DISEASES OE THE CHEST. THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF THE DISEASES OF THE CHEST. EI W. W. GERHARD, M. D., Lecturer on Clinical Medicine to the University of Pennsylvania, one of the Physicians to the Pennsylvania Hospital, &c. SECOND EDITION, REVISED AND ENLARGED. PHILADELPHIA: ED. BARRINGTON AND GEO. D. HASWELL. 1846. WF 194-6 Entered, according to the Act of Congress, in the year one thousand eight hundred and forty-two, by WILLIAM W. GERHARD, M.D., in the clerk's office of the District Court for the Eastern District of Penn- sylvania. TO CASPAR W. PENNOCK, M.D. My Dear Pennock, It gives me very great pleasure to inscribe this little work to you. The subject was for a long time an object of our mutual study, and must bring to your recollection many happy hours which we spent in its pursuit. With my best wishes for the entire restoration of your health, I inscribe myself, Yours, very sincerely, W. W. GERHARD. 1* P HE EAC E. To supply the wants of his class, and of others who felt an interest in the subject, the author published in the year 1835, a short treatise on the diagnosis of thoracic diseases, embodying what was most important in reference to the physical and general signs; this manual did not include the treatment, and was found upon experience to be less complete than was desirable. At the request of many of his pupils, he published a series of lectures, during the years 1840-1, in the Medical Examiner, which, with some additional lectures, were collected into the first edition of the present work. The form of lectures in the first edition was retained as the most convenient; some of them were condensed by a careful hand from the oral lectures of the author ; the greater part, how- ever, were written by himself, forming the substance of the course. They necessarily were less full than the lectures as delivered, and the illustrations were of course excluded, but they comprised the most important parts of the subject, such as are most worth being remembered, and seem essential to a knowledge of the subject. In the present edition, the work is thrown into the usual form of chapters, divided according to the subjects of which they treat. The whole work has been re- vised, numerous corrections have been made, and a consider- able quantity of new matter has been added. It was not thought advisable to increase very materially its size, so that it retains a form which is convenient for most purposes ; at the same time every point of much interest has been, nevertheless, developed. Few or no references are made to authors; these seemed un- necessary, for the history of the diseases of the chest is so well known, that there is little difficulty in determining the source from which the recent discoveries have originated. The pub- lication of the work of Laennec on mediate auscultation gave precision to the history of a class of diseases in which it was before unknown, and, as was soon found, the labours of this admirable observer, far from diverting attention from the ob- 8 PREFACE. servation of the rational symptoms, rendered them more avail- able for diagnosis. Andral, if not the first to discover the bronchial respiration, was the earliest to point out its value ; but his most important labours as regards the diseases of the chest, are the complete history, which he has given of their symptoms and pathological anatomy. The publication of the work of Dr. Louis on Phthisis was another important step in the history of pectoral diseases; it developed the pathological anatomy and symptoms much fur- ther than had hitherto been done, and rendered the diagnosis of consumption vastly more perfect. Since the publication of Dr. Louis's work, the additions made to the history of phthisis and pectoral diseases in general, have been much less important if taken singly, but in the aggregate are far from inconsiderable. The pulmonary diseases of children are much better understood, and are known to be more frequent causes of death than those of any other organ of the body; and amongst the affections of adults the pathology of phthisis has been studied in connexion with a general diathesis, or tuberculous predisposition, and not merely as a disease limited to the lungs. The therapeutics of phthisis have advanced to some extent, but in a less degree than the natural history of the disease. The diseases of the heart were but imperfectly known to Laennec ; later investigations, especially those of Bouillaud and Hope, have added more to their pathology than had been done for almost a century before. The therapeutics of these diseases have been, perhaps, more immediately improved by recent pathological investigations, than those of any other affections. Within a few years past, very good treatises on auscultation have appeared from Drs. Barth and Roger, Walsh, and others ; these have, in a great degree, replaced the earlier publications of Drs. Graves and Stokes upon this subject. They, none of them, however, enter much into the general symptoms of dis- eases of the chest, but are exclusively confined to the physical signs. The object of the present work is not limited to auscultation, it includes, on the contrary, the general symptoms and treat- ment ; and I may hope that it will prove useful to those who may require a publication of the kind. Philadelphia, March 10th, 1846 301 Walnut street. CONTENTS. Chapter I. Uses of Classification in the Study of Disease ; Comparison of Physical and General Signs.....13 Chapter II. Conformation of Chest; Circumstances influencing it; Mode of Examination ; Mensuration ; Succussion. . . 22 Chapter III. Percussion ; Rationale; Mode of Performing; Pleximeter; Di- vision of Chest into Regions ; Value of Percussion . 30 Chapter IV. Auscultation; Modifications of Respiration and Voice; Bronchial Respiration, Cavernous, Amphoric, Rude. Signs of the Voice, Pectoriloquy, Bronchophony .... 42 Chapter V.* Cough, Expectoration.......64 Chapter VI.* Pleurisy; Pathological Anatomy; Physical Signs; Symptoms ; Diagnosis; Treatment . . . . . . 73 * In the text these chapters are numbered wrong. They are correct in the contents. 10 CONTENTS. Chapter VII. Bronchitis ; Acute Varieties ; Signs and Treatment of Acute Va- rieties ; Bronchitis of the Old ; Chronic Varieties ; Peculiar Varieties.........97 Chapter VIII. Dilatation of the Bronchial Tubes.....121 Chapter IX. Emphysema of the Lungs ; Anatomical Characters; Symptoms ; Diagnosis ; Prognosis ; Treatment . . . . 124 Chapter X. Asthma ; Nervous Asthma ; False Asthma ; Paroxysms ; Dia- gnosis ; Treatment . . . . . . . 130 Chapter XI. Pneumonia; Anatomical Characters ; Physical Signs ; Symp- toms ; Treatment . . . . . . . 135 Chapter XII. Gangrene of the Lungs ; Pathological Lesions; Symptoms; Causes ; Diagnosis ; Treatment . . • . 162 Chapter XIII. Tuberculous Phthisis ; Nature of the Disease ; Anatomical Character; Mode of Attack; Symptoms; Physical Signs; Diagnosis ; Prognosis ; Treatment • 167 CONTENTS. 11 Chapter XIV. Pneumothorax; Anatomical Characters; Symptoms and Physical Signs ; Diagnosis and Prognosis ; Duration and Termina- tion ; Treatment.......210 Chapter XV. Pulmonary Haemorrhage; Division into Varieties; Mode of Attack; Symptoms ; and Physical Signs . . . . 216 Chapter XVI. Tubercles of the Bronchial Glands; Diagnostic Characters; Treatment........220 DISEASES OF THE HEART. Chapter XVII. General Considerations. .... . 222 Chapter XVIII. Pericarditis; Anatomical Characters ; Physical Signs ; General Symptoms ; Prognosis ; Causes ; Treatment . . 237 Chapter XIX. Endocarditis ; Anatomical Characters ; Symptoms; Diagnosis ; Treatment........ 12 CONTENTS. Chapter XX. Hypertrophy of the Heart; Varieties ; Anatomical Characters ; Causes ; Signs and Symptoms; Progress and Termination ; Treatment......• 251 Chapter XXI. Dilatation ; Anatomical Characters ; Causes ; Symptoms ; Diagnosis and Prognosis ; Treatment . . • 260 Chapter XXII. Diseases of the Valves; Nature of the Disease; Signs and Symp- toms ; Diagnosis ; Treatment .... 264 Chapter XXIII. Functional Diseases of the Heart ; Palpitation ; Pain; Intermit- tence; Angina Pectoris......271 Chapter XXIV. Diseases of the Aorta ; Aortitis ; Anatomical Characters ; Symptoms ; Diagnosis ; Prognosis ; Treatment . 275 Chapter XXV. Aneurism of the Aorta ; Anatomical Characters ; Symptoms ; Diagnosis ; Treatment......279 DISEASES OE THE CHEST. CHAPTER I. USES OF CLASSIFICATION IN THE STUDY OF DISEASE--COMPARISON OF PHYSICAL AND GENERAL SIGNS. In the study of diseases of the chest, as well as those of other cavities of the body, the classification adopted for the con- venience of the pupil must often be arbitrary and imperfect. Diseases which are naturally closely connected together, are separated into artificial subdivisions, while others which are essentially dissimilar are brought together in a manner which tends to lead the mind of the pupil from the study of their true relations ; still, the artificial divisions which have been admitted for a long time, are in general the most easily recollected, and for purposes of study possess many advantages; while the erroneous conclusions to which an artificial classification some- times leads may be obviated by attention to real points of simi- larity, and the natural connexion may finally be re-established after it has been for a time broken up. There is thus a double task for the author or teacher: first, that of analysis, for the purpose of discovering and pointing out isolated facts; next, that of synthesis, or of bringing together those which present, in common, strongly marked fundamental characters. Both of these tasks must be kept in view, or the true scientific connex- ions of disease may be forgotten, and the diagnosis will be merely local, and therefore imperfect, instead of being based on correct and enlarged data. The very division of diseases into those belonging to the several cavities of the body, is, in a great degree, artificial; and although many of these affections are strictly local, or nearly so, there are others which are nothing more than evident shoots from a diseased root, which extends itself widely throughout the body. In these cases the disease, when it shows itself in 2 14 USES OP CLASSIFICATION. the chest, is readily recognised, and is taken as a sign of the general disorder. Sometimes the local disorder grows rapidly, and becomes the prominent malady ; but in all such cases it is only a sign of a deeper and more extended mischief. The remarks which are applicable to the study of disease, are naturally extended to the means of discovering it. These are separated according to the various methods of investigation resorted t6, whether founded on the general symptoms or the physical changes of the part; and they are more or less decep- tive without a careful comparison, or collation of them, one with another. This is not done by a smatterer in pathology or in diagnosis; hence, the conclusions attained by him are uncer- tain, and cast discredit upon medicine, and especially on exact diagnosis. The rules of true philosophy, as applied to medicine, do not differ from those of any other science. The same mental discipline, and the same rules of philosophising are required ; and, with equally ascertained data, the same degree of certainty may be attained. We must first separate a group of facts into detached elements, examine them in every practicable way, and then bring them together again, and reinstate them in a regular and natural order. In all departments of science, especially the natural sciences, with which medicine is so closely connected, we examine the objects of our research in two ways : first, as actually existing; and, secondly, as past. The objects actually present, are known by evident signs; those past, are discoverable by the more obscure traces which they have left behind. We thus discern the modes of a disease, just as we learn the habits of a plant or an animal, from its footsteps, or the remains of its food ; and we can, in either case, learn the peculiarities which have characterised them during life, or during the continuance of the diseased action, by phenomena actually occurring, or the changes consequent upon them. We are therefore obliged to discrimi- nate in the study of disease, between those phenomena which are actually going on, and those which have terminated and are no longer of mischief; this obviates many grave errors, and pre- vents a disorder from being confounded with the lesions which often constitute the proof of its cessation, or it prevents us from mistaking the actions which are in their nature mischievous, for those which are useful and salutary. The latter error is one of more frequent occurrence than the former, for the severe diseased action may require for its removal a slighter, but more permanent deviation from the healthy functions of the part. And although this secondary disorder would, if occurring singly, constitute a disease, it ceases to be one when it is merely a GENERAL AND PHYSICAL SIGNS. 15 curative agent which exerts a favourable influence with the primary affection. These diseases are often very similar to blisters, or other powerful revulsive means, truly curative, and they then only become injurious when needlessly meddled with. The recognition both of the primary and secondary disorders, is more easy in affections of the thorax than in those of other cavities of the body, from our possessing the advantage of two distinct modes of investigation. These are the altered func- tions, including both those of the viscera of the thorax and of the rest of the body, and the physical signs offered by the dis- eased organ. The general symptoms of thoracic diseases are learned in the same way as those of other organs of the body; but the physical signs, on the other hand, are so much more applicable to chest affections than to any other disorders, that they are, in practice, with a few exceptions, used only in the diagnosis of the diseases of this cavity, and are generally de- scribed with direct reference to the chest. This peculiar fitness of the physical signs for the study of pectoral diseases, depends upon the conformation of the thorax and the structure of the organs contained within it. These are important viscera,—the lungs and heart, which are organs possessing different degrees of density, and constantly in motion; so that certain sounds are produced which serve to distinguish the healthy from the dis- eased action. Hence we may, from the examination of the thorax, not only ascertain the density of the organs when at rest, but we may, with great certainty, discover whether they act in a regular and natural manner, and what impediments in- terfere with their motion. These advantages are not offered by the viscera of any other cavity; for although the physical pro- perties of them are sometimes sufficiently marked to enable us to detect variations in form, or in density of tissue, they are scarcely ever susceptible of sufficient motion to cause an audible sound by their own contraction, or by the passage of a fluid throughout their cavity. The physical signs are, therefore, chiefly adapted to the investigation of diseases of the thorax. Physical exploration is much more extended in its applica- tion when combined and compared with the rational signs, than if used alone. For in itself it teaches us rather the condition of organs as modified by disease, than the manner in which the disease forms, or the mode in which it advances. This is espe- cially the case in the chronic diseases of the chest, which de- pend upon a general vice of the economy, for in order to dis- tinguish disease from health, by the physical exploration of the lungs and heart, it is necessary that a change should occur in 16 GENERAL AND PHYSICAL SIGNS. the structure of the tissue, — and as this alteration is only brought about slowly and gradually, we cannot always decide whether the tissue is or is not diseased to some extent; if it be diseased in a degree not sufficient to produce an important change in the conformation of the part. There is, therefore, no means of arriving to a correct conclusion in the diagnosis of pectoral diseases, other than a union of the two modes of inves- tigation, which will then work together as two different ways of arriving at the same end. When physical exploration is pro- perly understood, and compared with the symptoms, it will be found to be even more useful for its negative than its positive results, that is, it will be more useful as a means of showing that some diseases do not exist, or that a given disease is not arrived at a point of structural disorganisation sufficient to en- danger life, than as direct evidence of the mischief already done to the organs. The positive evidence derived from physical exploration is so simple and easily discovered, that after ac- quiring a certain familiarity with it, little attention is required to discover the full value of the signs; the negative evidence, on the other hand, is much more difficult, for a thorough know- ledge of the means of examination, and much practice in using them, are required to pronounce with certainty as to the exist- ence of slight alterations of a part, or the absence of decided structural change. But when the necessary familiarity is ac- quired, the certainty of the knowledge obtained from this source is such, that we may rely upon the negative evidence as confi- dently as upon the positive signs, especially when compared with the indications derived from general symptoms. The great value of the negative evidence of physical explo- ration depends upon its certainty. The process of reasoning which renders negative evidence of value in diagnosis, is called reasoning by way of exclusion; but, although it is of great utility when skilfully applied, it is useless unless a disease is announced by positive signs when it exists, and then we may look upon the absence of these signs as a proof that it is not present. If, on the other hand, the signs themselves be doubt- ful, the absence of them is of course no proof that the disease does not exist; or if these signs be of such nature that we can ascertain them with extreme difficulty, they lose the advan- tages of serving both as negative and positive evidence. Now, in the diseases to which physical exploration is applicable, this is not the case. The signs are, in general, very easily ascer- tained, and are always, under similar circumstances, the same ; hence they may be used in the way of exclusion with great confidence; that is, when they are not discovered by one who GENERAL AND PHYSICAL SIGNS. 17 is familiar with the means of exploring them, they may be con- fidently said not to exist. This negative evidence, as I have already stated, is useful in two ways: first, as evidence that there is no disease ; secondly, as evidence that there is no great change of structure. The first requires that the general symp- toms should agree, as it were, with the physical signs, in proving the integrity, or the comparative soundness of the part. The second requires that the physical signs should be, to a cer- tain extent, contradicted or disproven by the general symptoms. But, as this seeming discrepancy is applicable only to the de- gree of the alteration, and not to its nature, there is, in fact, no real contradiction between the two means of examination. On the contrary, they will be found, when compared together, to accord singularly in the principal deductions which are drawn from each of them. The extent of application of the physical means of explora- tion is, perhaps, novel to many persons who are not familiar with the beautiful application of the laws of diagnosis, by way of exclusion, in which the certainty of the physical signs ren- ders them even more useful, than in other cases in which a precision approaching to mathematical correctness is required; but this very certainty may render them an occasional source of error with those who are neither accustomed to their use, nor perfectly familiar with the ordinary symptoms of disease. That is, an art which is evidently based upon fixed physical laws, may lead to error when the data upon which the problem of diagnosis is founded are not perfectly settled, although the pro- cess of reasoning may still be the correct one. But, the abuse of a certain method of observation does not constitute a real objection to its employment; it merely proves that it is neces- sary to surmount the first difficulties which attend its acqui- sition. The great importance of the comparison of the general symp- toms and physical signs has become more apparent with the more habitual employment of physical exploration, as a really practical aid to diagnosis. The earlier writers on auscultation, especially Laennec, were rather disposed to separate physical from symptomatic diagnosis: this error depended upon the novelty of the art, and the overstrained efforts to extend its ap- plication, — but as physicians became more familiar with it, and had opportunities for testing its merits, it was placed on its real footing, and regarded as more useful than any symptoms taken singly, but as neither the only class of symptoms to be relied upon, nor as superseding the general signs. We are indebted to the French pathologists for pointing out the neces- 2* 18 GENERAL AND PHYSICAL SIGNS. sity of comparison of all the symptoms of pulmonary disease, and of connecting this comparison with their succession in order. It is a subject largely insisted upon in the writings of Andral, but one which was most completely developed in the lectures of Dr. Louis. It afterwards received much attention from Dr. Stokes, and others, who have occupied themselves with the study of pectoral diseases. Although it is not at this time necessary to insist upon the truth of the physical signs to those who are conversant with their use, their certainty may still appear questionable to a few who are not practically acquainted with them. As these signs are based upon the settled laws of physical science, and in fact involve some universally admitted principles, the only reason for doubting their accuracy is a want of due knowledge on the subject. But as a certain acquaintance with them is necessary to appreciate the evidence upon which they depend, I may pro- perly enough point out what is included under the terms physical exploration and physical signs. Physical exploration includes the modes of ascertaining the changes which occur in the physical structure of organs; these changes we appreciate by the altera- tions of form, and by the sounds produced in the interior of the body by the motion of solids, or of elastic or non-elastic fluids, or by the resonance which is yielded by the surface when tapped or struck by the finger. This latter mode of examination obviously depends upon the different density of organs, and in the cavity of the thorax, chiefly upon the existence of air, so that the per- cussion is more or less clear or dull, as the quantity of air con- tained within the thorax is greater or less. The alterations of form are few in number, and are readily learned ; but the signs dependent upon changes in the sounds produced by the passage of air and of blood within the thorax, or the resonance of the air when thrown into motion by the act of speaking, seem com- paratively difficult, and involve more complicated phenomena. The same remarks are applicable to the signs of percussion, which are not a little difficult; but in either case, the sounds are regularly and uniformly the same under similar circum- stances. The difficulty in learning the physical signs thus consists in two distinct points; first, in the acquisition of the sounds them- selves, considered as simple phenomena; secondly, in the know- ledge of the condition of the organs which corresponds to these sounds. The sounds themselves require not only to be learned well enough to be understood, but they must be fixed so thoroughly in the mind that no room should be left for mis- taking one for another. This demands time, attention, and GENERAL AND PHYSICAL SIGNS. 