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milk has been added. The effusion in chronic pleurisy is not as exempt from smell as that in the acute disease.

The false membrane in chronic pleurisy is not essentially different from that in acute pleurisy ; it is only firmer and more condensed, owing, perhaps, to the longer time it has been under the pressure of the effused fluid. It is capable of all the transformations of which we stated it to be susceptible in acute pleurisy; and to its conversion into fibro-cartilage, Laennec ascribes a particular change in the configuration of the chest, to which we shall presently have occasion to advert. It is more prone than in acute pleurisy to become the matrix of morbid developments, especially tubercle.

nosis of diseases of the chest was less certain than
it has been since the acquisition of the stethoscope,
the first form of chronic pleurisy was much more
common than it is at present, for this reason,—
that formerly being without the means of appre-
ciating the physical signs of the disease, when the
pain, the most prominent symptom, had yielded
to antiphlogistic means, it was then conceived that
the inflammation was subdued and the cure com-
plete; the patient then returning to his former
diet and resuming his usual occupations, was
often surprised by an attack more violent than the
former. Our improved mode of examination
teaches us that every symptom of inflammation
may have disappeared, every function apparently
be restored to its natural condition, and still there
may be considerable effusion into the cavity of
the chest until this be entirely removed, we
never can feel secure about our patient. Pleurisy,
in its essential chronic form, creeps on very insi-
diously, without much acceleration of pulse or
heat of skin; and when there is any unusual
sensation in the side, it does not amount to more
than a mere soreness: the difficulty or hurry of
breathing is sometimes so inconsiderable as not
to attract the individual's attention. An observer
is struck with the patient's unhealthy pallid ap-disorder...
pearance; there is a loss of appetite and a languid
look, which emphatically tells us of some mis-
chief going on; on close examination we find
that the absence of fever is not constant, but that
towards evening there is a febrile movement. A
dry cough, or one attended with scanty mucous
expectoration, and which has existed a considera-
ble time without any apparent dependence either
upon crude tubercles in the lungs or upon gastro-
intestinal irritation, should lead us to suspect the
possibility of chronic pleurisy.

The anatomical characters of chronic pleurisy do not differ very widely from those of the acute form, especially when it has been a mere transition of one form of the disease into the other. In this latter case, no matter to how distant a period the disease may be protracted, the fluid effused retains to the last its primitive character. As in acute pleurisy, it is a straw-coloured serum, but more consistent, apparently owing to its holding in suspension a considerable portion of the fragments of the false membrane, which, on the fluid settling, sink to the bottom. These condensed fragments, which, on opening the chest, are found in its most dependent parts, constitute, according to Laennec, a connecting link between the sero-purulent effusion and the false membrane. In essentially chronic pleurisy the effusion partakes more of a purulent character: in this case the disease closely resembles an abscess, the false membrane investing the pleura corresponding to the cyst, and endowed with the physiological properties of absorption and secretion. If the constitution be imbued with a scrofulous taint, (which is the habit in which we most frequently meet with this morbid condition,) the effusion will exhibit the ordinary characters of scrofulous pus, viz. a thin, wheycoloured matter, with flocculi of lymph floating in it. When the effusion is mainly purulent matter, mixed with a small proportion of serum, it is of a greenish colour, and very much resembles an effusion of tea to which a small proportion of

The lung is more compressed than in acute pleurisy; it is often reduced to a thin lamina, not exceeding six lines in thickness, lying down along the spine. There is also a more complete annihilation of its vesicular structure. It was this condition of the organ that led less careful examiners to pronounce upon its entire removal. Tubercles or other morbid growths may develop themselves in it, and, undergoing their proper changes, modify the symptoms of the original

The

Diagnosis of Chronic Pleurisy. physical signs of chronic pleurisy differ little from those of acute, except in being more prominently expressed; and apparently for this reason, that the disease, from its insidious character, has excited little constitutional alarm, and therefore the individual labouring under it has unconsciously permitted it to go on without seeking medical relief. In general, then, when it presents itself to the physician it has existed for a considerable time. The affected side is more rounded; the intercostal spaces are more dilated, and raised above their natural level, in some cases admitting of fluctuation being felt; the integuments of the side often become œdematous. When the disease has existed for a long time, the spine is observed to deviate from its natural direction, and to form a curve with its cavity looking towards the affected side. If the left side be the seat of the effusion, the heart undergoes the same displacement as in acute pleurisy.

