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exposure remains, and demonstrates that there are missing links in the chain of our knowledge, which can only be supplied probably when we are fully cognizant of all the operations of the internal economy.

Therefore, while we now know tolerably well from observation that exposure to cold may be an exciting cause of idiopathic pleuritis, and also of acute rheumatism, we also know that unless some antecedent condition exists which is propitious, that such exposure will not bring about the disease. Hence waiving the malarial theory of causation for each, it seems idle to pass the question of etiology solely to the stereotyped doctrine-exposure to cold.

Vallieux, I think it was, and after him Davis, of London, first called attention to the probable rheumatic origin of some cases of acute pleuritis, but they awakened very little thought in this direction, so that we find the point mentioned only in two or three of our books; but I believe that their view of the matter was right, and that if we closely study the typical cases of acute pleuritis we shall find in the idea of the rheumatic nature of idiopathic pleuritis a plausible explanation.

I have been quite impressed with this doctrine for the past few years-especially after having seen two cases: one the case of a fellow practitioner and one entirely under my own management that went on to a speedy and satisfactory cure upon the so-called anti-rheumatic treatment. To strengthen the position taken, let us briefly compare these serous membranes with one another, and the pathology and course of the two diseases-acute pleuritis and acute rheumatism.

Histologically, all of the fibro-serous membranes are identical, all proceeding from the meso-blast, or middle of the primordial layers, and ultimately developing into the endothelial layer, or lining proper of all closed cavities. This is situated upon a basement membrane, proliferated, probably, by the fibrous tissue or layer surrounding it, and constituting the framework. To this endothelial layer, in all cases, belongs the secretory property of

the part, which we know varies, as, for example, the presence of mucin in the synova. The statement of some histologists, that in the case of the joints, the fibrous, basement and synovial layers are proliferated from the outlying cartilage, does not alter the case, because the histological characters of the fully-formed tissues in question are the same-neither does the mode of origin and arrangement of the lymphatics, which seems to be an undecided question, for we know that each fibro-serous membrane must have, and does have, its lymphatic system, in one form or another. Therefore, we must accept as a fact that these several serous membranes belong to the same anatomical system.

Pathologically, also, the identity is marked. In acute pleuritis, pericarditis, peritonitis, and rheumatic or simple synovitis, the steps of the disease process are the same, or nearly so, viz., hyperæmia, effusion (either fibrino-serous, lymph, blood, pus, or a mixture of these).

I am aware that most authorities state that in rheumo-arthritis the fibrous element of the joint is the elective seat of the local disturbance; but if we look for a moment upon the diverse anatomical structure of the parts affected in the two forms of disease -pleuritis and acute rheumatism-together with the fact of the sparsity of the supply to the joints of lymphatic vessels and nerve twigs as compared with the pleura, we can readily understand the apparent discrepancy. The ultimate disposal of the effused material is nearly the same for each locality; for there may be complete or partial absorption, calcareous or fatty degeneration, adhesion and pyogenesis in either disease.

Again, directing our attention to the clinical history of acute and sub-acute rheumatism and idiopathic pleuritis, we can easily trace resemblances; for instance, the varying grades of constitutional and local disturbance, the modes of access, the intermittent, remittent or continued character of their course, or pyrexia and their complications-all these are certainly quite analogous. The symtomatology related before of the several types of pleuritis has its analogy in acute and sub-acute rheumatism. It must be

admitted, however, that there are two characteristic signs of acute rheumatism which are not often observed in idiopathic pleuritis, namely, profuse acid perspiration and the marked fugitive behavior of the local inflammation; the former to me is inexplicable, but the latter phenomenon would seem clear if we would take into consideration the small extent of tissue to be attacked in a joint, compared with the vast extent and room for effusion in the pleura.

Thus, allowing, as it were, full scope from the beginning for the local expression of the disease, this becomes more probable when we call to mind cases of acute rheumo-arthritis in which several joints have been attacked simultaneously, with the fugitive characteristic almost wanting.