19 organs of hearing which are not physically incapable of discri- minating between sounds which at first may seem nearly similar. The first difficulty is surmounted ; there still remains the other, which requires a knowledge of many circumstances which are connected with the pathology of the disease. These are those which relate to the physical condition of the viscera, or the pathological anatomy of the parts, and to the functional action of the organs, which is necessary for the production of most of the sounds. Hence the knowledge of the physical means of exploration requires no little time and attention, and cannot be learned in a careless or hasty manner. There is, therefore, this impediment to the study of the dis- eases of the chest, and of physical exploration, that the act itself is a matter of difficulty, and requires more labour than is will- ingly bestowed upon it. The whole process of investigation requires this attention ; even the manual or mechanical precau- tions necessary to be taken, are not to be learned at the first trial, but require time in the performance of this art, like that of every other; for the ear and hand are not at first capable of the delicate and varied actions necessary for the satisfactory exploration of the thorax. But, although the apparently com- plex nature of physical exploration may prevent many from at- tempting its study, the difficulties which at first present them- selves are readily enough removed by patient and laborious attention, and are more than compensated by the certainty which results from a mode of investigation based upon fixed physical laws. Every step in the acquisition of this know- ledge is appreciable, and in proportion as it becomes more accurate, the diagnosis of disease assumes a new character, which is never acquired when confined to the functional symp- toms. This is true even at present, when the comparison of local and general symptoms to which I have just alluded has rendered the latter much more clear, and their value better defined. The physical signs have served as a point of departure, with which to compare the rational symptoms, and have thus rendered the latter more easy of recognition, and more positive in their relations with the internal lesions of the thorax. This is so obviously the case, that a glance at the works of any of the later writers upon the subject, is sufficient to show that the rational signs have become of more practical service for the study of diagnosis than they have ever been be- fore, and that many of these symptoms have been investigated with a care which was never before bestowed upon them. Some symptoms, it is true, have fallen into comparative neglect, because they are no longer of decided utility in diagnosis, but 20 GENERAL AND PHYSICAL SIGNS. the greater number have derived new value from their connex- ion wTith the physical signs. As the diagnostic characters of the diseases of the chest are composed of several distinct sets of symptoms, they may be studied after each class of them has been separately learned, or the diseases themselves may be first observed, and the symp- toms analysed as they present themselves at the bed-side. The former method is naturally adopted in a systematic treatise, or course of lectures; the latter belongs more properly to clinical or demonstrative medicine, — a subject of which I treat more at large in another place. As the object of the present treatise is not only to explain the mode of application of these methods of investigation to the study of disease, but to teach the me- thods themselves, it resolves itself naturally into two parts. The first part will contain the explanation of the physical signs, and teach the method of acquiring them which I have found most convenient for the pupil. In connexion with this portion of the subject, I shall treat of those functional symptoms which are immediately connected with the organs of the thorax, and are therefore most conveniently learned at an early part of the study. The second part will be devoted to the examination of individual diseases in connection with their symptoms and treat- ment. The series will thus comprise, as nearly as my time will permit, a complete history of the modes of exploration used in the diseases of the thorax, as well as an account of those dis- eases themselves. The difficulties which attend the study of pectoral diseases, depend more, however, upon an imperfect method, than upon the subject itself, and may be obviated in a great degree by adopting an order which is in harmony with the natural con- nexion of these signs. In all essential particulars they are readily understood when they are pointed out by one who is practically familiar with them ; but one who is yet unpractised becomes embarrassed when he examines a patient without the aid of an adviser. Signs which are really different are some- times confounded together, and those which are mere varieties of the same species are thought to be perfectly distinct. If the signs are well characterised sounds, their discrimination should always be easy, and error would be impossible. That is, the correspondence between the sounds in certain physical condi- tions is necessarily exact, and the chances of error depend upon an erroneous interpretation of them. The interpretation is very different from the recognition of the sounds, and necessarily in- cludes more data and more complicated reasoning. There can be no reason for not detecting a sound connected with the GENERAL AND PHYSICAL SIGNS. 21 chest, it should be at least as easily recognised as the tone of voice or spoken language ; it does not require any peculiar nicety of organs, or a finely cultivated musical ear, but merely a good power of discriminating sounds, and the attention neces- sary for observation of any natural phenomena. I shall endeavour to arrange the physical signs in such an order as will facilitate this part of the study, and shall explain the method of acquiring them which will be found most conve- nient. The great secret is to give much attention to the signs at first, and fix each one in our mind as we go on. If we con- tent ourselves wTith detecting them when pointed out to us, and merely understanding the differential characters without actually knowing them, we will gain but little, and we will never ac- quire the knowledge of them which is practically useful. The best method of avoiding the habit of careless observation, is to dwell long upon each sign at first, and afterwards connect it with others which are closely related to it, and are met with either in the same or in other patients. The whole matter will in this way be rendered singularly easy. 22 CONFORMATION OF THE CHEST. CHAPTER II. CONFORMATION OF CHEST--CIRCUMSTANCES INFLUENCING IT-- MODE OF EXAMINATION--MENSURATION--SUCCUSSION. It was my object in the first chapter to prevent a frequent source of error, which often produces either an obvious or a concealed influence upon the mind. This is a desire to lay too much stress upon a single set of symptoms, to the neglect of others, and to examine a disease of a part of the body as if it were nearly or altogether unconnected with the same, or with different disorders which attack other organs and tissues. In commencing, therefore, a course of studies which are founded upon the positive evidence of anatomical lesions, and of the corresponding physical signs, I would put the reader upon his guard against too anatomical a view of the subject, too exclu- sive a study of lesions, and would warn him against allowing the results of disease to be confounded with disease itself; or the physical signs which constitute the key to so many import- ant researches, from being mistaken for actual diagnosis. It is the deductions from the whole of the physical signs and func- tional symptoms, which constitute the diagnosis ; not the naked examination of a single set of them. This may seem a matter which is too trivial to attract much notice ; but in practice it is of much moment, and the errors which I have seen from a ne- glect of it are frequent, and very readily committed. It may seem that this is reasoning against myself, as it were, and attack- ing the subject upon which I lay so much stress; but, in pro- fessing to give an essay on diagnosis and treatment, imperfect as it is, I am necessarily led to an enlarged study of pathology, and to the view of the subject which seems to me most consist- ent with facts, — that is, one embracing the relation of the phenomena one to another. I am also unwilling to diminish the value of positive observation, by drawing any inferences which the actual state of the subject will not fully warrant; this would be the case, if, at the commencement of our studies, we fall into a contracted, imperfect mode of reasoning. After giving this warning against the abuse of the physical signs, I may proceed to point out the best method of avoiding CONFORMATION OF THE CHEST. 23 or overcoming the difficulties which we meet with, at the com- mencement of our studies. They depend in a great degree upon the difficulty of finding fixed starting points, from which the study of the subject may begin. If we could acquire distinct ideas of the sounds of the chest from description, the difficulty would in a great degree cease, but this requires much care and attention, but by a little effort on the part of a physician who is interested in the subject, we believe that most of the difficulties may be obviated. To aid him, it is, therefore,- necessary to explain fully the best mode of learning the sounds, — that is, of acquiring a sufficient num- ber of sounds to serve as a point of departure, and guide for subsequent study. This method supposes that the sounds are analysed and separated into their elements, and requires at first more than an ordinary share of attention: but the whole time required for learning the art is much shortened, and the subject greatly simplified. Most of these initial sounds may be discovered in the healthy body, — that is, sounds sufficiently similar to those we meet with in disease, to enable us to recognise them when they are heard; and if these are thoroughly learned, the remaining sounds, which are the most easy, are quickly acquired. We will find it to our advantage therefore, to follow very nearly the process which I shall point out, for the purpose of simplifying those sounds; for although it is not indispensably necessary for us, it is highly useful, and really will shorten the time and at- tention required in their study. In studying the physical signs, I follow as nearly as possible the most natural method, reserving to myself, however, the privilege of deviating from it as often as may be advisable. The physical signs, properly speaking, may be classed under the heads of alteration in the conformation of the thorax, and of the resonance of the chest on percussion, and the sounds yielded by respiration, or produced during the act of coughing or speak- ing. These constitute the signs which may be regarded as strictly physical. There are some other signs, which, although less important, are, to a certain extent, classed among the phy- sical signs ; they belong more properly to the conformation of the thorax, than to any other division: under this head I shall treat of them. These are, succussion, or giving to the patient a sudden shake, to ascertain the presence of air and liquid in the cavity of the pleura, which is rarely practised, and is, in the majority of cases, both totally unnecessary and highly disa- greeable to the patient; palpation, or examining the chest by placing the hands upon it, and pressing them carefully along the lateral portions of it. 24 CONFORMATION OF THE CHEST. CONFORMATION OF THE THORAX. The thorax, it is well known, resembles an irregular truncated cone. It is flattened on each side, and presents numerous ine- qualities, depressed in one part, and elevated in another. For the convenience of study, it is usual to examine it anteriorly, posteriorly, and laterally. Of these surfaces, the lateral, or the axillary, are the most regular, — the posterior, the least so. The walls of the thorax do not represent precisely the space occupied by the lungs and heart; for the liver, spleen, and sto- mach, encroach slightly upon the lower part of the cavity. This is particularly the case with the liver, which rises on the poste- rior part of the right side of the chest, nearly half an inch higher than the corresponding boundary on the left side. On the whole, the lower boundary of the right side may be represented by a line drawn from the spinous process of the twelfth dorsal vertebra, to the lower bone of the sternum : on the left side, the boundary begins also at the twelfth dorsal vertebra, but passes at a distance of half, or at least one-third of an inch higher, until it reaches the precordial region. The lower boundary of the chest, as thus defined, is not always the same, as the size of the liver is of course variable, and the dimensions of the thorax are neces- sarily influenced by this circumstance. This line is not followed with perfect regularity, especially on the left side where the heart passes a little beyond the limit of the adjoining part of the chest. At the upper boundary, the difference'of the two sides is less; on the right it sometimes rises a little higher than upon the left, from the greater development of the muscles and bony parietes of the thorax on that side ; but this difference is, in general, so slightly marked, as scarcely to attract attention. The lungs extend a little beyond the clavicles, especially during the act of full inspiration, but to a distance not exceeding half an inch. At the posterior part of the chest, the upper boundary is formed by a line drawn from the upper dorsal vertebra, out- wards and downwards towards the point of the shoulder. When the conformation of the thorax is perfectly normal, it presents an irregular plane on each of its four sides; but the angles of these planes are sufficiently rounded to retain a gene- ral conoidal shape. Each side of it offers several elevations and depressions; at the anterior part these correspond with peculiarities of form of the viscera, and are really formed by the parietes of the chest; but the irregularities of form at the posterior surface are owing, in great part, to the muscles, to the spine, and to the scapulae. The clavicles form a ridge, which is slightly arched ; the space above them is therefore depressed, CONFORMATION OF CHEST. 25 except the patient be extremely corpulent, or labour under cer- tain diseases of the lung or pleura. Beneath the clavicle, another depression, but one much shallower, exists; it extends to the lower part of the second rib. The space below this depression is slightly and regularly convex as far as the upper edge of the liver; at that level there is, in many persons, on the right side, a slightly depressed line, which corresponds with the interval between the liver and the lungs. On the left side in young persons, there is often a prominence corresponding to the heart; this is slightly marked, and never decided, as it is in cases of real disease of this organ, or effusions within its investing membrane. The lateral portions of the chest are regularly bulging from the apex to the base ; and as the walls are here thinner than elsewhere, and nearly without muscles, the external form corres- ponds nearly to the lungs. The posterior surface is rendered irregular by the scapulae ; but at the part uncovered by these bones its form is nearly as regular as that of the other portions, gradually widening towards the base of the chest. A slight depression, or gutter, exists on each side of the spine, for the reception of the dorsal muscles. The lower and posterior portions are often dilated from effusion into the pleura, and yield to the pressure of liquid from within with great readiness. The upper part is not changed in conforma- tion, except the quantity of liquid be very large. The con- traction of "the chest is also extremely obvious at the lower por- tion after the absorption of pleuritic effusions. In children the form of the chest is much more rounded than in adults ; and in women, although the exterior seems more irregular than in males, yet the proper bony parietes are much more regularly formed, and are more conoidal in shape. The conformation of the chest, it is well known, is often characterised by individual peculiarities. Thus, some indivi- duals are called chicken-breasted, from the prominence of the sternum, and others present a well-marked depression at the lower portion of this bone, which is sometimes congenital, and at other times is caused by trades or occupations which oblige the followers of them to work in a constrained posture, leaning forwards ; this is particularly the case with shoemakers, who nearly all present this depression after working at their trade for a few years. Other individuals who are thin, and of a feeble constitution, offer a remarkable contraction of the parietes of the chest; but in all these cases, the contraction is more or less general, instead of being confined to a single part of the chest. When it depends upon disease it is much more local, and 3 26 CONFORMATION OF CHEST. is caused in nearly every instance by pleuritic adhesions, which draw the walls of the chest towards the lungs. Enlargement of the chest, beyond the natural average, is nearly as frequent as contraction. When it coincides with a general development of the body, and evidently depends upon a stout and large frame, it is of course indicative of health, rather than disease. The morbid dilatations, properly so called, are local, either limited to a part, or to the whole of one side of the chest; on this account they are readily recognised. They depend either upon an anormal development of the internal organs, or upon dilatations caused by effusions of air or liquid into the serous cavities of the chest. The comparison of the two sides is re- quisite, in order to recognise dilatations or contractions of the chest: and the thorax must be examined throughout in nearly every position, so that its true and relative dimensions may be ascertained. It is not necessary that the chest should be exposed in order to examine its conformation, although this is much more con- venient than to inspect it when covered. When no objection exists to exposing the chest, the patient should be placed in a sitting posture, or remain erect; if that be impossible, he should lie upon his back, and quite straight, so that the light may fall upon his chest; a cross light may of course give rise to error. The patient should then remain at rest, with his arms lying quietly by his sides or slightly crossed, if the posterior part of his chest be examined: in this way the whole of the anterior or posterior surface may be taken in at a glance. An examination of this kind is, of course, not practicable, in cases of women, or of patients who are sweating profusely; under such circumstances, we must content ourselves with the partial inspection, which is practicable when the body is more or less covered by clothing, and we may aid in this examination by passing the hands lightly over the thorax. For in most cases this mode of examination is amply sufficient for the purpose, and is free from the disagreeable circumstances which attend the exposure of the person. The examination by the touch is especially convenient for the posterior and lateral parts of the chest, where the morbid dilatation is generally most consi- derable. The examination by the touch is called palpation, but I do not think it at all necessary to multiply terms in the description of the methods of physical examination.. Palpation, then, is nothing more than the examination of the chest by means of the touch, it aids the sight, and often may be substituted for it when the patient is too thickly covered. The hand forms, as CONFORMATION OF CHEST. 27 it were, a kind of natural callipers, and will give very accurate results. If we examine the lateral and inferior portions of the chest, we may place the whole palmar surface of the hand upon it; if the anterior and upper portions be examined, the fingers may be passed lightly over it. In this way we can detect any abrupt deviations from the natural conformation, but a general and moderate rise or depression can scarcely be detected except by the sight. If we cannot resort to this means of investiga- tion, we must content ourselves with the other physical signs. Dilatation of the chest is necessarily produced by all diseases which give rise to enlargement of the pulmonary vesicles, or to distension of the pleurae. Those which act upon the pleurae are inflammation, the products of which are serum, lymph, and purulent matter, or dropsy, in which the secreted fluid consists merely of serum. The effusions arising from pleurisy are nearly always confined to one side of the chest, take place rapidly, and are much more local than those of hydrothorax, which ex- tend over a large surface, and are not confined to a single lung. Hence the pleuritic distension begins chiefly at the base of the lung, and extends upwards, involving the whole of one side only in those cases in which the quantity is extremely great. Pericarditis gives rise to dilatation from the same cause as pleurisy, and the prominence follows very nearly the shape of the pericardium, and is therefore somewhat triangular, the small extremity pointing upwards. The extreme dilatation which takes place in severe cases of pleurisy, in which the whole side of the chest is enlarged, elevates the shoulder, and gives the whole body an inclination towards the healthy side. This is often evi- dent when the patient walks or sits in the erect posture. The effusions of liquid into the serous membranes give rise to the most decided, and, as it were abrupt prominence of the chest; while the dilatation produced by enlarged vesicles is, in general, less decided, or, at least, more gradual. It gives rise to a more equable and moderate bulging of the chest, than that from effu- sions of liquid into the serous cavities. Of course it is most marked near those parts of the lung where the vesicles are most frequently dilated — that is, along the anterior portion of the chest, on each side of the sternum ; but, if it involve a large portion of the lungs the shoulders are sometimes elevated, and the space above the clavicles becomes prominent, instead of offering a slight depression, as it does in the natural state. Contraction of the thorax is a consequence of many diseases in which pleurisy has occurred, either as a primary or secondary lesion ; but it is most marked in cases of primary pleurisy, es- pecially where the quantity of effused liquid has been large. 