The oedematous state of the integuments lessens, at least, the value of percussion as a means of assisting our diagnosis. There is not only a more complete absence of respiratory murmur, but not even ægophony or bronchial respiration is present. Double chronic pleurisy is a very rare form of disease.

Partial or circumscribed chronic pleurisy is more frequently met with than the same modification of acute pleurisy; and although there are many circumstances connected with it calculated to embarrass the diagnosis between it and pneumonia, especially our seldom having an opportunity of observing it ab initio, still the marked expression of the physical signs seldom leaves us at fault. It sometimes happens that the circumscribed nature of the affection shows itself to the eye by a distinct line of demarcation intersecting the side of the chest. If it happens that the pleurisy occupies the inferior part of the side, (which is most frequently the case,) below this

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speedily an opposite state, or dilatation, will succeed to an emphysematous condition of the contained organ. A cause mainly instrumental in the contraction of the side is the atrophy of the muscles from disease, respiration being exclusively carried on by the opposite side.

line will be found the physical signs of pleurisy, | ing bony case should have its form influenced by with dulness of sound and absence of respiration; this condition of the lung, when we reflect how while above it, the only deviation from the ordinary state of things is puerile respiration. Pleurisy assuming a chronic character from its commencement generally occurs in a cachectic habit of body, or where the health has been broken down by previous illness. We have met with it more than once after fever, and usually When nature relieves herself of the accumulaeither in scrofulous habits, or in persons much ted fluid by a passage through the pulmonary tisaddicted to intemperance. sue into a bronchial tube, the individual, who has Prognosis of Chronic Pleurisy. The been for some time labouring under either a dry prognosis of chronic pleurisy is, generally speak-cough, or one attended with scanty discharge, is ing, very unpromising; however, if it exist as an suddenly seized with an abundant expectoration isolated affection, apart from any complication, it of greenish, purulent matter, which comes forth may go on for months, nay, for years. If, as is with such a gush as to appear to be vomited rather often the case, tubercles form and go through their than expectorated. The discharge from the lungs changes either in the compressed or in the oppo- continues from day to day, the quantity gradually site lung, the complication will have the effect of diminishing till it ceases altogether. In proportion precipitating the fatal termination. In the ordi- as the matter is discharged, we perceive the fulnary course of the disease, a slow, wasting fever ness of the side to give way, and to come down sets in; there is a gradual emaciation; the appe- to its normal dimensions. In this case a considetite fails; the pulse is languid, although not much rable time will elapse before percussion and ausquickened; the legs swell, and the face becomes cultation yield their natural results, the sound puffed; the expectoration often has a disagreeable continuing dull, and respiration feeble; still the alliaceous smell. Upon these symptoms well-de- function of the lung will ultimately be restored, fined hectic fever soon supervenes, and rapidly differing from the case of contraction of the side, wears down the patient. in which the dull sound and feeble respiration are permanent.

Nature often takes the cure of pleurisy into her own hands, and seeks to relieve herself of the fluid effused into the chest in one of the following ways: 1, by absorption; or, 2, when the fluid is purulent, by making a passage for it through the pulmonary tissue into a bronchial tube, from whence it is expectorated; or though the walls of the chest, from whence it flows immediately out; or in some cases she adopts these two last ways at the same moment.

When the disease has existed a long time, and nature at length takes upon herself a slow, gradual process of absorption, which she takes a considerable time to complete, we observe that remarkable change in the form of the side to which we before made allusion this side, which was before perceptibly longer than the opposite one, now becomes less; it is diminished in all its diameters, its circumference sometimes measuring less by an inch than that of the opposite side. Its length is not less encroached upon; the ribs are approximated, the shoulder becomes lower, and even the spine, in some cases, assumes a lateral inclination from the habitually bent position of the patient. The muscles of the chest, especially the great pectoral, seem to have lost half their volume. We shall easily comprehend the nature of this change, when we reflect upon the cause upon which it depends. Laennec, who was the first to notice it, charged it upon the fibro-cartilaginous nature of the false membrane, which continued to oppose itself to the lung's being restored to its original condition: it interfered with its vesicular texture so as to render it impervious to the air: the organ had, in fact, virtually undergone a change of dimensions, in consequence of which the relation between it and its containing cavity was lost. The atmospheric pressure acting upon the side, and not counterpoised from within, causes it, as it were, to fall in and accommodate itself to the altered condition of the lung. We cease to wonder that the unyield

