ward; but the place ofteneft affected is about the 6th or 7th rib, near the middle. The pain is of ten fevere; but fometimes dull and obtufe, with a fenfe of weight It is peculiarly fevere and pun. gent when occupying the ribs. It generally continues fixed in one part, but fometimes fhoots from the fide to the fcapula, or to the fernum and clavicle. Dr Cullen fuppofes that the disease is always feated, or at least begins, in fome part of the pleura. The term pleurify is improperly limited to that inflamation which begins in and chiefly affects the pleura coftalis. This he thinks is a rare occurrence; and that the pneumonia much oftener begins in the pleura invefting the langs, produciug all the fymptoms which belong to what hath been called the pleuritis vera. The word peripneumony has been applied to an inflammation beginning in the parenchyma, or cellular texture of the lungs, and having its feat chiefly there. But Dr Cullen doubts if any acute inflammation of the lungs, or any fpecies of peripneumony, be of that kind. In every diffection of perfons who have died of peripneumony, the external membrane of the lungs, or fome part of the pleura, has appeared confiderably affected. An inflammation of the pleura covering the upper furface of the diaphragm, has been called paraphrenitis, as fuppofed to be attended with the peculiar fymptoms of delirium, rifus fardonicus, and other convulfive motions: but it is certain, that an inflammation of that portion of the pleura, affecting also even the mufcular fubftance of the diaphragm, has often taken place without any of the above fymptoms; and no diffections fhow that an inflammation of the pleura covering the diaphragm is attended with delirium more than any other pneumonic inflammation. But though the inflammation may begin in one particular part of the pleura, the morbid affection is commonly communicated to the whole membrane. The pneumonic inflammation may terminate by refolution, fuppuration, or gangrene; but it has alfo a termination peculiar to itfelf; viz. when attended with an effusion of blood into the cellular texture of the lungs, which, interrupting the circulation of the blood, produces a fatal fuffocation. This appears to be the most common termination when it ends fatally; for upon the diffection of almoft every perfon who has died of this difeafe, it appears that fuch an effufion had happened; and that pileumonic inflammation commonly produces an exfudation from the internal furface of the pleura, which appears partly as a feft vifcid cruft, often of a compact membranous form, covering the furface of the pleura, particularly thofe parts where the lungs adhere to the pleura cottalis, or mediaftinum; and this cruft feems always to be the cement of fuch adhesion. This exfudation appears alfo by a quantity of a ferous fluid in the cavity of the thorax; and fome exfudation is ufually found to have been made into the pericardium. In fome perfons who have died after labouring under a pneumonic inflammation for a few days only, the bronchiæ have been found filled with a quantity of ferous and thickish fluid. Dr Cullen is of opinion, that this effufion into the oronchite often concurs with the effufion of red blood, into the cellular fubftance of the lungs, to

occafion the fatal fuffocation which often ends peripneumony: that the effusion of serum alone may have this effect: and that the ferum poured out in a certain quantity. rather than any debl ty in the powers of expectoration, is the caufe of that ceffation of spitting which precedes the fecal event. Nay, it is even probable, that in fome cafes fuch an effufion may take place without any fymptoms of violent inflammation; and in other cafes the effufion taking place may feem to remove the symptoms of inflammation which had appeare ed before, and thus account for thofe unexpected fatal terminations which fometimes happen. Pneumonic inflammation feldom terminates by refolution, without being attended with fome evi dent evacuation. An hæmorrbagy from the nose, happening on fome of the first days of the diffe has fometimes put an end to it; an evacuate from the hæmorrhoidal veins, a bilious evacua in by ftool, and an evacuation of urine with a co pious fediment, have feverally had the fame ef fect; but fuch occurrences have been rare. The evacuation most frequently attending, and feem ing to have the greateft effect in promoting refo lution, is an expectoration of a thick, white, or yellowish matter, a little freaked with blood, co pious, and brought up without much or vio ent coughing. Very often the refolution of this dif eafe is attended with, and perhaps produced by, a sweat, which is warm, fluid, copious over the whole body, and attended with an abatement of the frequency of the pulfe, heat of the body, and other febrile fymptoms