28 MENSURATION. In the secondary pleurisy which follows or accompanies phthisis, contraction almost invariably takes place, and usually occurs near the summit of the lungs, so that the natural depressions, both above and below the clavicle, are exaggerated. Some- times the depression reaches to the lower portions of the lung, as in ordinary pleurisy. The latter variety usually follows those cases of phthisical pleurisy which have commenced in the ordi- nary way, and in which the development of tubercles takes place rather late in the disease, after the inflammation has ceased, or at least has diminished. The general rule holds good, that contraction is evidence of previous pleurisy, — the exceptions are nearly all of a doubtful nature. In a few rare cases the tissue of the lung contracts from the partial or com- plete cicatrisation of a cavity, perhaps from inflammation, although the attendant pleurisy may not be sufficiently exten- sive, or the adhesions strong enough to account for the depres- sion. In these cases we are bound to admit that the pressure of the atmosphere has filled up the vacuum which would other- wise have been left. In the depression which follows pleurisy, it is true that the process is somewhat similar, as I shall show when speaking of this disease, but it is less strictly physical, and more dependent upon the contractile power of the adhe- sions. The absorption of the effused liquid in pericarditis does not give rise to a decided depression ; it sometimes exists, but only in a slight degree. These are the general indications derived from an examina- tion of the form of the thorax, and they are distinct chiefly from the results which are derivable from the sight and touch. In a few cases the chest may be measured on the two sides, in order to estimate the difference in the semi-circumference more ex- actly ; by passing a tape around the thorax, from the extremity of the spinous process of the vertebra, then marking the point corresponding to the middle of the sternum, and afterwards comparing together the two parts extending from the sternum to the spine. The seventh or eighth dorsal vertebra is the most convenient for this purpose. The measurement which is thus obtained is, of course, correct; but it applies only to those cases in which the difference is very evident, unless the dila- tation occurs at the left side. In the latter case the increased dimensions are readily perceived ; for the right side is naturally larger than the left, and the difference is more or less according to the habits which the individual may have of exercising the right arm, more than the left: a difference in favour of this side would therefore be comparatively of little moment, mensuration is therefore of little value as a diagnostic sign. SUCCUSSION. 29 There is another mode of exploration which is termed suc- cussion; it belongs to this part of the subject as properly as to any other. I use the term merely to explain the method of performing it, not to advise the reader to resort to it. The method itself is sufficiently simple, and consists merely in placing the hands on the shoulders of the patient, and giving him a sudden jerking motion. If both air and liquid are con- tained in the cavity of the pleura, a gurgling, almost a splash- ing sound, is produced. There are other methods of investiga- tion, which are sufficient to make the lesions which cause these sounds perfectly evident; so that we need not in any case resort to succussion. 3* 30 PERCUSSION. CHAPTER III. PERCUSSION--RATIONALE — MODE OF PERFORMING — PLEXIME- TER--DIVISION OF CHEST INTO REGIONS--VALUE OF PERCUS- SION. We now come to a highly important part of the subject — this is, percussion, or the method of estimating the density of the viscera contained within the thorax, by tapping lightly upon its surface. The rationale of this is very simple : the lungs occupy the greater part of the thoracic cavity, and are filled with air. If percussion be made upon them when removed from the body, they yield a very clear sound, especially if a solid yet elastic substance be laid upon them, so that it may receive the impulsion of the striking body, and prevent it from sinking into the soft pulmonary tissue : this elastic body, or sounding-board, exists naturally in the thorax, and is formed by ribs and carti- lages ; and a light tap upon their surface, that is, on the exte- rior of the chest, gives a clear, full, hollow sound. When the patient is thin, and the skin is very sensitive, he will not bear a smart tap without inconvenience ; and, on the other hand, if he be very corpulent, or if the subcutaneous cellular tissue be infiltrated with serum, the sound will be quite dull, and will not truly represent the condition of the internal organs. In order to prevent this chance of error to the observer, and of inconvenience to the patient, we place an additional elastic body between the chest and the end of our finger. This in- terposed body is called a pleximeter, and was invented by Dr. Piorry. Its only utility is to increase the body of sound, by giving more resonance to the elastic parietes of the thorax, and to prevent the direct impression of the fingers upon the chest of the patient. Though the ribs are an excellent natural plexi- meter; they are too sensitive at times, and at others are ren- dered useless for physical exploration, by the softer sub-cuta- neous deposits. By applying an artificial pleximeter we not only increase the resonance of the natural sounding-board, if we may so call it, but we bring it more fully into play, by com- pressing, and as it were, thrusting out of the way the tissues which impede its vibrations, and then we gain the important advantage for ourselves and our patients of preventing pain, and in this way perhaps of increasing the disease. The only -/- tfUrr/£**c f*+£*<"- • PERCUSSION. 31 method of performing percussion which is now practised, is that by means of the pleximeter. It has so many advantages over immediate percussion, or the striking with the ends of the fingers directly upon the chest, that it is much better fitted for every purpose. The pleximeters used are various ; that is, those that may be used ; for, practically, they are reduced nearly to the most natu- ral pleximeter, that is, the forefinger of the left hand. But if we choose, we may make use of a piece of gum elastic, of ivory, or of metal. We take this in the fingers of the left hand, and hold it firmly upon the chest, afterwards percussing in the usual way with the right hand. If it be not applied firmly against the chest, a clacking sound is immediately produced by the air which is interposed between the instrument and the skin : this clack cannot be entirely obviated, for the tap upon the instrument will of course give rise to sound. If the ma- terial be very dense, the sound will be sharp and decided, and interfere a little with the pulmonary sound, that is, the reso- nance developed by the tissue of the lungs ; for this reason there are some advantages attending the use of the gum elastic plexi- meter, rather than an ivory or metallic one, which is harder, and of course gives rise to more sound. The elastic instru- ment was, I believe, first proposed by Dr. J. B. S. Jackson, of-/- Boston, and is the most convenient. We can readily enough make one for ourselves, by taking a common piece of gum elastic of the flat kind, about a quarter or a third of an inch thick, and about two inches square, that is of a size convenient for holding in the fingers. The density of gum elastic is more nearly similar to that of the chest, than a harder material, which is an additional reason for its employment, as it contributes to give a clear, uncomplicated sound. The gum elastic pleximeter is easily made, but we are provided with one which is much more simple, and which I always resort to — it is the forefinger of the left hand. In thin persons, the finger is even more bony and more elastic than the ribs ; but in those who are fatter, or whose hand is remarkably stout and covered with a thick skin, the finger loses its elasticity, and is not so well fitted for the office of pleximeter. Still, under ordi- nary circumstances, it is the best one which we can employ, and is superior to any of the ordinary artificial instruments, from its ready adaptation to different parts and irregularities in the chest. The finger may in this way be placed behind the clavi- cle or below it, and be brought very near the lung, which could not be done if the pleximeter were a broad and flat plate : any single limited spot may be examined in the same way with great ease. This natural pleximeter may be used in two ways: we may apply the dorsal or palmar surface upon the chest, and of* 32 PERCUSSION. course tap upon the reversed side ; if we apply the palmar surface upon the chest, the dorsal side upon which the percus- sion is made is firm, and gives a sharp clear sound ; it is much better, therefore, for the accurate appreciation of slight devia- tions from the natural standard. The palmar surface is occa- sionally more convenient, especially when it becomes necessary to apply the finger to the depression behind the clavicle, — it is of course better for this purpose, that the finger should be curved to fit this depression ; hence, percussion must be made upon the palmar surface. Much of this nicety in the mode of applying the finger which serves as a pleximeter, will be found to be unnecessary, and may be dispensed with after a little prac- tice ; the shape of the hand and fingers of the observer will however, have some influence on the position which will be found in practice most convenient. The most difficult part of percussion is not, however, the application of the hand which serves as a pleximeter; this is very soon acquired. Much difficulty, however, is often met with as to the method of tapping or striking with the right hand upon the pleximeter finger. We may use for this pur- pose either one finger or several, but you will find that for chil- dren, and for persons who are very thin, and whose chests are therefore quite sensitive, a single finger will be most conve- nient. Whether we use one or more fingers, the essential part of the process is to hold the hand as firm as possible, and to give the greatest possible elasticity to the wrist. The motion should therefore be performed at the wrist, and not at the shoul- der or elbow ; if we strike with the whole arm, however gently it may be, we are apt to give the patient pain, and we are sure to deaden the sound. The sound depends mainly upon the elasticity of the wrist, and if the fingers be suffered to re- main in contact with the pleximeter, or the thorax, a moment longer than is necessary for the percussion, the sound will be proportionately obscured. The slowness of the motion with which the tap is given is a frequent error with those who are slightly acquainted with phy- sical exploration. They are apt to pause as soon as the finger touches the surface, and allow it to remain in contact with the part; this is altogether wrong. It is at first difficult to acquire the perfect freedom of motion which is essential to elastic, clear percussion ; still, it is perfectly practicable, with a little perse- verance and experience. There are some persons however, who never acquire much readiness with percussion, however long they may attend to the subject; the difficulty is in the form of their hand, which is too PERCUSSION. 33 stiff or the fingers too thick, to allow them to be readily bent and quickly struck upon the chest. They should therefore content themselves mainly with auscultation, trusting but very little to the signs of percussion. If we use a single finger for purposes of percussion, there is little difficulty in holding it in the proper position. Either the fore or the middle finger of the right hand may be selected as the percussor; we then bring it, as nearly as possible, into the form of a light mallet or hammer, and make the second and third phalanges serve as the head of the hammer; of course, they must be flexed at right angles with the first phalanx, and must be retained firmly in that position, otherwise the form of the hammer is lost. The extremity of the finger should be as nearly at right angles with the hand as possible, otherwise the tap is not made with the extremity of the fingers, but the pulp, which is a matter of essential consequence, as the pulp of the fingers is soft, and non-elastic, and deadens the sound. If the thorax be covered with fat, or the parietes be infiltrated, it is necessary to percuss more strongly than is possible with a sin- gle finger; in that case we bring the three middle fingers of the hand together, and allow them to rebound together after striking upon the pleximeter, they thus give a more forcible impulsion, and a sound nearly as clear as if a single finger were used. Indeed, we shall generally find this method the most convenient for the examination of the chest, although, as I have already stated, a single finger is the best percussor in cases of children whose chest is thin and very elastic, or in those whose thorax is very nearly in the condition of that of children, from great emaciation. Although when we use seve- ral fingers, our tap is of course stronger than if a single one be employed, we shall find in either case that it is not the force, but the sharpness and quickness of the impulsion, which pro- duces the sound. A hard blow causes so much clacking sound against the finger that it proves a source of error, and renders the full resonance of the chest more difficult to draw out. Plain and easy as these directions are, probably no one will at first practise them correctly; we shall find that the elasticity of wrist, and light, clear tap, are learned but slowly, and after many efforts. There is, however, an easy method of improving our knowledge of percussion: we must repeat the operation frequently upon ourselves, at night, when we have removed our outer clothing, and all is quiet around us, a slight difference in sound then becomes perceptible, and the causes which ren- der it dull are evident, and we thus learn to avoid those errors which are the more embarrassing from their apparent trifling 34 PERCUSSION. insignificance. Notwithstanding all the care we may take, we will not make equal progress in this matter ; to acquire a perfect facility, a light and rather thin hand, and a correct ear, are re- quisite ; if we have not these advantages, we of course experi- ence more difficulty, — but with increased practice and more attention, it may be overcome. An instrument has been contrived by Dr. Bigelow, of Boston, for percussion. It is a piece of whalebone or elastic wood, covered at the end with a ball of velvet or buckskin ; the ball is nearly an inch in diameter: it is a very good instrument if any accident should deprive us of the full use of our fingers : the objections to it are, of course, the trouble and complexity of its use; hence Dr. Bigelow himself advises it merely in hospital practice, where we have a large number of patients to examine, and our fingers sometimes suffer from constant tapping. If we use this instrument, we tap with the ball upon the pleximeter, which should be made of gum elastic. While I was at Paris, some years since, an ingenious friend of mine imagined an instrument for measuring the sound of percussion. It was to consist of a percussor somewhat similar to that of Dr. Bigelow, but inclosed in a large stethoscope. The percussor was to be set in motion by a spring and wheel, as in watches, and the ear to be applied to the stethoscope in the usual way during the action of the instrument. The idea was ingenious, but the practical application of it almost impos- sible. Any contrivance to assist the senses in diagnosis must be extremely simple, or it will be practically useless ; and, as a general rule, we do much better to trust to our hands alone for the percussion of the chest. Percussion is applicable to the study of abdominal as well as thoracic diseases ; indeed, it is largely applicable to the explo- ration of many diseases of the viscera of both cavities. The abdomen contains solid viscera, such as the spleen and liver, and tubes filled with gas or liquid. The gaseous contents are much more abundant than the liquid ; hence the sound of per- cussion is clear over the greater part of the abdomen from the gas retained in the alimentary canal. If the quantity of gas be increased, we necessarily have an increased resonance on per- cussion, and the converse is, of course, true ; this fact enables us to estimate the effusion of liquid in the peritoneum, the en- largement of the solid viscera, and the distension of the cavity of the intestine with a large quantity of gas, which causes a tympanitic resonance. The same manual method of percussion is applicable here as in the exploration of the thorax ; but, in general, we shall find that a very light tap, with a single finger, PERCUSSION. 35 is the best, especially in those cases in which the gas is con- tained in the larger intestines, and therefore approaches very near to the surface. Percussion of the abdomen is always practised when the pa- tient is lying upon his back, and the surface of the abdomen is therefore placed in the situation most convenient for examina- tion ; but in the thorax we vary the position, — that is, we vary it in all those cases in which the patient is well enough to change his posture at pleasure : if he be too feeble for this, we must, of course, examine him in any way that happens to be practicable. In ordinary percussion, our object is to place the patient in such a position that we may render the parietes of the chest as tense, and consequently as elastic as possible ; the muscles must therefore be put upon the stretch, and the skin drawn tightly backwards. In percussing the anterior part of the chest, the patient should sit upon a chair; or, which is still better, he may stand erect, and throw the shoulders slightly backwards, so as to render the pectoral muscles tense. For the posterior part of the chest the position should be reversed ; the patient must lean forward, and cross his arms strongly, to draw the scapulae from the spine, and throw out the arch of the back. To examine the axillary region, the arms should be raised above the head. The chest may be percussed at first in a cursory way on each side, to gain a general idea of the con- dition of the viscera, and afterwards we may proceed to the details, and compare the sonorousness of different parts of the lungs and of the heart. The lungs are not equally sonorous throughout their whole extent; for as the clearness of the sound depends upon the large quantity of air contained in the vesicles, and the small quantity of solid matter, a difference in the rela- tive proportions of these parts will give rise to various degrees of resonance ; thus, the sound is most clear wherever the vesi- cles are most numerous, and the larger bronchial tubes, whose walls are thick and firm, are least developed; for the thin pari- etes of the vesicles present no obstruction to the vibration of the air contained within them, but the hard walls of the bron- chial tubes offer a very decided obstacle. Hence, if other things be equal, the sound may be stated to be most clear at the lower part of the chest, and along the anterior margin of the lungs, while it is comparatively dull at the summit and root; in the rest of the lungs the sound is intermediate, neither dull nor clear. Where the lungs are so situated as to overlap the more solid portions of viscera contained in the chest, the sound is but moderately clear, becoming more dull as the thickness of the solid organ is greater than that of the lungs. This is the 36 PERCUSSION. case both with the liver and heart, and is a fact which is analo- gous to the phenomena observed in a diseased state of the lungs, where a lesion which renders the deeply seated parts of the pulmonary tissue more solid, makes the percussion dull over the corresponding parts of the lung. The dulness of sound is observed, notwithstanding the superficial portions of the chest, in which the lungs are placed may be perfectly pervious to the air. The relative quantity of bronchial and vesicular tissue gives rise to the modifications in the clearness of the sound in per- cussion to which I have alluded, and the resonance of the vesi- cular structure is quite different from that which would be caused by the same quantity of air contained in a single bag, or large vesicle. If the air contained in a large number of scat- tered vesicles were collected together, and percussion were made upon the sac which contains it, the sound would be drum- like, or tympanitic. This character is actually observed in cer- tain morbid conditions of the chest, but it is never similar to the healthy sound, which is more deep and hollow, but at the same time less gaseous. The difference between the two vari- eties of the clear sound will be appreciated at once if we exa- mine the chest, and then percuss downwards until we come to the hollow viscera of the abdomen, which yield the tympanitic resonance very different from the hollow sound, which is caused by percussion on the lungs, and which is called vesicular. After we have gained a general idea of the resonance of the chest, we should proceed to a more thorough examination of the various portions of it, one by one. For this purpose, it is convenient to divide the chest into regions or parts. These may be the anatomical divisions corresponding to the exterior of the chest; as the clavicular, scapular regions, &c.; or we may use terms expressive merely of the fractional parts into which the surface is divided, such as thirds, fourths, &c. For most purposes, the latter method has seemed to me to be the most convenient. When we wish to be more exact, we may subdivide these regions, or we may, in addition, designate them by a reference to their anatomical relations; but if we divide the anterior and posterior surfaces into three parts, and the axillary into two, it will be sufficiently minute for most purposes. The anterior surface may be divided, therefore, first, into an upper third, extending from the summit of the lung to the lower mar- gin of the second rib, and of course including the anatomical subdivisions of post-clavicular, or to the space above the cla- vicle ; clavicular, that corresponding directly to this bone; and sub-clavicular, or the region found immediately beneath PERCUSSION. 