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The third expedient which nature adopts for the discharge of the purulent fluid in the chest is to give the pleurisy the character of an abscess, making its way through the walls of the chest, and pointing externally. When the apparently small abscess on the side of the chest either opens spontaneously, or is opened by art, it discharges a quantity of matter quite disproportionate to its size, and this matter is pumped out at each expiration and cough. Sometimes the matter gets vent both through a bronchial tube and through the side of the chest at the same time. It is a singular fact, that when the fluid in the chest is discharged through the lung, and consequently through a communication established between a bronchial tube and the cavity of the pleura, pneumothorax does not ensue, although it is previously the same lesion that gives rise to this morbid phe-. nomenon; the difference being only in the mode in which this lesion takes place.

TREATMENT OF PLEURISY.-If the energy and activity of our practice in the phlegmasiæ should be in proportion to the importance of the part inflamed, there is scarcely any part in the whole animal machine in which the inflammation demands a more decided and uncompromising plan of treatment than the pleura. If we temporize in the treatment of pleurisy, the least evil we can anticipate is a protracted convalescence; whereas if we meet it, in limine, with vigour, we often, as it were, strangle it in the birth.

I. Treatment of Acute Pleurisy. — The treatment of acute pleurisy comprises all the means usually employed to reduce constitutional fever and local inflammation.

Bloodletting. In the first stage of the disease, when febrile excitement runs high, and is accompanied with much local distress, we should bleed with an unsparing hand from a large orifice, and in the manner most calculated to make the speed

with extreme caution. In circumscribed pleurisy, with which the constitution does not seem to sympathise, the application of a few leeches to the seat of the pain will often remove all uneasiness. If, as in phthisis, in which partial pleurisy is so common, the exhausted state of our patient will not bear even so small an abstraction of blood, the temporary application of a hot turpentine stupe will often answer our wishes.

Purgatives.-The saline purgatives are especially suited to this first stage of pleurisy, as they diminish the mass of the circulating fluid by greatly increasing the secretion of the intestinal mucous surface. We follow up this antiphlogistic treatment by other means calculated to reduce fever, by producing diaphoresis, or otherwise, viz. the different preparations of antimony, tartaremetic in very minute doses, James's powder, Do

iest impression upon the system. Should a sin-
gle bleeding, conducted in this way, fail to afford
very decided relief, we should resort to the opera-
tion again within a few hours, and repeat it at
more or less distant intervals, according to the
urgency of the symptoms and the capability of our
patient to bear further loss of blood. Some have
attempted to fix the precise quantity of blood to
be drawn in the cure of a pleurisy; a generaliza-
tion to which nature will not submit, the effects
of bleeding differing in different individuals. It
would be to trust to a very fallible guide, indeed,
were we to depend upon the indications of the
pulse. In this, as well as in the inflammation of
all other serous membranes, the pulse, so to speak,
as often underrates as exaggerates the extent of
the mischief, being rather a measure of the consti-
tional irritability of the individual than of the ac-
tual amount of disease. The usually accompany-ver's powder, &c.
ing pain is a symptom upon which we can place
more reliance, and the effects produced upon it
serve, in some measure, to guide us as to the ex-
tent of depletion; but even it, so far from being
proportionate to the extent or intensity of the in-
flammation, is often absent when the inflammation
occupies a considerable extent of surface; and
even when both sides are affected at the same mo-
ment, if it be present, it is often found not to
amount to more than a mere soreness. The dys-
pnaca, or rather the nervous dread of drawing in
a full breath, in many cases lasts for so short a
time, that we must see the patient in the first mo-
ments of the attack to have the value of this
symptom. Were we to lay down any general
rule, deduced from the common symptoms, as to
the limit to which we would carry sanguineous
depletion, we should be most disposed to regulate
this by the strength of the patient, and the relief
of the pain and consequent power of taking in a
full inspiration.