Therefore, hoping that these suggestions regarding the analogy in the nature of acute rheumatism and acute idiopathic pleuritis may induce you to apply the crucial test in the way of treatment, I leave the subject for your consideration.

DISCUSSION.

DR. BAKER: I would suggest the question whether there is a relation between this subject and the one on which I read a paper yesterday? I suggest that the fact is known in physiology as to the exudation of an albuminous constituent of the blood connected with the saline exudation, substantially as stated in "Dalton's Physiology." Given a mixed albuminous and saline fluid, like blood, at first through an animal membrane, only the saline exudations will pass, the albumen will not; but after the saline exudation has reached such a stage that about four per cent. of sodium chloride is present in the fluid, then the albumen passes. I simply wish to suggest that thought, and ask if it would not be desirable to have fluids drawn from the pleural cavity analyzed, and find their exact condition?

PARACENTESIS THORACIS.

N. H. WILLIAMS, M. D.,
Jackson.

The paper which I have the honor to present contains some of the results of my own experience in the operation of Paracentesis Thoracis, and that is my excuse for taking your time with the discussion of so familiar a subject; that, and one other reason, namely that I am convinced from personal observation, that the operation is performed less frequently than it should be, or what amounts to the same thing, that the indication for its performance, fluid abnormally present in the thorax, is not infrequently overlooked, the dullness on percussion, and absence of respiratory sounds, having been considered as resulting from a consolidated lung, and I claim that it is no great discredit to a physician's diagnostic ability to do so, if he relies upon the ordinary physical signs. I have seen experienced and acute diagnosticians err in this regard.

Where the history of a case is consistent with pleuritic effusion, and there is abnormal dullness over any part of the thorax, I invariably use the hypodermic needle as the quickest and surest way of deciding the question of the presence of fluid, substituting the sense of sight for that of sound; not confining myself to one puncture, but making several if necessary, the pain and discomfort to the patient being of the slightest, and the danger none with ordinary antiseptic precautions. In one case I made as many as five punctures in different parts of the thorax without finding fluid, and succeeded with the sixth. My own mistakes, and those of others, have taught me to place very great value upon the hypodermic syringe as an aid to diagnosis in diseases of the chest.

I consider the operation indicated in any case of acute pleurisy where the effusion is to such a degree as to produce distressing dyspnoea, either temporary or continuous, and whether fever is present or not. I am aware that the weight of authority is in favor of waiting until the fever has subsided, before operating, but in my own cases I have not considered the fever as a bar to the operation, and have never observed an untoward symptom, or any inconvenience or discomfort, but on the contrary, generally a relief of dyspnoea, better sleep, and general improvement. In about one half the cases where aspiration has been made during fever, the liquid has reformed, and been again withdrawn. But even in those cases I think the operation was a benefit, by the relief of dyspnoea, and in preventing a continuous compression of the lung. In such cases it has seemed to me better not to remove all the liquid, but to leave sufficient to prevent the contact of the surfaces of the inflamed pleura.

In any case of chronic pleurisy where there is effusion of serum, whether dyspnoea is present or not. In any case of empyema, unless it is decided to make an opening with the knife and saw.

In one case, that of a man twenty-five years old, with left empyema, I aspirated four times, at intervals of about one week, drawing off nearly a pint of pus at each operation. The patient made a good recovery, and is now working on his farm. In another case, of a man twenty-two years of age, repeated aspirations effected a perfect cure. In both cases the patients were emaciated, weak and febrile, but improvement began within a few hours after the first operation.

While a student, I saw the operation, for the first time, upon a case of empyema, by Bowditch. The patient was in the semirecumbent position, and the puncture made where Bowditch then advised it, namely, in the eighth intercostal space, a little towards the median line from the lower angle of the scapula, very near the diaphragm. About three pints of pus was evacuated with a Wyman aspirator.

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