37 it. This portion, in general terms, may be said to correspond with the summit of the lung, and is of great interest to the physician; for it is the ordinary seat of tuberculous diseases, which of course render the sound dull; and occasionally of pneumonia, which produces the same effect in a more marked degree ; and, thirdly, of emphysema, which renders the sound preternaturally clear. The middle third extends from the lower margin of the upper division to the space between the fourth and fifth ribs; it is less interesting for practical study, for its diseases are, for the most part, rather such as begin in the up- per or in the lower third, and extend themselves to the middle, than those which commence in it. Emphysema, however, is often more developed about the middle of the lung than in any other part of this surface. The lower third extends from the boundary of the second to the lower margin of the chest; it is the usual seat of pleuritic effusions and of hydrothorax ; in both of these diseases the liquid extends itself gradually from the posterior parts of the chest, towards its anterior margin, render- ing the lower portion dull. In the healthy condition the sounds of percussion are not equally sonorous in all parts of the anterior surface of the chest; in children the lower third is decidedly the most sonorous; in adults the middle is generally the clearest. In women we shall find it difficult to compare these various portions together, for the mammae interfere so much with percussion, that it is ex- tremely difficult to examine the middle third in a satisfactory way. The heart is another cause of dulness of sound at the internal part of the lower third on the left side. The praecordial dulness extends from the space between the fourth and fifth ribs at the sternum to the nipple, generally passing a little within this part. On the right the dulness is bounded by a line which follows the middle of the sternum ; the lower part of the heart rests upon the diaphragm, and the percussion is therefore dull to the base of the thorax. The axillary or middle surfaces are divided most conveniently into two portions by a line drawn transversely through the middle of the axillae. The sound in these parts differs in a very slight degree, and is throughout extremely clear, from the almost com- plete absence of the more solid parts of the lungs, and the re- markable freedom of this portion of the chest from muscles which necessarily deaden the sound to a greater or less degree. If the posterior part of the chest be divided into thirds, these portions are still more unequal in their resonance than they are at their anterior part. The upper third extends from the top of the lungs to a line passing along the spine of the scapula, prolonged 4 38 PERCUSSION. to the vertebrae. This, like the summit of the lungs at its an- terior part, is the common seat of tubercles, which are more frequently developed here than at any other portion. Percus- sion is, however, so difficult at this part of the lungs from the thickness of the muscles, that its results are not- of great value to beginners. Under all circumstances the sound is but moder- ately clear, becoming duller towards the external margin. The middle third extends from the lower margin of the upper, to a line drawn at right angles to the spine from the lower angle of the scapula. The natural sound is here much more clear than in the upper third, especially near the spine, where the scapula does not interfere with it. Upon the scapula the percussion is necessarily dull. The lower third corresponds to the largest mass of pulmonary tissue ; and from the conformation of the ribs, gives a remarkably clear sound in children, whose thorax is elastic. In adults, the greater firmness of the ribs and mus- cles, and the greater induration of the ligamentous and cartila- ginous tissue, renders this sound less hollow ; still it is always comparatively clear. This portion of the chest, with the middle third, is the usual seat of pneumonia ; it is also the commencing point of pleuritic effusions, — hence, in diseases it is often dull, when the rest of the chest is comparatively clear. After we have examined the chest in a cursory manner, the regions must be examined comparatively, —that is, each part should be compared with the corresponding one upon the oppo- site side at the same points. For purposes of convenience I generally begin at the summit of the lung, at the anterior part, and then pass downwards towards the diaphragm, percussing both over the ribs and in the intercostal spaces, and always placing the finger of the left hand parallel to the ribs ; this gives us the sound corresponding accurately with the portion of lung which is immediately beneath the finger, or very little more than the sound corresponding with that space. If we percuss across several ribs, the sound is more difficult to appre- ciate, as it is produced by a much larger portion of the lung, and is therefore of little value, except for the facility which it gives us of gaining a general idea of the condition of the lungs. If we are at all doubtful about the sound, I would advise that we should always compare the two sides together in very quick succession, while the impression of the sound is still fresh in our senses, and repeat the percussion until we arex satisfied whether there is, or is not a real difference. In a certain proportion of diseases of the lungs, the signs of percussion, united with the general symptoms, are sufficient for the diagnosis ; and, if combined with the other physical PERCUSSION. 39 signs, they are sometimes perfectly characteristic of the disease without the aid of the rational symptoms. We must remember, however, that percussion indicates merely the relative density of the lung, and is not sufficient for the diagnosis of most of its diseases without the aid of other means of investigation. But the signs of percussion, although comparatively few in number, are often of more value than any others, for their evidence is positive as far as it is applicable, and indicates with perfect accuracy the density of the tissue beneath the spot upon which the percussion is made; but as] the causes which influence the density are numerous, they are not explicable without the comparison of other symptoms. Percussion, is therefore, of all the signs of pulmo- nary disease, the most strictly physical, and of course the most mathematically correct. Percussion is not confined to the dis- eases of the lungs ; for as these organs surround the heart, the sound is clear as far as their tissue extends ; hence the size of the heart is measured by percussion of the lungs, rather than of the organ itself. It is, as we shall afterwards see, one of the most certain methods of learning the size of the heart The practical mode of acquiring percussion is of more interest to us than the mere detail of the signs derived from it. Like all the means of pectoral investigation, percussion maybe learned in two ways, — that is either on the healthy or diseased sub- ject. Those physicians who observe patients on a large scale, and have sufficient time to examine at their own leisure the cases which they meet with in practice, will learn percus- sion chiefly from patients and as it were, in connexion with other signs. But this is not always the more convenient method ; it is not at all fitted for those whose sense of hearing is not acute, or who may not possess the necessary facilities for studying disease among a large collection of patients. If the ear is to be educated as well as the hand, we will cause no little uneasiness to our patients in attempts to gain, little by little, a familiarity with the sounds. We will be sure to per- cuss much too smartly for their comfort at least, and we may possibly aggravate the symptoms of their diseases. We should therefore always learn on our own persons; or several who are engaged in this study may unite together, and form little clubs for mutual percussion, so as to get on much more rapidly. For the healthy chest presents every shade of percussion, from complete flatness to the most perfect sonorousness, and we may thus accustom ourselves to every variety of sound. At first we should examine the parts of the chest where the sounds are most distinct; and for this purpose it is best to select a young person, and, if possible, one who is rather thin, — then by per- 40 PERCUSSION. cussing first on the middle of the side of the chest near the sternum, and afterwards on the region of the liver, we may- gain a correct idea of the difference between perfect flatness, and the full, clear, pulmonary sound. This should be repeated frequently, until a good idea of the difference of these sounds is impressed upon the memory, and above all, upon the senses. The same points of extreme flatness and sonorousness will ex- plain the difference between the tapping with a single finger, and the deeper, but less sharp sound produced by decided per- cussion with several fingers. These comparative points should be examined on several individuals of different ages, and different degrees of flatness or thinness, until a correct idea of the average sounds is acquired. After the extreme degrees of sound have been repeatedly heard, the intermediate characters may be learned by percussion of the precordial region, where the sound is dull, but in the healthy subject not completely flat. There is also a little dulness of sound at the summit of the lungs; on the right side, in most individuals, it is a little less clear than upon the left. The repeated examination of these parts of the chest will not only give us a correct idea of the sounds themselves but will train our ear and hand to the manual performance of percussion. I have pointed out the great accuracy of the signs of percus- sion, and their uniform dependence upon the same physical condition of the lungs. It matters but little whether the disease is seated on the surface of the lung or in the internal parts of it; the quantity of air is necessarily diminished by every hard- ening of the tissue, which is sufficiently extensive to compress one or more lobules. Whenever the obstruction is sufficient to form an alteration in the sound perceptible to our senses, it may be readily recognised. The induration is perceptible enough, when three or four lobules become impervious to the air, but it cannot be recognised with certainty, if limited to a less extent. The deeper seated lesions are rather more obscure than those nearer the surface, as the air-vesicles which intervene between the ear and the indurated portion, of course give rise to a clear sound, but it is less full and hollow than it is when the lung is completely free ; for the plain reason that the mass of sonorous, that is, of aerated tissue, beneath the finger when we percuss, is less considerable. A compression of the lung necessarily acts much in the same way as an induration of its parenchyma ; hence effusions into the pleurae, or even into the pericardium, compress the pulmo- nary tissue, and render it less elastic, — that is, they diminish the size, and expel the contents of the air-cells. The compres- PERCUSSION. 41 sion which is at first produced does not give rise to as great a degree, of dulness as the induration of the pulmonary tissue, for the whole tissue remains pervious, and is merely a little less distended with air than usual; but in advanced cases of effu- sions into the pleura the flatness may be more complete than under any other circumstances, for the compression, although slow, may be carried to such a point as to alter the structure of the pulmonary tissue completely, and flatten it against the spine. In the pericardial effusions the compression is never so great as to destroy the resonance, except immediately around the liquid. Life has but little to do with the clearness or dulness on per- cussion, — for in the lung removed from the dead body we will find precisely the same condition of things under the same cir- cumstances, and we may readily verify the fact for ourselves, if we attempt to make the examination of the body of an indi- vidual dead of a disease which alters the structure of the lung, — or we may resort to the same experiment, by producing a change in the structure of the lung by artificial means, such as injections of wax into the bronchial tubes, or of liquids or of air into the serous cavities, when the percussion is flat; if, on the other hand, we distend the vesicles by inflating them with air, the percussion immediately becomes extremely resonant. We will find that in healthy individuals there is often a con- siderable difference in the sounds of percussion. I have already alluded to some of the causes of this difference, which may be perfectly external to the chest, and consist in accumulations of fat or serum beneath the skin ; or, on the other hand, they may depend upon a wTant of resonance in the thoracic parietes, and arise from the partial ossification of the cartilages. There is a third class of patients who offer less than the average degree of resonance of the chest; in these individuals the lungs contain less air than usual, and are apparently more firm and more similar to cellular tissue. The chest, on the other hand may be more resonant than the average, from either a real dilatation of the vesicles of the lungs, or from the patient being greatly emaciated without much disease of the lungs themselves. There is but one way of overcoming these difficulties,— and that is, to examine the chest in many patients until we acquire a knowledge of the average clearness or dulness of sound, and of the circum- stances which modify it without the development of positive dis- ease of the lungs. These accidental circumstances are altogether dependent upon ordinary acoustic principles: elasticity and thin- ness of the parietes of the chest favouring the clearness of sound, and thickness and rigidity of them producing a contrary effect, 4* 42 AUSCULTATION. CHAPTER IV. AUSCULTATION--MODIFICATIONS OF RESPIRATION AND VOICE-- BRONCHIAL RESPIRATION, CAVERNOUS, AMPHORIC, RUDE. SIGNS OF THE VOICE, PECTORILOQUY, BRONCHOPHONY. We now come to the most important means of physical ex- ploration,— that is, auscultation, or the act of hearing and interpreting the sounds produced in the chest either during the act of respiration, or of coughing or speaking, or caused by the action of the heart. Percussion teaches us merely the density of the tissue of the lungs; but auscultation goes much farther, and not only indicates the physical density of the tissue, but the functional play of the organs, and the obstructions which impede the passage of the air in the lungs, or of the blood in the heart. Hence the signs of auscultation are much more de- cided than those of percussion; they are developed by the patient himself, and of course cease with the termination of life. They are more complicated in their nature than the signs of percussion, and are less easily recognised, because they may be modified by a greater number of circumstances: but when these are taken into the account, the deductions from auscultation are quite as conclusive as those from percussion. The mode of practising auscultation is extremely simple ; we may apply our ear directly to the chest, or we may inter- pose between it and the thorax of the patient a solid or flexible tube ; hence auscultation is said to be either immediate or me- diate. That is, it is immediate when the ear is directly applied, but mediate when a tube is interposed between the ear and the chest. As the sounds are produced by the patient, and not by the hand at first, as in percussion, it is thus a very easy task; but it will be found of more difficulty when we arrive at the sounds themselves, and to their interpretation. Some, in them- selves, are not easily learned; but others are difficult, only be- cause they differ one from another by slight shades, and may therefore readily be confounded together. For most purposes, immediate auscultation, or the direct ap- plication of the ear to the chest, is preferable to the use of a AUSCULTATION. 43 conducting tube. Those who are perfectly habituated to the exploration of the chest, prefer this method in the great majority of cases, on account of its greater rapidity and facility of appli- cation, for there is no previous preparation necessary, nor is there any difficulty in passing the ear rapidly over the chest. But in those portions of the thorax, where the space for the application of the ear is extremely limited, such as the clavicular regions and the axillae, or above the mammae in females, the stethoscope, as the conducting tube is called, will be found pre- ferable. Besides these reasons of mere expediency, the sounds themselves are sometimes better characterised, or at least better limited in immediate auscultation; this is the case with the heart, and even with the lungs; for, as the instrument covers but a small space, and is perfectly isolated from the rest of the chest, the sound which is produced near the limited portion covered by its extremity, is alone conducted to the ear, — and that coming from the adjoining parts of the thorax is not heard, or at least is so feebly heard that it does not materially inter- fere with the result. When we apply the ear, we place the large surface of the head in contact with the chest, and as the bones of the chest and head are tolerably good conductors of sound, we hear the sounds of a larger portion of the lung than is desirable, and acquire less precise notions. But when we wish to examine rapidly a large portion of the chest, we will gain much time from this very circumstance, and take in at once the sounds from a large space, such as a whole lobe of the lung, or nearly so; and if we are really familiar with the sounds, they can be analysed and distinguished one from another, though heard at the same time, just as several instruments can be re- cognised in the same piece of music played by a complete orchestra. For ordinary purposes, therefore, immediate auscul- tation is much to be preferred. When we use an instrument for conducting the sound from the chest to the ear, we shall be obliged to take more precau- tions. This instrument is called a stethoscope, and is nothing more nor less than a tube of light wood, such as cedar; the extremity which is to be applied to the chest, is hollowed into the form of a cone, the apex of which terminates in the tube, and, of course, it serves as an ear trumpet to conduct the sounds. The substance of the tube, although a comparatively good con- ductor of sound, is of much less service than the column of air; for an ordinary flexible ear-trumpet in which the sound is con- ducted exclusively by the column of air, is an excellent stetho- scope. The diameter of the base of the cone should be from an inch to an inch and a quarter; if it be much larger, the 44 AUSCULTATION. sounds are confused, and the instrument loses its geatest ad- vantage, that of concentrating the sound within a limited space ; if too small, the sound is not loud enough. The essential point in the construction of a stethoscope is, that its cone should be deep and well hollowed out, at least an inch and a half or two inches deep, as is the case with all the good instruments now made. The cone should be perfectly simple, and not curved as was formerly the practice with many instrument makers. The length of the tube may vary from four or five inches to a foot; six or seven inches will be found to be of a very suitable length for most purposes. The diameter should not exceed a quarter of an inch, care must be taken to have it smooth and well polished throughout its whole length. The ear piece should be slightly convex or flat, or we may have a nipple- shaped projection, to insert into the ear; it should be of the same material as the rest of the tube, and not of ivory, as is often the case. For myself I prefer a tube with a perfectly smooth extremity, but there will be some difference of opinion as regards this matter, depending in part upon habit, and in part on the form of the ear. The ear should not be so near the chest as to expose you to the inconvenience of immediate auscultation, nor so far removed from it as greatly to diminish the intensity of the sound, for the sound becomes more gradu« ally less and less loud in proportion as the ear is further removed from the part of the lung in which it is produced. A flexible tube, that is an ordinary trumpet, about eighteen inches long, with the open end brought nearly to the form of the extremity of the stethoscope, is, perhaps, the best instrument for the examination of the sounds of the heart, as it does not conduct the impulse to the ear; hence the sounds alone are heard without the impulsion, which renders their analysis more difficult. Dr. Pennock of this city, who has devoted great attention to the diseases of the heart and their signs, was the first to introduce the flexible tube for this purpose, instead of the ordinary steth- oscope. I shall not enter further into the description of the mere in- strument of hearing, which we may procure from any turner, but I must give some cautions respecting the mode of applica- tion of the stethoscope. If we apply it directly upon the chest we must take great care that the end be placed flat upon the skin, without inclining to one or the other side, as the sounds are both modified and lessened by the admission of air be- tween the thorax and the tube. Indeed it is better not to place the instrument immediately upon the skin, but upon an under garment of muslin or flannel; this fills up the interstices between AUSCULTATION. 