While we distrust the indications of the pulse, which, in some cases, from its composure, is calculated to mislead, us as to the expediency or necessity of bleeding, so we should be equally on our guard not to be betrayed into the opposite error of considering an accelerated pulse, which may be produced by the depletion we have employed, as the index of continuing inflammation, and be thus led to push depletion still farther, and thereby originate functional disorder ultimately terminating in organic disease of the heart. We have seen this mistake so often committed, that we deem it necessary to subjoin this caution.

While we employ general bleeding, we may at the same time seek to relieve the local congestion by cupping and leeching. In the necessarily protracted operation of topical bleeding, we should manage it with caution, so as not to run the risk of exposing our patient to cold. Vencsection does not seem to be equally applicable to every modification of pleurisy. Thus, when it prevails as an epidemic, or develops itself in the progress of fever, or occurs as a puerperal disease,-in all these instances it assumes an asthenic type, when it becomes very questionable if general bleeding be at all admissible, or if we should not rather confine ourselves to local bleeding, with such other resources as art affords. This at least is certain, hat in these cases bleeding should be employed

Sedatives. These are often very useful in quieting the irritation of the cough, and thus procuring the repose of the organ affected. With such a view we derive much benefit from the use of hyoscyamus, conium, lactucarium, &c. Some recommend the use of opium in large doses after bleeding, by which we continue, as it were, the sedative impression of the bleeding, as well as allay the irritation produced by the pain, and soothe the cough.

Mercury.-The combination of calomel and opium enjoys an established celebrity in the inflammations of serous membranes; and after the use of venesection, and where there exists much pain, the remedy is invaluable, In such cases, our object is to bring the system as speedily as possible under the influence of mercury, by which we as it were supersede the morbid action which is going forward.

The treatment which we have just laid down applies to the earliest stage of pleurisy. However, it often happens that the patient does not present himself till the disease has existed at least for some days, and the intensity of the symptoms has in some degree abated, when the infiammation has assumed rather a subacute character, and has partly terminated in effusion. It is now that we have most reason to complain of the pulse not intimating to us the extent of the mischief. We now come to the long agitated question,—how late in the progress of pleurisy are we warranted in using the lancet? Without attempting to lay down a general rule upon the point, we would say that even now, notwithstanding the tranquillity of the pulse which often exists, we expect decided advantage from bleeding, inasmuch as we thereby, 1. check the further effusion of fluid; 2. promote the removal of the fluid already effused, by increasing the powers of the absorbing system at the expense of the circulation; 3. render the system more susceptible of the influence of the medicines we employ.

When the inflammation has nearly subsided, and the acute pain given way to a mere sensation of soreness, and we have the physical evidences of effusion, the indications of cure now are dif ferent, our main object being to promote the removal of the effused fluid. The means we employ for this purpose are either internal or external; the former comprising those medicines which,

acting by way of derivation either upon the kidneys or bowels, thus indirectly affect the effusion; the latter comprehending the different modifications of counter-irritation, which, by stimulating the absorbents, tend to produce the same effect more directly.

Diuretics.-The popular combination of squill, digitalis, and calomel, produces as speedy a diuretic effect as any we can employ. Laennec speaks highly of the infusion of digitalis from experience of its value in the particular case under consideration. It recommends itself to our notice upon the double grounds of its diuretic property and the control it exercises over the circulation; an important recommendation, when we consider the proximity of the organ affected to the source of the circulation, and the advantage from the blood being driven into it with diminished impetus. We may also employ, separately or in conjunction with the above, the saline diuretics, viz. the nitrate, acetate, and bitartrate of potash.

Purgatives. If the strength of the patient will permit, we may make use of the hydragogue cathartics, viz. elaterium, jalap, scammony, camboge, &c.; but the operation of these medicines is attended with so much exhaustion, that we can only employ them occasionally.

Diaphoretic medicines afford us such very feeble assistance at this stage of the disease, that they scarcely deserve a place among our remedial agents. We have not found tartar-emetic to sustain its character of an active antiphlogistic agent in uncomplicated acute pleurisy; but when the lung is involved in the same inflammation, we then find the advantage of associating with our remedies.

When we are endeavouring to affect the system with mercury administered internally, we may at the same time employ mercurial friction on the side, by which we assist the internal exhibition of the mineral, while we stimulate the absorbents.

Stimulating liniments carry with them the advantages that we can regulate their irritating property ad libitum, and that they do not unfit the surface to which they are applied for any future application.

