Some years ago, a Dr. Schnetter, of this city, wrote a lengthy article upon a condition he termed "Interlobar Pleurisy." His patients, to the number of three, all died, and a peculiar morbid state was found post-mortem. In most instances, the trouble was onesided. A pleuritis seemed to to have started at the base of the lung and gradually climbed upwards, as a vine does along a stone fence, dipped down into the interlobar spaces on the lung, and then continued upwards. The spaces between the lobes of the lung became shut off from the pleural cavity by adhesive inflammation at their margins. Thus, the pus became encapsulated between every lobe. The pleural cavity was obliterated.

These patients presented all the symptoms of phthisis, minus the hæmoptysis. No tuberculous bacilli were found in the sputum.

DISCUSSION.

J. W. DOWLING, M.D.: In discussing the paper presented by Dr. Schley there is but little ground for argument or question as to the several cases described. There can be no doubt as to the occurrence of a pleurisy involving that portion of the pleura covering the diaphragm, with or without subsequent extension to other portions of that membrane, more accessible to the methods of physical examination at our disposal. The diagnosis of this condition must be made, as in the cases described, more by exclusion than by positive physical signs. Of course, this applies particularly to the early diagnosis, for where the history as described is present, and subsequently a further involvement of the pleura occurs, the diagnosis is comparatively easy. The writer truly states, that in cases confined to the diaphragmatic pleura there will be an absence of physical signs, and that symptoms alone come to our aid, after excluding abnormal conditions of the liver, spleen, stomach, pancreas and intercostal nerves.

The second case described was a typical one of a diagnosis of diaphragmatic pleurisy by exclusion. There was nothing else which could give rise to the symptoms on the left side occurring during the course of the croupous pneumonia of the right lung. It is unfortunate that an autopsy could not be obtained to verify the diagnosis, as in the preceding case. In the third case, the diagnosis of this condition on the third day, which was confirmed later by the spread of the trouble to portions of the pleura more accessible, should emphasize the importance of careful consideration of the symptoms described, even when occurring during other conditions, which are apt to produce a similar group of symptoms. The fourth case could easily have been ascribed to acute inflammation of the liver, but here

again the absence of jaundice, tenderness over the liver as a whole, and increase of the size of the organ, warranted the exclusion of such a diagnosis. I can hardly close this brief discussion without alluding to Dr. Schley's introductory remarks and the criticism passed upon his paper of last year. I, too, have seen cases of pleurisy with effusion, correctly diagnosed, perseveringly treated with the carefully prescribed Homoeopathic remedy in different potencies, which failed to yield in the slightest degree. Many cases will yield to Bryonia and other drugs indicated, but I can hardly credit that a physician in active practice should not meet some cases that would not yield to remedies. I do not believe it possible to stop every case. It is true that in some cases the remedy hinders the effusion. In other instances it is only an apparent effect, for there are cases which, without remedies, do not present any amount of effusion, but rather result in a more or less thick fibrinous exudate, with a tendency to organization into connective tissue. It is hardly fair to claim that the remedy in every case will prevent effusion.

I, too, have never seen deformity in cases that had been operated upon when a proper diagnosis had been made in time. The cases of marked deformity from empyema, of which a number have come under my observation in hospital practice, have invariably been those in which operation had only been employed after the disease was of long continuance, or where, through ignorance or carelessness, nature had been allowed to attempt a cure by causing the pus to find its own opening through the chest-wall. I cannot question that the vast majority of Homoeopathic physicians, as well as those of every other belief, would coincide with Dr. Schley in his views as to the advisability of early operation in pleurisy with effusion, unless there were positive indications of a speedy diminution in the amount of the

effusion.

H. M. DEARBORN, M.D.: At the outset I desire to refute an impression which might inferentially arise from listening to or reading this paper, that errors of diagnosis are proportionately greater among practitioners of Homœopathy than among practitioners of the Old School. My clinical experience leads me to believe that if any difference exists on this point it is in favor of the New School. So it should be, for the habitual study of symptoms of all kinds and their classification ought to be the best aid to correct diagnosis. If at the bedside, a practitioner does not convert the symptoms obtainable into diagnostic signs of disease as well as into indications for treatment, he would seem to be little less than neglecting his opportunities. Yet, there are reasons to fear that many physicians of all schools, either from lack of training or want of time, fail to do their full duty in this direction. In obscure affections like the one treated of in this paper, while treatment does not wait on diagnosis, if recovery is arrested by failure of natural forces to respond to well