45 the tube and the surface, and prevents pain from too strong a pressure. This covering must be thin and not stiff, hence starched linen and silk are both improper, as they give rise to a rustling sound, and obscure the respiratory murmur. When patients are much emaciated we can hear very dis- tinctly the sounds of the chest through two garments, but under ordinary circumstances, it is best to auscult the patient clad only in flannel. The position of the patient for auscultation should be similar to that already directed for percussion, but the muscles and skin need not be drawn as tensely upon the ribs, for the pres- sure of the ear or the stethoscope against the chest will supply the effort performed by the muscles, and bring the parts as closely together as is desirable. The signs derived from auscultation are divided into those of the respiration, of the voice, of the cough, and lastly, of the heart. The signs of the respiration include both the modifica- tions of the natural sounds produced by the disease, and the rhonchi, or the new sounds, which are totally unlike those heard in the normal state. The latter class of signs are simple, and readily learned; the former are more important, and are produced by deeply seated alterations of the substance of the lung, producing a change in the density of its tissue. These signs are always attended with corresponding alterations in the percussion, and the resonance of the voice, which depend upon the same changes in the vesicular structure of the lungs, and in the condition of the bronchial tubes. They are thus learned, as it were, in connexion ; and the signs of the respiration are strengthened or disproven by the corresponding changes in the voice and the percussion. Hence we shall find it more easy to acquire them than it otherwise would be, for we may verify for ourselves at every step of the examination, and gradually ac- quire confidence in our powers of discrimination. The morbid alterations of the respiration are well marked in ex- treme cases, but gradually pass into the characters of the healthy respiration; there is, therefore, but one way of learning these signs. It is first to acquire the signs when strongly character- ised, and then to proceed to the cases in which the modifications of respiration are but slight. In the diseased subject we shall find that the strongly marked signs are very easily recognised ; and many who follow practical demonstrations with sufficient attention, will naturally begin their study by the examination of patients who present these signs. Still, the facility for ex- amining individuals in health is so much greater, that I should advise all beginners to familiarise and train their ear by the at- 46 AUSCULTATION. tentive study of those sounds presented by healthy individuals which approach most nearly to the signs of disease. And they will find that the characteristic marks of the radical sounds exist both in the healthy individual and in many diseased conditions. These characters in healthy individuals are founded upon the peculiarities of the sounds in different parts of the chest de- pendent upon the differences in the tissue. The lungs consist of tubes conducting the air to vesicles in which the arterialisa- tion of the blood takes place. The sound of the air entering the vesicles is different from that caused by its passage through the tubes; and the former is designated as the vesicular sound, the latter as the tubal or blowing sound. The vesicular sound is often called a murmur, from its softness and diffusion over a large space, and cannot be produced unless the vesicles are healthy, or nearly so. If you keep up artificial respiration in an animal stunned by a blow on the head, or suddenly killed, and apply your stethoscope upon the exposed lung, the murmur is heard very distinctly during the inspiration, so that we have direct evidence that the sound is produced by the passage of the air into the vesicles; the vesicles, however, empty them- selves in a noiseless manner, and the expiration is therefore nearly unheard. The tubal or blowing sound is quite different in its character; it is evidently produced by the passage of the air through tubes, and is heard very distinctly both in the in- spiration and expiration, — and is, in fact, much more distinct in the latter. The cause of this difference seems to be the dif- ferent manner in which the air impinges upon the vesicles and tubes. During the inspiration the terminating point is of course the air vesicles, — and the air, if forced into them with tolerable rapidity, produces a sound ; this is the same, whether the im- pelling force be the pressure of the atmosphere, upon the column of air in the bronchial tubes, when the parietes of the chest are elevated by muscular action, or the force communicated by the bellows, when artificial respiration is carried on. The sound is in part owing to the vibration of the air, and in part to the noise produced by the dilating of the vesicles themselves. At least, the sudden dilatation of a partially collapsed vesicle is, in all probability, attended with sound, caused by the membranes; for, when the parietes of the vesicles are thickened, the sound probably becomes louder and more distinct. It is a point, how- ever, which is difficult to decide, and one that is of little prac- tical moment, — for, admitting either explanation, it is equally necessary that the vesicles should be clear, and that the air should pass freely into them from the adjoining tubes. The expiration produces a faint, vesicular sound; almost no sound AUSCULTATION. 47 in. those portions of the lungs where the vesicular tissue is not traversed by bronchial tubes of a certain calibre. This proba- bly depends upon the gradual manner in which the pressure upon the vesicles expels the air from them into the larger tubes through which it may readily pass towards the exterior: but as the air is forced out from the vesicles very slowly, and of course not in a regular stream or current, they contract without sound. The vesicular murmur is compared to various sounds not very like to it; but it can be learned only in one way, — that is, by listening to those portions of the chest in which it exists in the greatest purity, especially towards the lower and lateral por- tions of the lungs. The murmur will be found to vary in in- tensity in different individuals: in some it is always feeble, and in others comparatively loud. It is louder in those persons of a nervous temperament in whom the necessity for rapid respi- ration is greatest, than in stouter individuals. It is also stronger in women and in children than in men and adults. The vesi- cular sound is indeed so much louder in children, that the term puerile respiration is used as synonymous with loud and full vesicular sound. In most persons, the dilatation of the vesicles is obviously incomplete, except in forced inspirations, and in some is much more so than in others. This imperfect dilatation is rather more marked at the lower portions of the lungs than the upper, probably from the longer course and smaller size of the bron- chial tubes, which require a more powerful effort to produce their full distension. The tubal respiration is often called bronchial, from its pro- duction in the larger bronchial tubes, — or tracheal, from its development in the trachea, — the term tubal being thus al- ways confined to the most intense degree of this sound. In the healthy individual this may be heard in a very marked degree at the trachea, immediately above the sternum, and the air is then heard very easily as it passes through it, both in the in- spiration and expiration. The sound is always blowing, and very different from the vesicular murmur ; this character is best marked in the expiration. The cause of this difference will be very obvious if we attend to the sound of our own respiration ; we will find then, if we breathe rapidly, that the expiratory sound, which is heard out of the chest, is much louder than the inspiratory, and that it is produced in the upper portion of the bronchial tree, and in the nasal fossae, where the air passages are large, and the rapidity of motion of the air is greatest. It is for this reason, in the trachea the respiration is most decid- edly tubal, or if we choose to use the term, tracheal. It gradu- 48 AUSCULTATION. ally becomes less and less so as we approach more nearly to the parts of the lungs where the vesicular structure is most abun- dant, and contains tubes of the smallest calibre, and furthest removed from the surface. We may thus analyse the different sounds heards in various parts of the respiratory passages ; and it will then be found that the blowing sound is heard only at the trachea, and the vesicular only at the lower part of the chest — whilst at the roots of the lungs there is a mixture of the two varieties of sound, so that the vesicular is combined with the blowing sound. Passing from the root of the lung we will find a gradual diminution in the loudness of the bronchial sound,— but it is still heard as far as the summit, and much more dis- tinctly on the right side than on the left. The difference in the two sides arises from their anatomical structure; for the tubes leading to the upper part of the right lung are shorter and larger than those going to the left, on which side the large bron- chus passes under the aorta, and is therefore much longer and more tortuous than upon the right. The larger but shorter tubes of course approach much more nearly than the longer and smaller ones to the physical condition of the trachea, in which the air circulates with such freedom as to give rise to the loudest double blowing sound. The louder blowing sound exists on the right side, both at the anterior and posterior part; hence a given amount of induration of structure, which may tend to increase the loudness of this sign, will be much more perceptible on the right side than on the left, — while on the other hand, in the state of health, a perfectly natural peculiarity may be mistaken for disease. The blowing sound, if it be heard only on the right side, must be well characterised to be- come a sign of disease, and when it is slight is not of much value unless combined with other corroborative evidence. This difference of respiratory sound on the two sides of the chest dependent upon the different structure of the lungs, was not pointed out previously to some researches which I under- took upon the subject, at the Children's Hospital of Paris, about eight years ago. My attention was called to the subject by the observation made by my lamented friend Dr. James Jackson of Boston, who laid great stress upon the characters of the expiration observable in commencing phthisis, and other diseases attended with consolidation of the lung. His remarks upon early development of the blowing expiration in com- mencing phthisis, were perfectly well founded ; but at the com- mencement of his researches he was sometimes led into error from not making due allowance for the difference of the two sides dependent upon peculiarities of conformation. AUSCULTATION. 49 In the study of the respiration we have a plain course to fol- low : we must examine as often as possible the region of the trachea, and then the lower and vesicular portion of the lungs, and thus fix in our minds the difference between the two lead- ing varieties of the respiration, or the tubal and the vesicular. Some may find this study a matter of no little difficulty, while others can seize the distinctive characters at their first effort. They must not be in doubt as to the cause of this difficulty when it exists ; it arises in part from a less acuteness of hearing, but much more from a defect of attention, which may be readily supplied by our own efforts; and,itmustbe admitted, that we know nothing of auscultation until we have mastered this subject. After the best marked sounds are learned, we may proceed to those parts of the chest in which we will hear the two varieties of the respiration at the same time ; we then analyse their pecu- liarities, and may ask at each moment whether we have attained a clear idea of both sounds, as they are heard together. The same process should be repeated in different individuals of various ages, sex, and conformation; and we shall find that although they present numerous shades of difference, the radical features are the same, and must always be the same, for they depend on known principles of acoustics. In connexion w7ith this part of our studies, we may properly enough accustom ourselves to the shades of difference offered by the parts of the lung, where other viscera, such as the heart and liver, occupy a portion of the space beneath the ear, and we may in this way learn the abrupt manner in which the respira- tion generally ceases at the level of the lung. During our ex- amination we should direct the patient to breathe with different degrees of rapidity, sometimes quite naturally, and at others, much more quickly, so as to force the air into the vesicles. In the examination of diseased individuals nearly the same order is followed, — and after placing our ear for a moment upon the chest of the patient while breathing in a quiet and regular manner, we usually direct him to make a forced inspiration, which clears out the mucus in the brochial tubes, and supplies a full proportion of air to each vesicle, or we direct him to cough, so that a forced inspection may follow the expirations, which constitute the act of coughing. In cases of disease of an acute character obstructing a portion of the lung, there is no necessity for directing the patients to breathe rapidly, as the obstruction in the diseased part of the lung causes the respiration in the rest of the pulmonary tissue to be much exaggerated or puerile. After learning the radical characters of tracheal or bronchial 5 50 AUSCULTATION. respiration, which differ merely by a shade from those of the vesicular respiration, which is intermediate to the two leading varieties, we may proceed to the study of the morbid altera- tions of the respiratory sounds. These are classed according to their greater or less accordance with the natural characters of the respiration. This is the bronchial respiration, and its varieties, which include the cavernous and amphoric respiration. The bronchial respiration, as it occurs in a diseased lung, is essentially the same with the tracheal respiration of the healthy chest. The bronchial respiration is developed by causes which harden the parenchyma of the lungs, and destroy the vesicular texture : these are the infiltration of the tissue of the lungs with blood and plastic lymph in pneumonia, the compression of the lung by pleuritic effusions, and the deposits of various anomalous productions, such as tubercle and cancer, in the tissue of the lungs. If the induration be seated around the larger bronchial tubes, the bronchial respiration is much louder than in the portions of the lung where the tissue is chiefly composed of vesicles, for the essential cause of this, sound is the passage of the air through the tubes. The induration of the substance of the lung merely developes the tubal or bronchial sound where it is not generally heard, or increases it in those parts of the lung in which it exists naturally. The bronchial respiration is produced then partly by the obliteration of the vesicles, and partly by the closure of the smaller tubes. That is, the air in passing through the tubes of a certain size is suddenly inter- rupted and repelled from their sides, because their terminating branches are closed. This repulsion of the air produces sound and causes the blowing inspiration and expiration, whieh is heard most loudly when the air, instead of diffusing itself throughout the vesicular tissue, is, on the contrary, forced through the larger bronchi, which are converted into closed cylinders, from the occlusion of their branches by the progress of the disease. The bronchial respiration is often accounted for in the following way : — The passage of the air in the tubes is, under ordinary circumstances, not attended with sound; as the sur- rounding tissue is a bad conducting medium, and deadens the sound. When this tissue is rendered more solid, the sound already produced in the tube, becomes audible, and is con- ducted to the ear. This explanation is valid only to a certain extent; the bronchial sound exists only in a slight degree in the natural state, for a tube through which the air is constantly and equally drawn during the respiration, gives rise to a very faint sound, but if the tubes passing into it be cut off, the pas- AUSCULTATION. 51 sage of the air is at once hurried, and by its friction against the parietes of the bronchus gives rise to the usual bronchial sound. In disease, therefore, the blowing sound is very often much louder in those portions of the lung where it does not exist naturally, than over the trachea or the larger tubes, which are almost immediately beneath the ear ; and this extreme loudness depends upon the circumstance to which I have already alluded, — that is, the sudden reflection of the column of air from the interrupted tube. The large size of the tubes is, however, as I have already stated, a circumstance highly favourable to the development of bronchial respiration; and if the tubes be superficial, like the trachea the influence of size becomes more obvious. If the tubes be enlarged, while the parenchyma remains healthy, the respiration becomes bronchial, but to a less degree than if the tissue be hardened, and the tubes retain their usual calibre ; for the induration is a more efficient cause of bronchial respiration than simple enlargement of the tubes. The bronchial respiration is not perfect except when the in- duration of the pulmonary tissue is complete ; this takes place in a few cases of phthisis, and in pleurisy with large deposit of lymph, but it is much more frequent in pneumonia than in any other disease, for in none other is the hardening of the tissue so perfect: this sign is therefore one of the best indications of the second stage of inflammation. In dilatation of the tubes the respiration becomes very bronchial when the surrounding tissure is indurated, that is, when complicated with pneumonia. The bronchial respiration, then, is produced by the passage of the air through tubes of the middle and larger size in an indurated lung, and also by the enlargement of these tubes. The cavernous respiration is another variety of sound which is closely analogous to the bronchial respiration, and depends upon the passage of the air into a cavity communicating with the bronchi. For physical purposes this cavity may be consi- dered as a mere dilatation of the bronchus with which it com- municates ; but as the termination of the tubes themselves is never so abrupt as the morbid cavity, the air in the bronchial respiration proper is gradually diffused through the tissue, and is slowly lost to the ear, — but in the cavity it is abruptly reflected from the walls of the excavation, and there- fore seems to be more circumscribed, and comes from a limited point. This diffusion of sound in the one case, and the con- centration in the other, constitute the principal difference be- tween these varieties of forms, and they therefore run into each other by insensible shades. As the line of distinction is an 52 AUSCULTATION. arbitrary one, it is sometimes impossible to discriminate between them, but it is not generally a matter of much practical moment, for the signs of a cavity generally become more and more dis- tinct in proportion to the duration of the disease, and these which seemed doubtful, usually become clear in a short time. The amphoric respiration is a modification of the same sound, but is more unlike the bronchial respiration. It is produced by the passage of the air into a large cavity with firm walls. If the communication between the cavity and bronchi be free, the expiration is also loud, and the signs differ from the caver- nous respiration in one respect only — it is fuller and more musical, somewhat similar to the sound caused by blowing into a glass or metallic vessel. Both the inspiration and expiration are blowing, and there is no trace of the vesicular murmur. If the communication with the bronchi be interrupted, or too small to allow of the free passage of the air, the inspiration alone is distinctly heard, as the air passes out of the cavity too slowly to produce much sound. The most common cause of amphoric respiration is a large tuberculous cavity near the surface, which is surrounded by indurated lung. It may also depend upon per- foration of the pleura ; in which case the amphoric tone is ex- tremely well marked, as the cavity is much larger than one formed in the lungs, and its walls are large and elastic. If the amphoric respiration depends upon a gangrenous cavity, it generally renders the sound more obscure ; so that it is less marked than in tuberculous excavations, as the surrounding tissue is usually soft, and is therefore a bad conductor of sound. We now return to the bronchial respiration as our standard of comparison, and pass from it to the vesicular murmur, revers- ing the order we have just followed. The varieties of the res- piration intermediate between the vesicular murmur and the true bronchial respiration, are very numerous, but they are properly enough classed under the general designation of rude, or rough respiration, which is applied to those varieties in which the vesicular murmur is still retained, but the blowing sound is at the same time more developed than is natural in the part of the lungs where it is heard. It may be attended with a feeble or an increased loudness of the vesicular murmur. When this is more feeble, the obstruction to the air occurs about the smaller tubes, and gradually compresses them; when loud, the morbid deposit is situated rather in the course of the larger tubes, than at their terminating branches, which still receive their full sup- ply of air while the respiration becomes blowing from the in- creased conducting power of the hardened tissue. The rude respiration is one of the most interesting varieties of the respi- AUSCULTATION. 53 ratory sound,.for it occurs in those cases in which the lesion is not yet much advanced, and a portion of the pulmonary tissue remains permeable to the air; hence it is a sign of the earlier stages of phthisis, as well as of the commencement of pneumo- nia and of pleurisy. It is a sign which can only be learned with some difficulty, because both the primitive sounds of the respiration are present, and they can only be separated by a careful analysis. From the rude respiration we naturally return to the vesi- cular murmur ; which may be exaggerated, or enfeebled, but still retain its essential characters. The exaggerated or puerile respiration, generally depends upon disease in other portions of the lungs than those in which it is heard. The healthy portions then perform double duty, and arterialise more than their proper share of blood. From the occurrence of puerile respiration in a part of the lung of a patient who labours under dyspnoea, we can very often determine that some obstruction must exist in other parts of the lungs; and from the know- ledge of the acute and chronic diseases which generally give rise to this obstruction, we can with tolerable certainty discover the nature of the lesion. The respiration is rendered feeble in disease, either by the compression of the vesicles from effu- sion upon the exterior of the lung, or the development of solid matter in the parenchyma, or lastly, from obstruction of the smaller tubes. There are some other varieties of the respiration, which it would be difficult to bring within a systematic description ; they should be learned after the leading varieties have been first studied. They generally arise from slight changes in the condition of the vesicles or smaller tubes, and sometimes from the mode in which the respiration happens to be performed, but rarely depend upon important organic changes in the lung. They may be reduced to the following : 1st, the incomplete or interrupted respiration ; in this variety the inspiratory sound seems to be arrested before the air passes completely into the vesicles; it arises from two causes, — a nervous spasm, and a partial thickening or congestion of the smaller tubes. It is a peculiarity which is often observed when we examine for the first time a nervous, sensitive patient, who is alarmed by the exploration of the chest; and it is sometimes met with in the infiltrated or congested state of the lungs which attends the forming stage of tuberculous disease, as well as certain varie- ties of bronchitis. 