534. Caufes, &c. The remote caufe is commenly cold applied to the body, obftructing perfpira tion; and determining to the lungs, while the lungs themselves are expofed to the action of c These circumftances operate chiefly when an flammatory diathefis prevails in the fyftem; and therefore thofe principally affected with this d eafe are perfons of the greateft vigour, in cold ch mates, in winter and fpring, when viciffitudes a heat and cold are frequent. This difeafe, he ever, may arife in any feafon when fuch varie take place. Other remote caufes alfo may hav a fhare, fuch as every means of obstructing, strain ing, or otherwife injuring, the pneumonic orgy The pneumonic inflammation has fometimes bee fo much an epidemic, that it hath been fuppris to depend on a specific contagion; but Dr Cu len never met with an inftance of its being cot gious.

$35. Prognofis. In pneumonic inflammation a violent pyrexia is always dangerous. The ger, however, is chiefly denoted by the difficti of breathing. When the patient can lie on fide only; when he can lie only on his be when he cannot breathe with tolerable eafe. cept when the trunk of his body is erect; who even in this pofture the breathing is very diff and attended with a turgefcence and fluth the face, with partial fweats about the bead neck, and an irregular pulfe; these circum ther mark the degrees and danger of the difeaf. frequent violent cough is always the fymptom an obftinate difeafe; and a dry cough is alw an unfavourable fymptom. An acute pain, r much interrupting infpiration, is always the m

of a violent difeafe, but not of a more dangerous one, than an obtufe pain with very difficult refpiration. When the pains, which had at first affected one lide only, afterwards fpread into the other, or when they pais entirely into the other; thefe are marks of a dangerous disease. A delirium coming on during a pnuemonic inflammation, is always a fymptom denoting much danger. When pneumonic diforders terminate fatally, it is from the 3d to the 7th days of the first week. This is most common; but, in a few inftances, death has happened at a later period. When the disease is violent, but admitting of refolution, this alfo happens often in the courfe of the first week; but, in a more moderate disease, the refolution is often put off to the ad. The difeafe generally has a remiffion between the 3d and 7th day; but it fometimes returns again with as much violence as before; and in fuch a cafe with great danger. Sometimes it difappears on the 3d day, while an eryfipelas appears on fome external part; and if this continue fixed, the pneumonic inflammation does not recur. If the difeafe continue beyond the 14th day, it will terminate in a fuppuration or PHTHISIS. The termination by gangrene is much more rare than has been imagined: and when it does occur, it is ufually joined with the termination by effufion; the fymptoms of the one being hardty diftinguishable from thofe of the

other.

536. Cure. This must proceed upon the geval plan mentioned under SYNOCHA ( 468); bu, on account of the importance of the part ected, the remedies must be employed early, and as fully as poffible: and these are chiefly directed with one of three views, viz. to obtain a relation of the inflammation in the thorax; to tigate the urgent fymptoms before a refolution can be effected; and to counteract or obviate the confequences of the difeafe. Venefection is the chief remedy, and may be performed in either ara; the quantity taken away ought to be as large as the patient's ftrength will allow. The reifion of the pain, and the relief of refpiration during the flowing of the blood, may limit the Quantity to be then drawn; but if thefe fymp. toms of relief do not appear, the bleeding should e continued to a confiderable extent, unless lymptoms of a fyncope come on. It is feldom that one bleeding will cure this difeafe; and though the pain and difficulty of breathing may be relieved by the first bleeding, thefe fymptoms commonly after a thort interval recur, often with as much Frience as before. In this cafe the bleeding is to be repeated even on the fame day, and perhaps to the fame quantity as before. Bleedings are to be repeated according to the ftate of the lympts; and they will be more effectual when practied within the first 3 days than afterwards; but they are not to be omitted, though 4 days may have elapfed. If the fift bleedings have not been fuficiently large, or even though they should have procured fome remiffion, yet, upon the return of the urgent fymptoms, bleeding may be repeated at any time within the first fortnight, or even later, if a foppuration be not evident, or if after a feeming Station the difeafe return. The quantity of blood which may be taken away must be different, ac