a

selected remedies, their diagnosis must determine treatment, must decide whether operative art shall be employed to remove a primary morbid product before it has had time to produce secondary conditions attended with liability to greater disaster. How important early discovery of diaphragmatic pleurisy is in relation to treatment ad prognosis, was well shown in a case lately under my observation hospital practice. The patient was admitted to the hospital with Spposed hepatic disease of four months' duration. The seat of pain had been throughout in the infra-hepatic region and at times in the right lumbar. There had been no rigors and no very high or rapid changes of temperature. At times there was considerable thoracic oppression and general prostration. On examination the liver was found normal in size though somewhat lowered in position. The right lung was compressed upwards to the nipple line by an accumulation of fluid in the pleural cavity. In brief, the results of physical examination in connection with the clinical history, indicated that the primary condition was one of diaphragmatic pleurisy with probable extension in some degree to other parts of the pleura, followed by effusion and a failure by nature to reabsorb the accumulated fluid. This patient was entirely relieved of pain by treatment, but failed to make satisfactory gain in other ways and finally died of exhaustion. While we cannot say beyond a doubt that any case of fatal sickness would have recovered under different management, it is a fair inference in this case, that had an early diagnosis of the true condition been made and operative art at the right time had co-operated with pathogenetic art, recovery would have followed.

It is beyond comprehension why any Homœopathic practitioner should object to the removal of the obvious causes of or conditions which maintain disease. The philosophy of the renowned founder of our School teaches quite otherwise, and the opponents of measures to remove obstacles to recovery from disease, can easily be put in the position of being half Hahnemannians rather than of being strict Hahnemannians.

No one, I am sure, who has had considerable hospital and consulting practice can otherwise than agreee with the author of this paper regarding the importance of diagnosis of diaphragmatic and other forms of pleurisy the necessity of watching the course of the effusion, if it occurs, and the need of assisting the natural forces by removal of the mechanical obstacle to recovery by mechanical (operative) means if they fail to do so within a safe limit of time.

That the majority of cases of uncomplicated pleurisy only require rest and the indicated Homoeopathic remedy or remedies, I, of course do not deny.

NEURASTHENIA-AN ANALYSIS OF ITS SYMPTOMS AND THEIR TREATMENT.

BY GEORGE H. MARTIN, M.D., SAN FRANCISCO, CAL.

It is my purpose in this paper not to give a minute description of this condition, but to analyze some of its most important symptoms, their cause and treatment.

Neurasthenia, from the Greek, vɛupov “a nerve,” and åœ@tveta "weakness," is more properly a symptom than a disease; and yet the nerve weakness is often so general, and affects the various organs of the body in so many different ways, that we necessarily have a conglomerate mass of general and local symptoms, which are best described under this one term.

Some authors have given this disease two different names: cerebral-neurasthenia or spinal-neurasthenia, according as the brain or spinal cord is most affected; but it is so rare that we have one of these organs affected without the other being more or less involved, that I think it best to consider it under the general designation of nerve weakness."

It

may

be truly called an American disease, as it is more common in this country, where the rush to acquire wealth rapidly, and the ambition to attain a prominent position, is carried to greater extremes than in any other part of the globe.

It is a disease which attacks both men and women, and the ratio seems to be very nearly equal; the preponderance perhaps being on the side of the woman. It may develop during the adolescent period of life, or during early manhood or womanhood, or in middle life.

The persons attacked are usually of the intellectual class, noted for their brightness and ambitious aspirations; persons who are not imaginative or given to introspections or forebodings.

They are apt to be the precocious children of whom much is hoped by fond parents and loving friends. As children they are apt to be delicate, and while not troubled with any particular illnesses

during childhood, yet they have to be carefully watched, so that they will not go beyond their strength.

The heredity is usually bad, the mother having suffered from some form of nervous trouble, or the father a dipsomaniac or of a neuropathic tendency, beget weaklings who enter life handicapped from the

very beginning. Thus the seed is sown, the harvest of which is to be reaped by the new being at the proper time.

Given the neuropathic constitution, the exciting causes of the disease are many. In men, masturbation holds a most important position; over-study during the period of youth, and the inability to carry out the ambitious designs in business or professional life, which had been planned, due to lack of nerve force to withstand the mental and nervous strain consequent upon such extensive enterprises.

In women these same causes operate to a greater or lesser degree, as in men, but they have also added to their burden, the results of functional or organic uterine diseases, as well as the consequences of child-bearing. The demands of society upon many women are so exacting, that if a young woman wishes to attain a high social position, she many times goes beyond her strength, and becomes a nervous wreck, due to late hours which naturally mean insufficient. sleep, or sleep at the wrong time, which is unrefreshing and exhausting. The theatre, the party, the ball, the musicale and the social calls, all assist in contributing to her downfall.

Aa important cause of nervous exhaustion either in young or middle aged men and women, is eye-strain, due to muscular error, or some error of refraction. While this may be congenital, it may not manifest itself for many years after birth, and it is more than probable that the symptoms of nerve weakness will be noticed before any eye difficulty is discovered.

Trauma is a cause as evidenced by the many cases of so-called "railway-spine" which has with it so many symptoms of neurasthenia.

Shock, either mental or physical, of sudden joy or sorrow, or from fright, may produce this disease.

Our present system of education is without question doing more. to ruin the health of our children, than any one factor. A child is put into school at the age of five or six, and rushed from the very beginning, until he completes his course. Six hours a day in school