2. The rustling sound of the respiration is one of the characteristics of emphysema, in which the vesicles dilate and contract with difficulty, and seem to produce sound 5* 54 AUSCULTATION. rather from the rustling of the membrane, than from the pas- sage of the air which impringes against it. There are other and slighter deviations from the natural tone of the respiratory murmur; but, although they are very obvious to an experienced ear, yet they are neither sufficiently permanent or well marked to be reduced into a systematic classification. OF THE VOICE. The varieties of the respiratory sound correspond with varieties in the resonance of the voice, which often are nearly as well characterised ; still, the natural tone of the voice has so much influence upon its aptness for vibration, that the signs are not always as perfectly distinctive as those of the respiration. In the ordinary act of speaking the voice vibrates throughout the chest; and if the hand be placed upon its parietes, a slight tremour is very perceptible ; if we apply one ear to it, we will hear a thrilling, but distant and confused sound. This sound becomes louder, and is brought nearer to the ear, if we listen near the summit of the lungs, especially on the right side, or at their root; and placing the stethoscope upon the trachea we find the resonance loud, and the words pronounced nearly as dis- tinctly as they by the mouth. In fact, the voice is conducted by the column of air, so that articulated words seem to enter the ear from the trachea. This distinct and loud resonance at the trachea is perfectly similar to pectoriloquy; and it is in this situation very perfect, especially if the voice of the individual be naturally clear, and rather shrill. At the sternum and at the root of the lungs between the scapulae, the resonance is less perfect, and the voice seems to enter the ear less com- pletely than in pectoriloquy ; it is therefore not quite so well characterised a sign, and is called, from its position, broncho- phony. In the rest of the lung the resonance of the voice is gradually less and less loud as we pass from the bronchi to the vesicular structure, where we hear nothing but a faint vibra- tion. There is, therefore, a uniform relation between the voice and the respiration, the resonance of the voice being greatest when the blowing sound of respiration is most intense. In disease the same proportion exists ; a cavity gives rise to cavernous respiration in breathing, and to pectoriloquy in speaking,— and a consolidated lung, especially around the large bronchi, produces bronchophony and bronchial respiration. The same relation exists between a mere loud resonance of the voice and rude respiration, and between the ordinary vesicular murmur, AUSCULTATION. 55 and a slight thrilling vibration of the voice. In cases in which the murmur is enfeebled, the resonance of the voice is less: but sometimes there is a low, purring sound, communicated to the ear as well as the hand, which is analogous to the rustling sound of emphysema, and depends upon the same causes. The blowing respiration may continue very loud when the re- sonance of the voice has become quite feeble, for an accumu- lation of mucus may be forced aside by full inspiration, but cannot be thrown outof the way by the act of speaking, and there- fore obstructs the vibration of the column of air ; in these cases it is not, however, totally destroyed, for the sound of the voice is conducted by the hardened lung from the neighbouring tubes. When a cavity in the lungs is very large, there is, of course, amphoric respiration at the same time. On careful examina- tion we then find amphoric resonance of the voice, which often scarcely differs from pectoriloquy; that is, if the cavity be not much larger than a hen's egg, and its walls remain firm. But if the cavity increase much beyond this size, the resonance of the voice is extremely metallic, or has a clear ringing sound, which, like the respiration, is very similar to that produced by speaking in a glass bottle without quite closing its mouth, at the same time the voice is less loud than in pectoriloquy, so that it is not unfrequently difficult to ascertain that it is really amphoric. When the large cavity is situated in a soft permeable portion of the lung, the amphoric respiration may become very obscure, like the resonance of the voice under the same circumstances. The bronchial respiration which results from pleuritic effu- sions, is not very loud, but differs so slightly from the other varieties, that it is usually not separated from them while the resonance of the voice w7hich takes place under the same cir- cumstances, is very different. Its vibration is very great, and is so peculiar that [the sound is called egophony, from the bleating tone of the voice, somewhat similar to that of a goat or sheep. This is not an invariable result of pleuritic effu- sions, but it is produced in almost all cases in which the effusion is sufficient to compress the lung without entirely flattening it out. If the quantity of liquid happens to be very great, but the lung is stiff and more solid than usual from previous inflammation of its substance, the egophony continues longer than it otherwise would do, and rarely ceases during the course of the disease. Egophony is, however, in the large majority of cases a very- transitory sign, ceasing generally in a few days after it has been 56 AUSCULTATION. heard. Sometime the sign is only perceptible for a single day, disappearing as soon as the quantity of liquid is increased; for the sign is only perceptible when there is a moderate effusion. In other cases we do not recognise the sound at all, throughout the whole course of the disease. In a few individuals the voice is egophonic for a very long period ; but these are quite excep- tions and very rare cases. We generally hear egophony most distinctly when it is present, by listening when the patient speaks, to the neighbourhood of the scapulae : that is about the upper margin of the effused liquid. The cause of this modifi- cation of the voice is very difficult to explain, it is somewhat like bronchophony, and probably arises very nearly from an analogous condition of the compressed lung to that which is found in cases of inflammation; that is, the lung is slightly in- durated from the compression and the air is afterwards thrown into a peculiar resonance by passing through the effused liquid. The signs of the voice are learned by the same process as those of respiration. After having acquired a good general idea of the characters of the respiration, we should examine them in connexion with the signs of the voice, confirming or disproving one by the other, and then practising percussion, which will throw additional light upon the subject. We need not, of course, restrict ourselves to the healthy subject, but we would also study those cases of diseased lungs, in which the dia- gnosis is comparatively easy from the functional signs alone, such as examples of decided phthisis and pneumonia, and then search for cavernous and bronchial respiration, with the connected signs of the voice and percussion. The cavernous resonance of the voice in pectoriloquy was the first physical sign discovered by Laennec. He happened to place some paper rolled up into the form of a cylinder upon the chest of a patient, in order to feel the pulsations of the heart, when he was surprised to find that, during the act of speaking, the voice of the patient seemed to enter his ear. He examined immediately the chest of a large number of patients in the same way, and detected the same phenomena in a great number who were evidently labouring under advanced phthisis; the cause of this was afterwards found to be cavities in the lung communicating with the bronchial tubes. Pectoriloquy was divided by him into three varieties, the perfect, the imper- fect, and the doubtful: in the perfect, the voice seemed to pass through the stethoscope (which Laennec always used) to the ear, in the second to enter the tube, and in the third the resonance was quite confused. These distinctions are of little value and rather tend to confuse our ideas. AUSCULTATION. 57 The following table will give you the relation between the voice and the respiration. Amphoric Respiration, Amphoric Resonance of Voice, Cavernous Respiration, Pectoriloquy, Bronchial Respiration, Bronchophony, Rude Respiration, Strong Resonance of Voice. Vesicular Respiration, Slight Thrilling of Voice. THE RHONCHI. There are a number of sOunds produced by the respiration in certain states of disease of the chest, which are totally unlike the sounds heard in health. These sounds are called the rhonchi; and they are mainly produced by impediments^ mo- tion, either of the lungs upon the ribs, or of the air in the bron- chial tubes. Those which belong to the lungs proper are caused by obstacles to the passage of the air through the bronchial tubes ; these are the most interesting and important of the class. There is another set of sounds to which the term of rhonchi is sometimes applied, but which differ in some respects from them. They arise from the friction of the serous membranes in the chest, and are common to both the lungs and the heart. They occur when the effusions in these membranes consist chiefly of lymph which coats the surface of the serous tissues sufficiently to cause a slight creaking sound. This creaking or friction sound in the pleura, takes place during both inspiration and expiration, but especially at the commencement of the expira- tion, when the ribs first begin to sink down, and the pleura is drawn rather rapidly over them. It is not limited to a single spot, but shifts about, with the dilatation and contraction of the chest; and is generally most evident about the lower angle of the scapula, and often extends from that point across the axilla to the sternum. It is a sign which is proper to pleurisy, either primary or secondary; and it is in general readily recog- nised after the bronchial rhonchi are known, especially if the friction be sufficient to give to the parietes of the chest a thrill- ing motion, which may be felt by the hand. The rhonchi, properly so called, are divided into the moist and the dry. The moist rhonchi are the mucous, including the gurgling of cavities, the sub-crepitant, and the crepitant. The dry rhonchi are the sonorous and the sibilant, to which may be added the dry crepitant. The moist rhonchi are caused by the resistance offered by a liquid in the tubes or vesicles, to the passage of the air ; the liquid forms bubbles of various sizes, and their successive break- 58 AUSCULTATION. ing is the chief cause of the rhonchus. The dry rhonchi are produced by real thickening or spasmodic contraction of the mucous membrane, which gives a musical tone to the respired air; they are most evident in the expiration, while the moist rhonchi are for the most part heard during the inspiration. The rhonchi are not necessarily permanent, except the crepitant rhonchus; for the obstructions forming mucous rhonchus, or the thickening of the larger tubes may be removed for a time, in many cases, by an effort of coughing. The mucous rhonchus is the loudest of the moist rhonchi; it is caused by the breaking of bubbles of tolerable size con- tained in the larger tubes ; the sound is readily enough recog- nised, and is scarcely ever mistaken, even on a first examina- tion. This is the sound which is often audible at a little dis- tance from the chest of the patient, especially if it extend over a large portion of the lungs. The mucous rhonchus is heard wherever there is an abundant secretion of liquid into the larger bronchi and this generally arises from the second stage of bron- chitis, it is also quite common in phthisis and the third stage of pneumonia ; and the blood which is poured into the bronchi in haemoptysis, may give rise to almost the same phenomena. The mucous rhonchus is generally heard both in the inspiration and expiration, that is when the air returns with sufficient force from the lungs to agitate the liquid, and form bubbles, as a general rule, however, it is heard chiefly during the inspiration. There are two varieties of the mucous rhonchus, which are almost peculiar to phthisis; these are the dry crackling, pro- duced by the softening of the thick, pasty matter of tubercle, which gives a peculiarly dry and sharp sound, and the loose, but concentrated gurgling of a cavity. Any disease which gives rise to a cavity in the substance of the lung, will produce this cavernous gurgling; hence it may arise from gangrene of the lungs, pneumonia, or even a dilated bronchus. But as cavities depend much more frequently upon phthisis than any other cause, probably nine-tenths of those which you meet with, may be referred to softened tubercles. The gurgling differs from mucous rhonchus merely by its greater concentration ; it is in this respect that, like the other signs of cavities, it is distin- guished from those of the bronchi; and it passes into mucous rhonchus by an insensible gradation. We may place, there- fore, the dividing line between the mucous rhonchus of small cavities, and of the bronchi, where we please. Large cavities can never be mistaken. But there are some cases of dilatation of the bronchial tubes which extend over a considerable por- tion of the lung, in which the secretion of liquid is abundant, AUSCULTATION. 59 and the mucous rhonchus very similar to that of an ordinary tuberculous cavity. The liquid gurgling is heard both in the inspiration and expiration, for the air is reflected from the sides of the cavities during expiration, and of course causes an almost continuous rhonchus. You will find that both the crackling and gurgling are liable to disappear, although the cavity remains ; for the liquid secretion may be for a time suspended, or the matter may be expectorated, and the walls of the cavity may for a time remain dry. The subcrepitant rhonchus differs from the mucous in two respects: the bubbles are finer, and they break in a more gradual and regular succession. The rhonchus is therefore con- fined to the smaller tubes, through which the air passes rather slowly, and the bubbles nearly fill up their calibre. It is heard in various parts of the lungs, but much more frequently at their lower and posterior part than elsewhere, for the liquid accu- mulates there in the smaller tubes more than in any other part. The subcrepitant rhonchus is heard very faintly during the ex- piration. The crepitant rhonchus is the most important of the moist rhonchi. It is either fine or coarse, the latter variety differing very slightly from the subcrepitant. When the crepitant rhonchus is fine, it is pathognomonic of the first stage of pneumonia; and it is then produced in the vesicles of the lung, and perhaps in the small tubes which ramify through the lobules, — but when it is extremely fine, the sound is probably strictly vesicular, and seems to depend upon two causes, the breaking of the minute bubbles of thick mucus, and the dilatation of the thickened and stiffened vesicles. If the crepitus be rather coarse, it seems to arise more from the smaller tubes than from the vesicles, although this is a point which is not susceptible of a rigorous demonstration. A crepitant rhonchus is a sign which is con- nected with the parenchyma of the lungs, and can never occur in the larger tubes ; and it is not produced by other diseases of the parenchyma than pneumonia, because it is only in the latter disease that you will find the thick, viscid secretion, and the stiffened, yet still dilatable condition of the vesicles. The pure crepitant rhonchus is strictly confined to the inspiration; the air does not pass in the expiration with sufficient rapidity to break the tenacious liquid. The crepitant rhonchus generally forms trains of bubbles, something like the successive explo- sion of a small train of wet powder; and the sound is com- pared to various trivial noises, such as the crackling of salt, and the rubbing of a lock of hair ; but, like all the signs of auscul- tation, nothing out of the body gives a correct idea of its char- 60 AUSCULTATION. acter. We, must, therefore, learn it in patients labouring under pneumonia; and if we have not opportunities for examining cases in connection with persons who are familiar with physical signs, I would advise those engaged in this study to select a case in which the pneumonia is advanced to the second degree, and the general symptoms of the disease accord with the physical signs. In such cases the diagnosis of the disease may be re- garded as quite certain ; and we may trace the crepitant rhon- chus as it proceeds from the interior of the indurated lung towards the exterior. There are certain sounds connected with the pleurae which are similar in many respects, as I have already stated, to the moist rhonchi. These are two in number, the friction sound, and the metallic tinkling which is heard generally when the external air communicates with the cavity of the pleura, but is occasionally observed in cases of large cavities in the substance of the lung. The friction sound differs in some cases very slightly from the sub-crepitant, and I have sometimes been puzzled to discriminate between them ; of course I do not allude to the well characterised variety, in which there is a thrilling motion extending along the chest, and felt as well as heard, but to those cases in which the friction is very slight. The deposit of lymph is then generally very small, but such is not neces- sarily the case, for there may be little friction when the effusion is large, especially if the lung be separated from the pleura by serum, which prevents the two surfaces from coming much into contact. The best method of distinguishing the slighter variety is to attend to the manner in which it follows the act of respira- tion ; in the true sub-crepitous rhonchus the bubbles break regu- larly, and follow the passage of the air; in the slight friction sound there is not this regularity, and its position is never as permanent; there are besides, generally, some collateral circum- stances, such as the existence of the sub-crepitant rhonchus in other parts of the lungs, which will aid in distinguishing the two sounds. The metallic tinkling is a peculiar sound produced by the escape of bubbles of air from beneath a stratum of liquid, situa- ted in a cavity whose walls are firm and elastic. The liquid must occupy only a portion of the cavity, the upper part re- maining filled with air. It was supposed that the sound was caused by a drop of liquid which fell from the upper surface of the fluid. Dr. Bigelow, of Boston, suggested the explanation which is now commonly received, that the sound is not caused by the fall of a drop, but by the bursting forth of a bubble of air from beneath the liquid. This is the case, but it is not ne- AUSCULTATION. 61 cessary that the air should be driven forcibly through the bron- chial tubes; a very small portion of air contained within the liquid is sufficient to give rise to the tinkling. The sound is called tinkling, because it is somewhat similar to the light tinkle produced by striking with a pin or some other light piece of metal upon a glass vessel. It is always heard in connexion with the amphoric respiration, which depends upon the physical condition necessary to produce it. The sound, therefore, is not of great practical value. The dry rhonchi are the sonorous, sibilant, and the dry or rustling crepitant; the latter of these is of very little value, and hardly differs from the rustling sound of the respiration, to which I have already alluded. They are, for the most part, heard chiefly during the expiration, and are caused by tempo- rary or permanent thickening of portions of the mucous mem- brane of the larger or smaller tubes. In the large majority of cases they are heard in the earlier stages of bronchitis, before secretion has occurred, or in the chronic stages of this disease in which. the secretion is not sufficient to remove the swelling of the membrane. But they may depend on a purely spasmodic state of the bronchial tubes, for there is no doubt that these tubes are occasionally subject to spasmodic action. The sonorous rhonchus is generally very loud and well marked; few can have ever heard it, without recognising it merely from description. It is a loud cooing sound, somewhat similar to that caused by drawing the bow slowly over the bass string of a violin, or to the cooing of pigeons. The sound may be compared most exactly to the note of the violin, but the rhonchus itself is so peculiar from its deep musical tone, and so unlike any other sound heard in the chest, that we can scarcely mistake it. It is most frequent along the upper part of the lungs, both anteriorly and posteriorly, and cannot be produced except in the larger bronchial tubes, for the smaller ones do not yield so deep a note. In acute bronchitis, and even in the chronic cases of this disease, this rhonchus is so fugitive that it sometimes ceases and returns almost with every act of respira- tion. But we can generally find it in some portion of the lungs, although it may not remain long in a single spot. It is, how- ever, not always so moveable. In the numerous cases of secondary bronchitis which attend the diseases of the lungs and various acute disorders, the sonorous rhonchus is frequent, but it is not found in the most severe and dangerous cases of these disorders, or at least not exclusively. It is in all cases a sign of bronchitis, and when not connected with the moist rhonchi, generally indicates a mild form of the disorder. 62 AUSCULTATION. The sibilant rhonchus bears the same relation to the smaller tubes, that the sonorous does to the larger ; it is a low, whistling sound, heard principally, but in general, not extensively, during the expiration. Generally it is very short and variable in situa- tion. Of course we may find it in those portions of the chest where the bronchi are rather small, and, at the same time, are not sub- ject to congestion or accumulation of secretion, — that is, at the anterior margin of the lungs. The sibilant rhonchus is chiefly heard in the various stages of bronchitis without effusion, especially in the chronic dry catarrh, and in almost every case of the secondary bronchitis of typhoid fever. Both these dry rhonchi are easily learned from this descrip- tion alone, for they have a sufficiently close analogy to the sounds which are selected as objects of comparison. Thus the deep bass note and the musical tone are quite characteristic of the sonorous rhonchus, while a whistling and slightly musical sound are equally distinctive marks of the sibilant. The latter rhonchus is even more moveable than the sonorous, and is ex- tremely irregular in its time of re-appearance. The mucous, sub-crepitant, sonorous, and sibilant rhonchi are sometimes heard combined together in a variety of chronic catarrh, attended with asthmatic paroxysms; they were then sometimes called by Laennec the " song of all birds, — cantus omnium avium." More frequently, however, we may find two at least of these rhonchi present at the same time, as the sonorous and sibilant, the mucous and the sub-crepitant; a dry may be combined with a moist rhonchus. This depends upon an obvious cause; the various portions of the mucous mem- brane may be affected to different degrees, and in one part secretion may have commenced, while another remains turgid and dry ; besides the secretions tend to accumulate at the pos- terior and inferior part of the lungs; hence we find the moist rhonchi sometimes in this position, when the same inflamma- tion gives rise merely to a dry rhonchus elsewhere. The rhonchi may also be connected with other physical signs, as the bronchial respiration and resonance of the voice; and it is sometimes a matter of some difficulty to distinguish them. This is especially the case with the bronchial respiration and the sonorous rhonchus; one not accustomed to these signs may easily mistake one for the other when they occur singly; and if combined, the sonorous rhonchus may mask the bronchial respi- ration to an inexperienced observer, for both these signs are chiefly heard during the expiration, and there is a certain de- gree of similarity between them. The only certain distinguish- ing mark when there is a difficulty is to examine the part of the AUSCULTATION. 