and the term of illness much shortened. Warm fomentations by means of hot wet flannels, or poultices, are of very general application, and tend to promote diaphoresis. The oiled silk jacket, applied early and worn until convalescence, fulfills the same indications more agreeably.

The cardiac sedatives, veratrum viride, digitalis and gelsemium sempervirens, are all lauded for the purpose of controlling the morbid activity of the circulation. My own preference, after considerable experience, is in favor of the gelsemium, given in doses of five or ten drops every two hours until the desired effects are produced; occasionally larger doses will be required, but it is better to increase the frequency rather than the quantity given at one time.

Antimony may be occasionally given where there is great intensity of the febrile reaction, and it will aid other sedatives and promote diaphoresis; but its tendency to produce depression will lead us to use it cautiously-generally it is not indicated.

The pathology of the disease shows us that expectorants will have little effect upon the local disorder, and the good they achieve is through their influence over the circulation and the excretions. The bowels should be kept open by mild salines, but catharsis is to be avoided, except at the outset of the attack, when it may be permitted as a derivative. Mercurials are of more than doubtful advantage so far as their specific effects are concerned, but a mercurial cathartic will be advisable when a loaded tongue, with nausea and gastric irritability, indicate portal obstruction.

Opiates are invaluable in both the first and second stages of the disease to allay pain and restlessness and soothe the nervous excitement, so often a source of distress. Its happiest effects will be exerted by small, frequently repeated doses.

Constant watchfulness is needful to guard against the tendency to asthenia, and support, by means of food, must be afforded at an early day. Carbonate of ammonia may be given as soon as the stage of hepatization is established, and continued steadily through the attack. I have found cases so treated to progress more favorably, resolution occurring earlier than where it was

omitted. Another use which has been attributed to carbonate of ammonia, is that of increasing the alkalinity of the blood, and thus guarding against heart clot.

Quinine will be early and freely borne, and as soon as the febrile excitement is controlled, and convalescence progressing, iron may be added.

The syrup of the phosphates of iron, quinine and strychnia, afford a most excellent combination. For children I am very partial to the compound syrup of the hypophosphites.

The indications for alcoholic stimulants are the same as in other asthenic diseases, and the urgent call for support by the failing energies should not be waited for, but the probable need anticipated.

We not infrequently see cases of pneumonia characterized by symptoms of great depression from the outset; the vital powers are low, and the morbid process is intensely asthenic, as shown by the feeble heart beat. This form is often denominated typhoid pneumonia. Its treatment must be stimulant from the initial chill-carbonate of ammonia, quinine, wine and concentrated nourishment, must all be skillfully played off by the physician against the tendency to death. A most important point here, is postural treatment; the patient, from sheer feebleness is very prone to remain for hours in one position, and percussion will show that there is a tendency of the fluids to gravitate to the lowest point, and in this manner the lungs become mechanically blocked up, without the deposit of any active inflammatory products. The danger may be avoided by changing the position in bed frequently, not allowing the maintenance of any one decubitus for more than an hour or two at a time.

During the period of a favorable convalescence from pneumonia, as the strength returns, gentle exercise in the open air, in bright weather, is a useful adjuvant; there is little danger of a relapse after the disease is fully controlled, and unless the purulent stage has been developed, the lung returns to the perfect performance of its functions with great rapidity. Where, however, pus is found in the sputum, supporting and tonic treatment must be continued for a longer period. The various chalybeates

much aid.

and vegetable bitters are indicated, and cod liver oil will afford Friction over the surface with almond or olive oil will be found agreeable and useful.

You observe, gentlemen, that I have left untouched many points of interest in the consideration of this subject, and have entirely ignored many important varieties and complications of the disease, which future opportunity will enable us profitably to consider.

NOTE. --Since the above lecture was delivered, my colleague, Professor Noyes, has given me the following interesting account of his experience with pneumonia in Maine, many years since. The locality was a damp valley, where the disease was endemic and characterized by intense disturbance of the circulatory system, the indications presented calling apparently for the most active treatment. Patients were attacked with severe rigors, speedily followed by intense febrile symptoms, hard-bounding pulse, features injected, lips purple, agonizing distress for breath, and sense of impending suffocation imminent, even in the stage of engorgement the sputum appearing almost like clear blood: an assemblage of symptoms in which it would seem that venesection was imperatively demanded. Professor N. followed out at first the directions of Watson. Two members of one family were attacked-powerful young men, lumbermen-and bleeding was at once practiced, a full stream from a large opening being taken, and prolonged until full relief was experienced. Nevertheless every case died. Three of the remaining members of the family suffered from the same disease, one an old man nearly seventy years of age. In these, too, the symptoms were equally severe; venesection was not practiced, but postural treatment instituted, the laboring sufferer elevated to the sitting position, and active derivative measures taken by means of friction, induction of diaphoresis and cupping. A short time sufficed to remove the immediate danger, and the patients recovered, even without the use of antimony. Further experience in the same region proved that depletion was illy borne, the disease proving fatal in a larger proportion of cases, and where recovery was accomplished, running a longer course. G. P. A.

Selections.

GENTLEMEN

PARACENTESIS PERICARDII.

By T. Clifford Allbutt, M. A., M. D.