When the milder counter-irritants, as auxiliaries to the internal means employed, have failed to make any impression upon the fluid, we resort to blisters. Andral's work (Sur les Maladies du Poitrine) abounds in cases in which the removal of the fluid seemed to date itself from the application of a blister. A succession of blisters acts more effectively than a single one of which the discharge is continued by an irritating application. As long as fever and inflammation are present, we of course insist upon rigid abstinence. But when these have subsided, and have left their effects alone behind them, the reasons for continuing the same strict system are scarcely less cogent; for in this way we lower the circulation, and thus establish a physiological ratio between its powers and those of the absorbing system, whereby the latter are much increased, and act with much more avidity upon the fluid in the chest. We find it extremely difficult to carry this part of our treatment into effect; for our patient will regain a degree of health, and feel very little if any inconvenience from the fluid in the chest, and not being VOL. III.-74

able to reconcile our severe restrictions with his sensible amendment, will become impatient of restraint, and, yielding to his improved appetite, will in all probability bring on fresh inflammation.

Sometimes a considerable time will elapse before any impression is made on the fluid, the system seeming as it were to stand out against the operation of our remedial agents up to a certain point, and then suddenly yielding, its removal rapidly ensues. At other times our medicines begin to take effect quickly, and remove the fluid gradually. We recognise the effects of our remedies by the side losing its fulness, by the reappearance of ægophony, by the return of the respiratory murmur and clear sound to situations where we before sought them in vain. Percussion will continue to yield a dull sound for a considerable time after the return of the respiratory murmur.

It seldom happens that in acute pleurisy we have to resort to the operation of paracentesis thoracis; nor should we ever think of it as long as we have any prospect of removing the fluid otherwise; still it may happen, from the other lung becoming affected either with bronchitis or pneumonia, or from having been already emphysematous, that to relieve the urgent sense of suffocation we have no alternative. In almost all these cases we find the operation to be attended with no more than a mere temporary relief, the fluid soon collecting again. It is an ascertained fact that the operation is, in general, less successful in acute than in chronic pleurisy, the reasons for which we shall endeavour to explain when we come to speak of the treatment applicable to the latter form of the disease.

I. Treatment of Chronic Pleurisy.—The treatment of chronic pleurisy, or of that modifica tion of the disease which from its commencement exhibits some of the characteristics of an acute inflammation, is as different from that of acute pleurisy as the respective natures of the two forms of the disease. Antiphlogistic means, whose activity is measured by the intensity of the febrile symptoms and the strength of the individual, constitute the treatment of acute pleurisy; and amongst these means, bleeding, as we have seen, occupies a most prominent place. In essentially chronic pleurisy, we seldom, if ever, have occasion to resort to constitutional bleeding. The weakened, if not the vitiated habit of body in which it generally takes place, will not admit of the exhaustion which this operation would produce; even local bleeding must be employed with considerable caution. The indications of cure are, to remove the fluid from the cavity of the chest, and to improve the dilapidated state of the system. The means by which we try to promote the removal of the fluid may be divided into constitutional and local; the former comprising those agents whose action is directed to some organ or set of organs at a distance from the seat of disease, and which effect the object we contemplate by establishing a counter-irritation and increased secretion at the expense of the diseased secretion, which continues to take

* This effect was ascribed by Laennec to the transmis. sion of the voice through a diminished stratum of fluid; but we consider it to be rather due to a less compressed

state of the lung from the diminution of the compressing fluid.

place into the chest until it is as it were super-lying under the pressure of the fluid. In many

seded.

Most of the means which we adverted to as applicable to the stage of acute pleurisy when effusion has taken place, may be seasonably employed in chronic pleurisy, qualified alone by the consideration that in the latter form of the disease the habit of body in general is not such as will bear the operation of active medical agents. When we employ mercury, we must manage its exhibition with caution, and beware lest, in pushing its use too far, we give rise to an irritative fever, which would soon exhaust the weakened constitution in which this modification of pleurisy usually presents itself: we should content ourselves with slightly affecting the gums. When hectic symptoms show themselves, we should cautiously abstain from the use of mercury altogether. We employ the same diuretics as in the second stage of acute pleurisy. We cannot, without incurring the risk of weakening our patient too much, resort to active purgation; we must, therefore, be satisfied with the mildest medicines of this class, and those whose operation draws least upon the stamina, viz. castor oil, manna, &c. Diaphoretic medicines lend us more aid in this than in the second stage of acute pleurisy; for instance, Dover's powder, James's powder, &c.