63 chest by percussion ; if this be flat it will prove that there is bronchial respiration wherever the tubes are large; if both bronchial respiration and sonorous rhonchus are present at the same time, the flat percussion is so far useful that it indicates the more important sign. The chances of error, therefore, be- come extremely small, and are still more diminished if we attend to the musical tone which attends the sonorous rhonchus; this does not characterise the bronchial respiration, which is a pure blowing sound. After having gone through the description of these sounds the reader may be tempted to make the same remark which has often been repeated to me. That is, that the difficulty is not in understanding the description of the sounds, but in acquiring the habit of rapidly and readily recognising them. To be practically useful we must distinguish them with certainty, and we must do this without great loss of time to ourselves, or the fatigue to our patient which necessarily results from a protracted examination. If an inexperienced physician should be tempted to lay too much stress upon his newly acquired knowledge, he may perhaps be induced to fall into the errors against which I have warned the reader at the beginning of this treatise, that is, of trusting too much to physical diagnosis. Now, we must avoid both these errors, and we do this by the same means; that is, by making our diagnosis by the gene- ral symptoms, and merely adding the physical examination to this as a matter of instruction, until we are sure of our own progress. The caution is designed for those who trust chiefly to their unaided exertions ; these are, under ordinary circum- stances, sufficient, though necessarily attended with more trouble, and requiring more time. I shall bear these remarks in mind when describing individual diseases, and will group the physi- cal and general signs together, that one may mutually assist the other. There are another set of symptoms which are not physical, yet are so local in their character that they should be described before you proceed to the study of special diseases; these are the cough and expectoration, which may properly form the sub- ject of another chapter. 64 COUGH. CHAPTER VI. COUGH, EXPECTORATION. Cough is produced in diseases of the thorax from two causes — the accumulation of liquid in the bronchial tubes, and the sympathetic irritation caused in the larynx by pain or stricture in the chest. In the former variety, the cough is useful, and is productive of relief to the patient, in the latter it is often a cause of aggravation of the symptoms. The true excretory cough occurs only in the diseases of the bronchial mucous membrane, and of the parenchyma of the lungs which directly communi- cate with this membrane. The irritative cough takes place not only in the earlier stages of inflammation of the bronchial tubes, and of disorders of the parenchyma and serous membranes which do not communicate with the bronchi, but it is also a frequent dependent upon diseases of the heart, and even of the stomach, and in many cases is caused by disordered condition of the nervous system, which is totally foreign to the chest. It is evident, therefore, that the causes of the irritative cough, are extremely various, and that the cough itself, in many cases, throws but little light upon them. I shall now attempt to define the varieties of cough and of the expectoration, which are closely connected together. The dry or irritative cough. — The term irritative may pro- perly enough be applied to this variety, which is nothing but a short and quick cough, — that is, a short and rapid expiration, which is the essential character of cough. The term dry cough is so well known as the designation of this variety, that it is universally understood. It is followed by no real secretion ; there is sometimes an expectoration of the small quantity of mucus which is naturally found in the fauces and bronchi. The diseases of the lungs in which it occurs, are the early stages of phthisis and certain cases of serous inflammation. It is also an attendant upon the elongation and inflammation of the uvula, and may cease abruptly after its removal. In diseases of the stomach and bowels, and in affections of the mucous mem- branes of the abdomen as well as in peritonitis, the same variety of cough is observed. Indeed, we may generalise the subject COUGH. 65 much farther, and say that the short, dry cough, is the most frequent form of irritative cough, and the most persistent; and that, although in itself it is of no moment, it is often the sign of a commencing disease of the thorax. On the other hand, our knowledge of the circumstances which give rise to a dry cough, must lead us to look for other causes of it than the dis- eases of the chest, — and after our physical examination has taught us that there is no important lesion in the thorax, the next object will be to examine other portions of the body, and ascertain whether some disease of the abdominal viscera, or a mere nervous irritability, will not account for this cough. Sonorous cough. — There is another variety of cough which is not very unlike the dry ; that is, the sonorous cough : this is always loud, and at times very ringing and clear, so as to be heard at a considerable distance from the patient. This variety belongs to many morbid conditions : it is found in the chronic dry catarrh, but chiefly in the earlier stages of ordinary acute catarrh, before secretion has commenced. In its most marked degree, however, the sonorous cough is not indicative of dis- eases of the lungs, but of many and various conditions of this morbid nervous action ; and, as may readily be supposed it is most apt to occur in young girls, who are much more subject than any other class of individuals to diseases attended with deranged nervous action. Hence the cough is very irregular in its indication; and although when it is of recent occurrence and short duration, it is nearly always connected with disorder of the bronchial tubes, — yet, when chronic, it is most frequently either a true nervous cough, or an attendant upon chronic dis- eases of the larynx, especially those in which there is a morbid growth which projects into the rima glottidis, and acts as a con- stant cause of irritation. This cough is therefore rather a matter which must exercise the sagacity of the physician, than a correct indication of any special disease. The suppressed cough is, like the dry, a short cough ; but it is checked by a voluntary effort of the patient; for as the act of coughing is, to a certain extent, independent of the will, a patient may arrest the violent expiration if he be aware that it will cause him much pain ; hence the cough becomes suppressed in serous inflammations of the chest, where there is little or no secretion from the bronchi, and the pain is much more con- siderable than in ordinary cases of disease. In pertussis, the fear of exciting a violent fit of coughing will frequently cause it to be suppressed. In the early stages of pneumonia there is very little secretion into the bronchi; hence the necessity for cough and expectoration is but slight, while the accompanying 66 COUGH. pleuritis, inflammation acts as in cases of simple pleurisy, and suppresses the cough. The laryngeal cough is various in its character; still, as it depends upon thickening or ulceration of the larynx, the tone of the cough is stridulous and somewhat stifled ; at times, al- most whistling. In the advanced ulceration of the larynx, which constitutes laryngeal phthisis, the cough is alternately loud and whistling, and again almost aphonic. This variety of the cough is attended with a peculiar alteration of the voice. The loose, or mucous cough, is well known as the cough which attends the resolution of acute bronchitis, and is therefore of favourable prognosis in this disease ; it is connected with a free secretion into the bronchial tubes, and is of course accompanied by mucous rhonchus, and generally by expectoration. As there are many diseases in which there is an abundant liquid secre- tion into the bronchial tubes, the mucous cough is very far from being confined to bronchitis; it occurs also in the advanced stages of phthisis, in the third stage of pneumonia, haemoptysis, &c. Hence, like most of the varieties of cough, it becomes useful as a sign, chiefly when combined with other symptoms. In certain cases of large cavities from phthisis or gangrene, the cough sometimes is not merely mucous, but it is loud and rattling; that is, as it is caused by the free agitation of the air in a large cavity, it partakes of the characters of the cavernous respiration, and differs in being much louder and more gurgling from the ordinary mucous cough. The spasmodic cough is the last variety of cough which is sufficiently characterised to admit of a separate description. The type of this variety is found in pertussis, in which disease the cough is more decidedly spasmodic than in any other. But there are numerous other cases of disease, especially lesions situated about the larynx, which are attended with a severe cough, returning in paroxysms, and sometimes accompanied with a noisy, whooping inspiration. Although it is most fre- quent in obstructions about the larynx and upper part of the trachea, the enlargement of the bronchial glands will often give rise to it, and the peculiar cough is sometimes a valuable diag- nostic sign in an affection which is always obscure. In certain cases of asthma the cough recurs in paroxysms which are often attended with a noisy inspiration. In general terms, we may state, cough does not bear an ac- curate relation to the extent of the pulmonary lesion ; frequently the cough seems to be almost in inverse proportion to the mass of parenchyma involved in the disease. For if a large portion of the lungs be rendered unfit for the performance of the res- EXPECTORATION. 67 piration, the patient cannot make the forcible expiration neces- sary to produce a decided cough. It is often rather a sign of laryngeal and tracheal irritation, than of deep-seated pulmonary disorder. The cough is of less value as a sign in the aged than in those enfeebled by disease, or than in other patients, for in them it may be wanting throughout the whole course of a grave disease : the same remark is applicable to young children, who cough much less frequently than those who are older. In dis- eases of the lungs in general, the cough may completely cease if the brain becomes seriously involved ; for a cerebral disorder renders a patient unconscious of the irritation, which, under ordinary circumstances, would give rise to severe cough. Secondary inflammation of other organs, as the stomach and bowels, sometimes produces a similar effect, but to a much less degree: this is in accordance with the general pathological law, that a severe intercurrent inflammation will obscure, and, to some extent, replace the symptoms of the primitive affection. THE EXPECTORATION. The expectoration is less frequent in diseases of the chest than the cough ; but its signs are more definite, and in some cases they afford very accurate indications of pulmonary dis- ease. As a general rule, the sputa come from the lining mem- brane of the bronchial tubes, or from the larynx and trachea, and from cavities or softened portions of the parenchyma, which communicate directly with the bronchi. Hence, their value as positive signs is chiefly confined to the diseases which affect the mucous membranes of the chest. The sputa, however, may contain other liquids besides the ordinary secretions of the mucous membranes, such as blood, tuberculous and calcareous matters. The secretion of liquids in the bronchi is necessarily inde- pendent of the will, but the expectoration is a voluntary act. It is performed imperfectly when a person is averse to making the necessary muscular exertion, on account of the pain it may give him, or other reasons; there are no sputa when the feeble- ness of the patient prevents his making an effort. For similar reasons, children below the age of six years do not expectorate ; they do so but rarely until the age of puberty. In very old people the expectoration is rare, and not proportioned to the extent of the disease. When the sputa are not copious, they are chiefly expectorated in the morning, on waking from sleep, during which they accu- mulate in the bronchi. When the sputa are copious, but the 68 EXPECTORATION. expectoration causes pain, they are also retained in the lungs until a paroxysm of coughing comes on, and they are discharged in large quantities. Except in the cases above mentioned, the sputa are rarely wanting during the whole course of a disease, but they do not usually assume their characteristic appearance until the disease is sufficiently advanced to be recognised by the more certain physical signs. In some exceptional cases the sputa are pathog- nomonic, when the physical signs are doubtful, on account of the remote situation of the lesion or the state of the surrounding tissue. 1. Of the quantity of the expectoration. — It is small when it does not exceed a wine-glassful in the twenty-four hours; mode- rate, when from two to six fluid ounces ; large, from six ounces to a pint, and very large if more than a pint. In descriptions of the sputa, it is advisable to state the quantity. 2. Of the colour. — The saliva and the mucus of the bron- chial tubes are transparent; and may be more abundant than usual. A higher or rather more prolonged degree of inflam- mation of the bronchial mucous membrane, gives a whitish colour to the sputa, if the catarrh pass into resolution ; or, if it assume a chronic form, the sputa are yellowish, and frequently of a greenish tinge, and altogether opaque. In acute inflam- mation of the air-vesicles and of the minute bronchial tubes, the sputa are at first transparent and colourless, but soon become tinged of an orange hue, or they are rust coloured, or even sometimes of a bright scarlet colour. In inflammations of the lungs, with great prostration, the sputa are brownish, of a mahogany colour, or like that of stewed prunes. In gangrene of the lungs the sputa are generally of a dull white colour, but sometimes they have a yellowish tinge. In pulmonary phthisis they are in part of a whitish creamy appearance, and in part consist of a thin mucous, or muco- serous liquid. In pleurisy and other inflammations of the serous membrane of the chest, the sputa are comparatively rare, and are usually quite transparent. 3. Consistence and chemical composition.— In general, the sputa, if colourless, are thin and very liquid; those that are yellow and opaque, are thick, and flow less easily. The shining transparent sputa of pneumonia though small in quantity are more viscid than any other, are often heaped up in the centre of the cup, and adhere strongly to its sides. In one variety of chronic catarrh, and in some affections of the tonsils, the matter expectorated is very small in quantity, and almost solid. The sputa frequently consist of two parts, one more EXPECTORATION. 69 solid, and the other nearly of the consistence of water. If much air be mingled with the sputa, they are light and frothy. The chemical nature of ordinary bronchitic sputa scarcely differs from that of the healthy mucus of the bronchial tubes, but if the inflammation be more advanced, the sputa are more opaque, and become more albuminous. The increasing thickness of the sputa is a sign of a tendency to resolution in acute bronchitis, which is but slightly influenced by the mucous expectoration of its earlier stages. When pus is mixed with the mucus, the con- sistence is immediately increased ; the thick pasty sputa which occur in advanced stages of phthisis, in which the softening is very rapid, are very consistent, but adhere together less inti- mately than the sputa of pneumonia. 4. Form. —When the sputa are composed of simple mucus from the bronchial tubes, they run together and form a mass which is perfectly homogeneous, — and when they become albuminous, they offer no peculiar form, but are generally com- posed of two parts — one consisting of the whitish opaque mucus, which, in the form of shreds, is diffused through the mass of the liquid, and the other more transparent. In some cases of bronchitis, especially of the chronic varieties, in which the sputa are more albuminous than in any other, the matter is moulded into the form of the smaller bronchi, and is expecto- rated in little cylinders, which are diffused through the secre- tions of the larger tubes. The viscid, transparent sputa of pneumonia, blend together perfectly well, and form a mass which is often with difficulty separated into smaller parts : and the sputa, both of the early and latter stages of this disease, are so nearly similar to those of different stages of bronchitis, that they can scarcely be distinguished from thern. The form assumed by the expectoration of phthisis is similar to that of bronchitis in its early stages; after softening has been com- pleted, the sputa are moulded in the cavities, and form irre- gular, rounded masses, with loose cottony edges; these consti- tute the nummular sputa ; when the softening is very rapid, the sputa run together, and lose their nummular form. The sputa, in gangrene of the lungs, retain no peculiar form, but vary according to the consistence of the matter in different cases of the disease. 5. Odour. — Transparent sputa are without decided odour ; the thick, yellow liquid has generally a faint, nauseous smell, which is very marked in cases of phthisis. Gangrene of the lungs is distinguished by a peculiar fcetor, sometimes gangrenous, at other times resembling the smell of moist plaster. Occa- sionally, a variety of chronic catarrh and one of tuberculous 70 EXPECTORATION. phthisis, in its advanced stage, are attended with foetid expec- torations. Of the foreign matters mingled with the secretions of the bronchial tubes. — Pus is often intermixed with the mucus secreted in bronchitis, phthisis, and the latter stages of pneu- monia, when the sputa are said to be muco-purulent. Some- times a portion of the pus is uncombined, and sinks to the bottom of the mass. Blood may be intimately combined with the sputa, as it is in pneumonia, when it communicates a general rusty or reddish tinge to them ; or it may be mixed in streaks with the mucus, and still retain its florid red colour ; or, lastly, it may be unmixed with the bronchial secretions, when it con- stitutes haemoptysis. The tuberculous matter may sometimes, though rarely, be detected in the sputa under the form of minute yellowish opaque grains, not often exceeding the size of a pin's head ; this appearance coincides with the softening of the tubercles. In a few cases it is sometimes found in distinct masses. Calcareous matter is sometimes, though rarely, ob- served when the tubercles are dry and contain much of the salts of lime. Portions of gray or dark pulmonary tissue have also been expectorated, after separation from the adjacent tissue. In cases of jaundice or pneumonia, complicated with disease of the liver, the sputa are sometimes tinged with bile. I have seen the expectoration composed almost entirely of pure bile from a fistulous opening between the liver and the lungs, following a wound of these organs. I have confined these remarks on the expectoration chiefly to the text of a short work on physical diagnosis which I pub- lished a few years since. They might be much extended ; but as the subject is one to which I shall be obliged frequently to recur when speaking of individual diseases, I do not wish to annoy the reader with unnecessary repetitions. Still it is essential for us to acquire some idea of the general characters of the expectoration. The best method of examining the sputa is to direct the patient to spit in a white or transparent vessel, — a common tumbler will do well enough for this purpose, — and then inspect them within a few minutes after they are dis- charged. The chemical analysis of the sputa has thus far led to few or no practical results; for the characteristic distinctions between the various forms of mucus, albumen, and pus, are extremely slight. Indeed, it is not necessary for us to inves- tigate, or rather to attempt to investigate, these slighter differ- ences in the expectoration, which were at one time regarded as important. Amongst these, are the numerous tests between EXPECTORATION. 