cording to the ftate of the difeafe, and the conftitution of the patient. In an adult male of tolerable ftrength, a pound avoirdupois is a full bleeding. Any quantity above 20 oz. is a large, and any quantity below 12, is a small, bleeding. An evacuation of 4 or 5 lb. in the course of 2 or 3 days, is generally as much as moft patients will bear; but if the intervals between the bleedings, and the time during which the bleedings have been employed, have been long, the quantity taken upon the whole may be greater. When a large quantity of blood hath been taken from the arm, and when the recurrence of the pain, rather than the difficulty of breathing, becomes the urgent symptom; then cupping and scarification fhould be made, as near as poffible, to the pained part. An expectoration fometimes takes place very early; but if the fymptoms continue urgent, the bleedings must be repeated notwithstanding the expectoration but when the symptoms have fuffered a confiderable remiffion, we may truft the cure to the expectoration alone. Bleeding, during the first days, does not ftop expectoration, but often promotes it: it is only in a more advanced state, when the patient has been exhaufted by large evacuations, that bleeding feems to stop expectoration; and even then, this does not take⚫ place fo much from the powers of expectoration being weakened by bleeding, as by its favouring the ferous, effufion in the bronchiæ. Every part of the antiphlogistic regimen ought to be carefully employed: the patient must keep out of bed ; muft have plenty of warm diluting drinks, impregnated with vegetable acids, accompanied with nitre, or fome other cooling neutral falt; and the belly ought to be kept open by emollient glyfters, or cooling laxatives. Vomiting in the beginning is dangerous, but in an advanced ftate of the dif eafe is the beft means of promoting expectoration. Fomentations and poultices to the pained part have been found ufeful; but bliftering is much more effectual. A blifter, however, ought not to be applied till after one bleeding, as venefection is lefs effectual when the irritation of a blifter is prefent. If the difcafe be moderate, a blifter may be applied immediately after the firft bleeding; but in violent cafes, where it may be prefumed that a 2d bleeding may foon be neceffary after the first, it will be proper to delay the blifter till after the 2d bleeding. It may often be of ufe to repeat the bliftering; and in that cafe the plafters fhould always be applied fomewhere on the thorax, for when applied to more diftant parts they have little effect. The keeping the blistered parts open, and making what is called a perpetual blifter, has much less effect than a repeated bliftering. Many methods have been propofed for promoting expectoration; but none appear to be fufliciently effectual; and fome of them being acrid ftimulant fubftances, are not fafe. The gums ufually employed feem to be too heating; the fquilis lefs fo; but they are not very powerful, and fometimes inconvenient, by the conftant naufea they occafion. The volatile alkali may be of fervice as an expectorant, but it ought to be referved for an advanced ftate of the difenfe. Mucilaginous and oily demulcents are ufeful, by allaying that acrimony of the mucus which occations too frequent coughing,

M m 2

and

and which coughing prevents the ftagnation and thickening of the mucus, and thereby its becoming mild. The receiving into the lungs the fteams of warm water, impregnated with vinegar, has often proved useful in promoting expectoration; and, for this purpose, the machine called the INHALER, invented by Dr Mudge of Plymouth, is of great fervice. See that article, and the Plate. But antimonial emetics, in naufeating doses, promife to be the most powerful for promoting expectoration. This difcafe often terminates by a fpontaneous fweating. When, after fome remiflion of the fymptoms, fpontaneous fweats arife, they may be encouraged, but it ought to be without much heat, or ftimulant medicines. If, however, the fweats be partial and clammy, and a great difficulty of breathing ftill remain, it will be dangerous to encourage them. Phyficians have differed much with regard to the use of opiates in pneuionic ailections. In the beginning of the difeafe, and before bleeding and bliftering have produced fome remiffion of the pain and difficulty of breathing, opiates increafe the difficulty of breathing, and other inflammatory fymptoms. But when the difficulty of breathing has abated, and when the urgent fymptom is a cough, opiates may be employed with great advantage. Opium, combined with calomel, has been highly extolled in this and other inflammatory difeafes by Dr Hamilton of Lynn-Regis, who has given a full account of the fuccefs attending his practice with this remedy, for 16 years, in the 9th volume of the Edin. Med. Comment. And the fame remedy has often been employed fince by others with great benefit.

537. VOMICA, or Abfcefs of the Lungs.-Vomica, Boerh. 835, Junck. 35.-Pleurodyne vomica, Suv. fp. 21.-This fometimes follows pneumonia, though the cafe is not frequent. The fymptoms fo much refemble phthifis, that it can molt properly be treated of under that head. See $702, 708-718.