It is now two years and a half since I advised the operation of paracentesis pericardii in the case of a patient in the Leeds Infirmary who was at the point of death from effusion into the pericardium. The case was an acute one, and the operation was brilliantly successful, if I may be allowed to say so. particulars were published in the Medical Times for November 3, 1866; and Mr. Wheelhouse, who operated for me, also read a

The

paper on the case to the Surgical Section of the British Medical Association at its last meeting. I shall now describe to you, and comment upon, an unsuccessful case of the same kind, in which Mr. Teale twice operated for me.

On the 29th of April last I was urgently called to see Miss H—, a patient of Mr. Mann's, who was suffering from pericarditis. Mr. Mann had been called to her but a short time previously. The patient, a weakly girl, twenty-seven years old, had been suffering from slight rheumatic pains for some days; medical advice had not been sought, and Mr. Mann, on his arrival, found that pericarditis had silently crept on, and that the patient was in much danger; the pains in the limbs had almost entirely and rather suddenly ceased. At the time of my visit I found the patient suffering from what Jaccoud has well called the "paralytic form" of pericarditis. The girl was crouched on her left side; her face was deadly pale, very anxious, and covered with a cold sweat; her lips bloodless, her hands and feet cold, her respirations 90 in the minute, and there was some tendency to agitation. She clutched at the left breast, and complained of dreadful oppression at that part. On examining the chest as much as I dare, I was able to verify Mr. Mann's diagnosis, and to ascertain that the pericardium was greatly distended with fluid. There was evidence also of mitral regurgitation, for the first sound of the heart was quite inaudible, and a faint blowing murmur, synchronous with the systole, might occasionally be heard at the apex. The lungs were everywhere resonant, except over a small region at the left base behind, where there was some deficiency. Moist sounds were to be heard all over both lungs, before and behind; and there was cough, with some watery and mucous expectoration. Her temperature was 104°. Her pulse was scarcely to be counted, and often imperceptible. It was quite clear that we had to deal with a very dangerous form of pericarditis: a form which, like some forms of pleurisy, runs silently and quickly to effusion, rather than to coagulating and organizing exudation; a form, moreover, which, from the tendency to syncope from failure of the heart's action, has, I say, been named "paralytic." The patient was reduced indeed, to use Mr. Teale's happy parallel, to the state of one laboring under embolism of the pulmonary artery. There was the same deficiency of blood-supply to the lungs, the same congestion of the venous side with evidence of general pulmonary edema, the same distress, and the same symptoms of poisoning by carbonic acid. I explained to Mr. Mann the operation I felt inclined to advise, but I shrank, more than I now should do, from having it performed at once. I did not expect the girl would live through the night; and, in any case, I was disposed, before operating, to try to restore her a little by cordial and supporting treatment. I said that if she survived the night I should counsel the operation. Mr. Mann most generously placed himself and his patient

in my hands, to call in Mr. Wheelhouse, or do as I thought fit. The following day we found the patient with a little better force and better pulse. She had taken fairly of whisky punch and some food. Her pulse was 180, her temperature 104°, and there were the same symptoms of failing heart's action and of lungoppression. We were now able to examine the chest carefully, and meanwhile we sent for Mr. Wheelhouse. On examining the chest in front we found dullness extending upward to the second rib fully, and to the first rib partially, on the left side. It extended laterally to the right sternal border on the one side, and downward and outward toward the axillary line on the other. Below, it reached a line drawn from the epigastrium to the axillary line. The dull space formed a triangle, of which this last formed the base line, while the blunt apex of it lay a little to the right of the middle point of the left collar-bone. The upper half of the dull space lightened up a little on inspiration, and was deadened again when the lung receded on expiration. The most complete dullness was from the root of the great vessels up to the heart's apex. A very distinct friction sound could be heard over most of this space, and the apex-beat of the heart could be felt. The apex was displaced a little downward and to the left, but was well within the base line of the dull triangle. The diaphragm was probably depressed, but neither spleen nor liver were much displaced. The apex moved a little to the left with that position of the patient-a sign which, at the time, I believed, in obedience to the statement of Oppolzer, to be diagnostic of pericardial effusion. I find, however, Gerhardt has shown that in healthy persons the apex-beat may travel about two centimetres to the left when the position is changed to the left side. I have been accustomed to believe also that a full friction-sound could scarcely persist when effusion was in quantity. In our case, however, nothing could be clearer than this, that the apex was distinctly to be felt, and the rubbing to be heard, and even felt also, while at the same time there was as certainly a great effusion. On looking up this point, I find that Oppolzer describes the initiatory rub, the separation of the parts by effusion, and the returning rub during absorption, without any qualification. Niemeyer, however, says that the rubbing sounds are not only heard when the effusion is small in quantity, but also when it is considerable. ("Sondern kommon auch bei sehr copieser Ansammlung von Flüssigkeit in Pericardium vor.") So that the presence of extensive friction did not, and rightly did not, prevent my urging the operation. The heart sounds themselves were as the day before; the first being replaced by an exceedingly distant murmur, the second being audible, but distant. The feebleness of the heart, and the consequent syncopic tendency and lung mischief, were so great that I believed myocarditis, or even fatty degeneration of the heart's tissue, as described in pericarditis by Virchow, was present. On