cases chronic pleurisy is attended with such slight constitutional symptoms as scarcely to deserve to be considered more than a local disease; still in most instances hectic fever sooner or later sets in. At this stage of the disease, change of air is productive of the most decided benefit, often effecting an almost instantaneous amelioration in the symptoms: the night perspirations cease, the appetite improves, and sleep becomes refreshing. In the exhibition of tonics we have had reason to prefer the infusion or decoction of bark, combined with sulphuric acid, to the more concentrated sulphate of quinine. We have found much advantage, in these and similar cases, from the mineral acids in decoction of Iceland moss. When our curative means take effect, we recognise their success by the physical signs of the disease gradually disappearing; by the side losing its fulness; by the intercostal spaces sinking down to their ordinary level, and being less dilated; and by the return of a feeble respiratory murmur, and a less dull sound on percussion; and, in case of the left side having been the seat of the disease, by the heart's pulsation being felt in their normal situation; and by the liver ceasing to be felt below the margin of the right false ribs when the disease has occupied this side. But when, instead of these evidences of the efficacy of our means, we find the fluid to increase, and all the sensible signs of the disease more marked, and in consequence the dyspnea more distressing, the operation of tapping the chest is our last and only resource. We must confess that the results that have usually attended this operation are far from being calculated to inspire us with encouraging anticipations, (see EMPYEMA;) still even the few cases in which either complete recovery or relief for a considerable time has followed it, prevent us from despairThe external applications, and upon which we ing. It is impossible to judge what might be the place our principal reliance, comprehend the event were the operation undertaken earlier; this different modifications of counter-irritation, viz. must be a matter of conjecture, as we must ever blisters, setons, issues, stimulating liniments, &c. look upon an operation, the unavoidable conseBlisters are unequivocally the means most calcu-quence of which is the admission of air into the lated to promote the absorption of the fluid secreted into the chest, as well as to interfere with its further secretion. We employ a blister commensurate with the extent of surface involved in the inflammation, and repeat its application in preference to keeping the blistered surface open by means of irritating substances, each repetition having as it were the effect of renewing the counter-irritation.

Constitutional means or internal medicines, we must in candour admit, do not assist very much in the removal of the fluid.

[Iodine has been highly extolled, employed both internally and externally. Dr. Stokes (Op. cit.) advises, that Lugol's solution should be taken freely; and that from a quarter to half an ounce of the compound iodine ointment should be rubbed daily over the side. By others, the use of iodide of potassium is preferred, and, in more asthenic cases, iodide of iron.]

The next part of the treatment of chronic pleurisy regards the improvement of the habit of body and relief of the constitutional symptoms which most commonly accompany this form of the disease. We are not obliged to prescribe the same restricted diet as in acute pleurisy, but would admit a certain latitude, always taking care to avoid such substances as are calculated to produce febrile excitement, and conséquent acceleration of the circulation; for, as we before observed, the powers of absorption and circulation observe an inverse ratio, and as we require the efforts of the former to remove the fluid, we should defeat our object did we not observe this caution. It is, besides, an object of importance that as little blood as possible should be transmitted through the lung

inflamed cavity of the chest, as a serious matter, and only warranted by the failure of other means to produce the object we desire. We have similar effects produced in chronic abscesses when opened. As long as they had no communication with the air, so long they produced no constitutional disturbance; but no sooner is the air admitted than hectic symptoms quickly supervene. The cavity of the chest affected with chronic inflammation resembles a chronic abscess, both in its physiolo gical and pathological conditions. The failure of success of the operation for empyema may be ascribed to the following causes ;-to the irritative fever which often follows immediately upon the operation; or to the condition of the lung, occupied by tubercles in different stages, and giving rise to constitutional symptoms; or to the lung having been so long pressed upon by the fluid as to render its natural elasticity quite irrecoverable. We have before observed that the operation, undertaken under the most auspicions circumstances, is not exempt from a certain share of danger.

[It must be borne in mind, too, that twenty cases of complete and permanent recovery from empyema, by absorption, have been recorded by

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