$38. EMFYEMA. This is another confequence of a pneumonia terminating unfavourably, and is occafioned by the effufion of a quantity of purulent matter into the cavity of the thorax, producing a lingering and painful diforder, very often incurable.

539. Defcription. The firft fign of an empyema is a ceflation of the pain in the breaft, which before was continual: this is followed by a fenfation of weight on the diaphragm; and a fluctuation of matter, fometimes making a noife that may be heard by the by-ftanders: the acute fever is changed into a hectic, with an exacerbation at night: a continual and troublefome dry cough remains. The respiration is exceedingly difficult, becaufe the lungs are prevented by the matter from fully expanding themselves. The patient cau le cafily on that fide where the matter is effused, but not on the other; because, then, the weight of the matter on the mediaftinum produces uneafinefs. The more the hectic heat is augmented, the more is the body emaciated, and its ftrength decayed. In fome there is danger of fuffocation when they ftoop down, which goes off when they alter that pofture; and in fome there is a purulent fpitting. These fymptoms are acompanied with great anxiety, palpitations of the

heart, and faintings. Sometimes the patients have a fenfation like a hot vapour ascending from the cavity of the thorax to their mouth. Others, in a more advanced ftate, have a putrid tafte in the mouth. At the fame time, profufe night sweats wafte the body, and greatly weaken the patient. The face at firft grows red on that fide where the matter lies; at laft the Hippocratic face comes on, and the eyes become hollow. The pulfe, efpecially on the affected fide, is quick, but more frequently intermitting. Sometimes the nails are crooked, and puftules appear on the thorax; the feet often fwell, and on the affected fide of the breaft, there is an inflation and fwelling of the skin.

540. Caufes, &c. An empyema may arise either from the bursting of a vomica of the lungs, or from a fuppuration taking place after the inflammatory ftage of the pneumonia; or sometimes from a fuppuration in the case of a quinfy, when the inflammation had extended to the afpera arteria; whence arifes a kind of bloody fpittle, and the patients are afflicted with an empyema, unles they die on the 7th day. It may arife alfo from external violence, as wounds of the thorax, &c. blood extravafated, corrupted, or changed into pus. It is a rare diftemper, but may attack all thofe fubject to pneumonia.

541. Prognofis. Very few recover after an empyema has been once formed, especially if the operation of paracentefis be neglected. After this is performed, if a great quantity of bloody fetid pus be discharged, if the fever continue, and if the patient fpit up a purulent, pale, frothy, livid, or green matter, and feels a decay of ftrength there is no hope: but when a fmall quantity of pus, of a white colour, not very fetid, is dis charged; when the fever and thirft quickly ceafe the appetite returns, and fæces of a good conf ence are discharged, the ftrength alfo return n in fome degree, there is hope of a perfect reco very. If the matter be not dried up in 7 weeks the difeafe changes to a fiftulous ulcer, which i difficult to cure. An empyema affecting bot fides of the thorax is more dangerous than tha which affects only one.

542. The Cure confifts in evacuating the purt lent matter contained in the cavity of the thor: which is beft done by the operation of paracer tefis. See SURGERY. Afterwards the ulcer to be treated with abftergent and confolidat medicines; and the fame internal ones are tot given as in a PHTHISIS.

543. GEN. XIII. CARDITIS. Inflammation the HEART.-Carditis, Sauv. gen. 111. Vog. 54-Pericarditis, Vog. 53.-Carditis fpontanea, Sas fp. 1. Senac. Traité de Cœur, lib. iv. chap. Meckel, Mem. de Berlin, 1756.-Eryfipelas pu monis, Lomm. Obferv. lib. ii.

544. Defcription. This difeafe is attended w all the symptoms of pneumonia, but in a hig degree: it is alfo accompanied with hydrophet fymptoms, fainting, palpitation of the be a feeming madnefs, a funk and irregular po watery eyes, and a dejected countenance, with dry and black tongue. On diffection, the bet and pericardium are found very much inflamed, a even ulcerated, with many polypous concretio

545. Caufes, &c. The fame as in pneumos