible on the right side, but it was intensified on the left, and percussion elicited a dull sound over the whole of the right half of the thorax, which was also bulged slightly. It was at once seen that the case was not pneumonia, but pleurisy with effusion. Alcoholic stimulants were carefully administered, and under these the patient to a certain extent revived; but it became more and more evident that the only hope of recovery lay in paracentesis thoracis, which I consequently performed a few hours after admission. Four pints of fluid were removed, and the lung shortly began to expand. Six hours' sleep was obtained by the subcutaneous injection of one-sixth of a grain of morphia. The pulse, respirations, and temperature fell gradually till they reached the natural standard, and contemporaneously the mental state improved until reason was quite restored. A course of cod-liver oil and tonics completed the cure, and the patient was discharged on the 31st of May in all respects well and strong. A few weeks ago I heard from his relatives that he has preserved both his mental and bodily health, and that he is daily employed at his trade.