71 pus and mucus, which were sought in order to decide upon the distinctive characters of phthisis and catarrh; all these were found more or less fallacious ; the best are the most simple,— that is, the yellow, purulent colour of the expectoration, when pus is mixed with the mucus, for it is rarely found in a separate state. This very admixture is one of the reasons which must make it impossible to discriminate in all cases, as to the mucous or purulent character of the expectoration. The whole subject is now placed in its proper light; the expectoration furnishes us with a most valuable secondary means of diagnosis, but one less important than many other methods of investigation that have now come into general use. There is another class of symptoms which may be almost classed among the local signs of thoracic diseases, — that is, the mode in which the movement of the chest is performed during the act of respiration. In reference to this part of the course I shall content myself with quoting the observations con- tained in the work to which I have previously alluded. ON THE MOVEMENT OF THE THORAX. In health, the act of inspiration is performed partly by the elevation of the shoulders and ribs, and partly by the depression of the diaphragm. The passage of the air through the nostrils does not cause them to dilate evidently. When the respiration becomes difficult, the different muscles, whose action concurs in respiration, act irregularly, and much more forcibly than in a a state of health. When there is no dyspnoea, without pain in any part of the thorax, all the muscles concerned in respiration act with increased energy. The nostrils dilate widely, the shoulders and ribs are forcibly elevated, and the diaphragm depressed. In acute diseases, the degree of the dyspnoea is nearly commensurate with the extent of the pulmonary affec- tion. In chronic diseases, this is by no means the case. There are even some instances in which there is extreme dyspnoea, but no appreciable lesion of the lungs. When there is acute pain in the sides of the thorax, or at the diaphragm, from in- flammation of the serous membranes, the parts of the chest nearest to the inflamed pleura move less than they do in a state of health. The motion becomes free as soon as the pain sub- sides. If effusion of liquid occur into the pleura or the pericar- dium, the motion of the ribs at the corresponding part is im- peded by the mechanical distension, though there maybe no acute pain. When the liquid is absorbed, and false membranes unite the two surfaces of the pleura, the dilatation of the diseased side 72 EXPECTORATION. is always imperfect. The diminished motion of the side of the chest, most affected in phthisis, depends upon the adhesions produced by the frequent inflammations of the pleura. The number of the inspirations in the adult is generally from twelve to sixteen in the minute, in some persons they may be a little more frequent, as many as twenty ; but when the lungs or the pleura are much inflamed, the inspirations may increase to thirty or forty; and, when the disease is extremely violent, the number may be as high as sixty or seventy. This extreme frequency is most remarkable when all the serous membranes of the chest are inflamed at the same time. In acute diseases, the frequency of the inspirations is at first nearly proportioned to the violence of the affections ; when they have lasted a certain time, the patient seems to accommodate himself to a diminished supply of air, and breathes less frequently. The respiration of children affected with diseases of the chest is very frequent, especially when the lobular pneumonia has extended to a large portion of both lungs. In the state of health even, they breathe more often than the adult. When the extreme frequency of the respiration in acute diseases has ceased, the inspiration re- mains more hurried than usual; sometimes it is performed in as short a time as the expiration — after which a pause ensues. In health, the time required for the inspiration is about twice as long as that of the expiration, both in children and adults. PLEURISY. 73 CHAPTER V. PLEURISY--PATHOLOGICAL ANATOMY--PHYSICAL SIGNS--SYMP- TOMS --DIAGNOSIS--TREATMENT. We now come to the study of individual diseases of the chest. These may occur in the substance of the lungs and heart, or in their investing or lining membrane. The affections of the upper portion of the respiratory system are also closely connected with those of the thorax, and will require at least a passing notice. Both lungs and heart offer an investing and a lining mem- brane, which are more frequently inflamed, or otherwise affected, in connection with the parenchyma, than separately. Never- theless, these inflammations are sometimes met with in an iso- lated form, and it is then that they are most readily studied, afterwards the more frequent, but more complicated forms, may be analysed, and the symptoms belonging to the different parts may then be separated The study of special diseases may begin with the inflammation of the serous or of the mucous mem- branes. In the present chapter I thought it best to deviate somewhat from the ordinary course, and shall commence the study by the examination of the serous membranes. These are the most simple of all the tissues composing the lungs, and the symptoms of many of their diseases are nearly as regular and readily learned as their pathological lesions. Still, in all such cases, we must beware of the difficulty into which an imperfect study of the subject may sometimes lead us ; for in diseases of the chest, more than in any others, a partial analysis, and a limited diagnosis, may become the sources of error. We must prosecute the examination until we have arrived at the know- ledge of all the symptoms ; otherwise the physical signs may limit our views, instead of extending them, and we may rest satisfied with the discovery of a single disorder, instead of taking into the estimate the numerous diseases with which it may be complicated. This is a common error with those who are commencing the study of auscultation ; they are apt to be too well satisfied with a partial discovery of the symptoms, and to forget that many other things may be concealed which a more thorough examination would explain. 7 74 PLEURISY. Pleurisy, as is well known, is an inflammation of the serous membrane involving the lungs ; it is very regular in its progress and symptoms. Like the other inflammations of this tissue, it is sometimes simple and readily diagnosticated, and at other times is singularly complex, or perhaps consecutive to other dis- orders of a different and more constitutional character. For example, it may be connected with tuberculous diseases in several ways: first, tubercle may be developed in the adherent and more cellular portion of the serous membrane, and the in- flammation may directly coincide with this development; in these cases the tuberculous deposit is formed, as it were, by the same process as the inflammation, and apparently by the same action of the vessels. In other cases the pleurisy is consecu- tive to the tubercles already formed in the lungs; in a third variety the pleurisy may attack an individual in good health, and afterwards give rise to the tuberculous deposit, partly from the general shock given to the constitution, and partly from the V determination of the diseased action towards the lungs. This latter variety usually occurs in persons of a tuberculous ten- dency ; but it may prove a purely accidental cause of tubercles, and take place in those whose constitution is not previously tainted by this diathesis. Pleurisy also occurs in a more acute form as a complication of affections of the parenchyma of the lungs, when the latter approach the surface of the organ invested by the pleura. Pneumonia is the disease of the lungs which most frequently gives rise to this form. There are some other lesions producing the same effect, which are, however, of rare occurrence, viz., gangrene and scirrhus; when these approach the surface of the lung, they cause inflammation of the serous membrane, with an effusion of lymph, — this inflammation being in almost all cases preservative, as the adhesion which takes place prevents an effusion of the morbid matter into the cavity of the pleura. We have, then, three principal varieties of pleurisy, — 1st, simple pleurisy ; 2dly, pleurisy complicated with a deposition of tubercular matter ; 3dly, pleurisy complicated with acute lesion of the parenchyma of the lungs. The pathological changes connected with ordinary pleurisy are regular in their progress, and proceed, step by step, with the symptoms, which afford us a means of measuring the inten- sity of the inflammation. The first change which takes place is the injection of the membrane, caused by an enlargement of its vessels, which, in the natural state, do not transmit the red globules of the blood. These vessels are situated in the subjacent cellular tissue, and PLEURISY. 57 are disposed in an immense number of branches, which are interlocked in various directions, and form a complete network. In the midst of this, there are numerous bright red points, appa- rently formed by minute extravasations of blood from the vessels. Almost simultaneous with this increase of vascularity is the development and effusion of lymph. This is at first deposited on the serous surface in minute points, which are transparent and scarcely visible, but may be readily detected by the touch. These points, as they become more numerous, gradually collect into groups, which, finally coalescing, form a continuous mem- brane. This deposit of lymph has received the name of a false membrane, and is more abundant at the lower portions, where it is in some cases as much as a fourth or even half of an inch in thickness, while at the upper portion it seldom exceeds the eighth of an inch. The character and amount of the effusion vary according to the form of the disease, and the constitution of the individual affected. In cases of local pleurisy, especially if occurring in robust persons, the amount of serum effused is very small, while there is a considerable deposit of lymph ; the same also occurs in persons who are not robust when the in- flammation is confined to a small portion of the membrane. On the contrary, if the patient be thin, and of a lymphatic tempera- ment, and the inflammation diffused, the effusion of serum will be very great, with but a slight trace of lymph. The thin and serous part of the effusion tends to diffuse itself over the surface of the pleura, gravitating to the most dependent portion, and shifting its position with the movement of the patient. When, however, it is principally composed of lymph, it is confined to the part of the lung which is affected, and exhibits no such ten- dency. The serum increases in quantity as the disease ad- vances, and decreases with its decline ; but the lymph is more persistent in character, and, instead of being removed, becomes organised, and assumes the character of a serous or cellular membrane, according to the circumstances in which it is placed. When the inflammation continues for a considerable length of time, a secretion of pus takes place, and the serum is entirely replaced by purulent matter. The lymph in this case being bathed in pus, is modified in colour by its assuming a yellowish hue. When the serum is abundant, the lower portion of it is turbid, while the upper portion is clear. This results from the greater specific gravity of the lymph, in consequence of which it settles to the bottom of the fluid. During the recovery of the patient, the following changes are observed to take place. . As the serum is absorbed, the pres- sure of the atmosphere forces the parietes of the chest towards 76 PLEURISY. the lung, and adhesion takes place between the two surfaces of the pleura. As the lung is compressed against the spine, and in that position is covered with a coating of lymph, it remains permanently flattened, and cannot rise to meet the ribs. In those cases in which the pleurisy is slight, and the effusion very small, there is either no contraction of the chest, or it takes place to a very slight degree. The contraction is not entirely permanent; the lung after being compressed, does again ex- pand to a certain extent, and rises partially towards its original form. The adhesions become gradually organised during this pro- cess, and new vessels are formed in the lymph. The particles of blood are deposited in the lymph under form of dots, and gradually collect in trains or streaks ; vessels are afterwards formed around the blood, which then finally inosculate with the Original vessels of the subjacent serous tissue. The contraction of the chest is not great when the serum is but moderate in quantity ; but in cases of abundant effusion, the contraction is equally well marked with the previous distention. The altera- tion of conformation, therefore, is a purely pathological state, which corresponds accurately with the quantity of liquid exhaled. If, therefore, the effusion be limited, it does not produce a very decided dilatation, or subsequent contraction: a less quantity than a pint is scarcely appreciable ; a quart gives rise to a very decided alteration in the shape of the chest, and larger quanti- ties distend it sufficiently to incline the body towards the sound side. In the same way, if the contraction which follows pleu- risy be very great, the body is inclined towards the diseased side. The nature of the liquid is not always the same ; the greatest portion of it consists of serum in the early or inflammatory con- ditions of the disease. This is mingled with flocculi of lymph of various density, which seem to be detached from the surface of the pleura. In the chronic varieties of the disease, the liquid consists almost exclusively of purulent matter, although at first the serum is merely tinged with pus from a small admixture of g obules with it; but as the disease continues, the purulent globules become gradually more and more abundant, until the liquid consists nearly of pure pus : the pleurisy is then often called empyema. It is in these cases that the distention of the chest is greatest. In the early stages of some cases, pus is mixed with the serum and lymph in small quantity, giving the liquid a slightly yellowish tinge; but, as a general rule, it is quite transparent, but of a light greenish yellow colour In a few instances it coagulates spontaneously immediately after PLEURISY. 77 death, becoming a mass of tolerably dense albumen. In a number of cases it contains blood in small quantities, and occa- sionally, although rarely, the proportion of blood is large. These varieties in the exhaled fluid belong to the same disorder, which is in all these cases inflammatory ; but the product varies according to the general condition of the individual's previous health, and other circumstances difficult to discover. In general, the product of inflammation of the pleura, and other serous membranes, is most consistent and most highly animalised; when the patient is strongest, and the disease most violent. These changes are very regular, aud give rise to an equally regular succession in the physical signs. When the inflamma- tion is severe, and the effusions very large, these signs are pa- thognomic of the disease ; but when it is small, the physical characters are so far useful, that they either confirm the indica- tions of the functional signs, or prove that the disease is not advanced beyond a certain point. When the effusion of serum takes place, the sound on percussion is immediately dull, be- coming gradually flat as the quantity of the liquid increases. The flatness is much more decided at the lower than at the up- per portion of the chest, and becomes gradually less in ascend- ing towards the summit; for the liquor of course gravitates towards the most depending portions. Still, the serous effusion is not the only cause of the flatness ; it depends, in part, upon the thick deposits of lymph at the inferior portion of the lungs, and does not disappear entirely when the position of the patient is changed, although a change in the level of the liquid is always attended by a change in the degree of flatness. If the effusion be very large, the flatness gradually becomes more complete, and at the same time extends over the side of the chest, until the resonance is either completely lost, or is limited to a small portion of the chest near the spine, where the lung generally contains a little air. The increase in the flatness enables us to estimate the extent of the effusion with great accuracy ; but the converse of this is not true in its declining stage, — for when the compression of the lung is carried to a great extent, it recovers its elasticity but slowly, and remains either permanently or for a long period in a more solid state than is natural; hence the clear sound returns slowly, and generally never recovers its original sonorousness. A moderate but diffused resonance does not, therefore, prove that the lung has not recovered from the inflammation. The enlargement of the affected side accords with the dulness on percussion, and is always met with when the dull sound is 7* 7S PLEURISY. at all decided. If, in the early stages of the pleurisy, we exa- mine the lower and posterior parts of the chest, we may readily detect slight changes in the conformation ; and this is then ge- nerally limited to 'an alteration of the natural convexity of the thorax, and is scarcely perceptible in the whole semi-circumfe- rence. The quantity of liquid which is sufficient to cause a decided change in the conformation, varies from a pint to several gallons. When it exceeds a gallon, the distension is of course very great. I have, on one occasion, in which the bulging of the affected side was immense, found no less than five gallons in the right pleura. In these extreme cases the healthy lung is compressed towards the ribs of the opposite side, at the same time that the diseased one is forced against the spine, and death usually occurs from suffocation. The semi-circumference of the chest may be measured with a tape on a level with the sixth or seventh dorsal vertebra, in order to give ymi an idea of the changes which take place in the quantity of the liquid ; but this method is of little use except in cases in which the effusion is very large. The position of the heart is another sign which is closely connected with the alteration in the conformation. If the pleurisy occur on the left side, the heart is sometimes forced to the right of the sternum ; if, as is most frequent, the pleurisy attack the right side, the heart is removed towards the left axilla. The respiration in the early stages of pleurisy is always feeble,—that is, if either the pain is tolerably acute, or the effusion at all considerable. But at the beginning, the feeble- ness depends much more upon the pain than the mechanical pressure of an effusion which is still quite small in quantity. When the dilatation of the vesicles in a part of the chest is attended with pain, that portion of the lung becomes to a great degree motionless, and remains so until the pain diminishes. This rule is so general in its application, that if the serous mem- branes of the chest be inflamed, in a great extent, and over both lungs, the patient may perish from the dyspnoea which arises from the inactivity of so large a portion of the pulmonary tissue. The feebleness of the respiration continues throughout the disease in those portions of the lungs in which the bronchial tubes are small; where they are much larger, the respiration becomes more or less bronchial, or at least rude. The intensity of the rude respiration varies very much, and chiefly according to the condensation of the lung; when this is very great, the bronchial respiration is very intense, sometimes quite as loud as in the most severe cases of pneumonia. The condensation of the substance of the lung is, therefore, a circumstance which PLEURISY. 79 favours the bronchial respiration. The density of the effused liquid is another cause of the loudness of the bronchial respi- ration if there be a large proportion of lymph, or a thick, viscid liquid in place of the usual thin serum, the conducting power of the substance which intervenes between the tubes and your ear is increased, and the same result is produced as if the lung itself were inflamed. When there is bronchial respiration in pleurisy, the resonance of the voice becomes bronchial, and you will observe a true bronchophony. This has, however, a peculiar vibration or quivering in its tone, which never exists to the same degree in pneumonia proper. If the bronchial respiration is not so loud, the resonance of the voice becomes less bronchial, but its vibration is increased, and its resonance is termed egophony. This takes place in those cases in which the effusion is but of moderate density, or little more thick than ordinary serum ; and it is heard most distinctly from the anterior portion of the axilla to the scapula, and between this bone and the spine. It is therefore most evident when the bronchial tubes are moderately large, and there is a tolerably strong compression upon the vesicles. The depth of tone of egophony is modified by the density of the liquid more than any other cause ; if the liquid remain thin, the egophony will continue; but in proportion as the density of the lung and of the effused fluid approaches more nearly to that of pneumonia, the resonance becomes more like bronchophony than egophony. When the egophony is perfectly pure, it is less loud, and often less easily recognised than in those cases in which the body of sound is decidedly increased by the hardness of the lung. In certain cases of pleurisy there is little resonance and no vibration of the voice ; this must depend upon the obstructions which prevent the passage of the air through the tubes, and of course destroy the resonance. It is difficult to state what these obstructions are; in some cases they may depend upon the pressure of the liquid upon the tubes, in such a manner as to interrupt the column of air, or upon accidental collections of liquid in them. If the lung-remain soft and uncompressed, it will also give rise to an egophony which is but moderately loud ; the circumstances, therefore, which favour its development, are moderate pressure and a little increase in the density of the tissue of the lung. If the voice be shrill and clear, the egophony is of course much more decided. The friction sound is another sign of pleurisy, which is much more irregular than the resonance of the voice. It occurs under two different circumstances, at the beginning and towards the 80 PLEURISY. termination of the disease, — that is, at those times in which the effused matter consists almost exclusively of lymph, and not of serum; for if there be a large and thin effusion, the friction of the two surfaces of the pleura, which is the essential cause of this sound, will be prevented. When this sound occurs early in the disease, it of course takes place in the variety of pleurisy which may be termed dry, whether it continue in that stage or not; the friction is then very slight, and is inappreciable by many persons ; it is more like the slight noise produced by rub- bing together two pieces of tissue paper than any thing else. When it occurs at the close of the disease, after the absorption of the liquid, it is much louder, and then offers the peculiar character of the true friction sound. This is sometimes quite per- manent, lasting several days, or even much longer. These irregular sounds are not of value for the proper diagnosis of pleurisy ; they are only of accessory importance, and should be recollected by us, because every thing should be known which may become of use under any circumstances. The signs of the lungs, properly speaking, are of great nega- tive importance in the diagnosis of pleurisy. In fact, it is at times impossible to distinguish the cases in which the lung is unaffected, in any other way. If, therefore, we find no signs of pulmonary disease, such as are indicated by the rhonchi and respiration, the case maybe regarded as one of simple pleurisy. But, in order to form this opinion, we must take into the cal- culation both the general and local signs of pulmonary disease ; and even then it will stand good only for the time, for we may be afterwards obliged to modify our opinion. Still, in simple pleurisy, it should be recollected that there are no signs of dis- ease of the lungs, other than those which arise from their con- solidation by the pressure of the liquid. In practice, the com- plicated cases are probably quite as frequent as those which are more simple. In the recovery from pleurisy, restoration to health takes place but slowly, and the lung does not recover its natural respiration for a considerable time ; the sound remains feeble, and the percussion dull: after a very long period, sometimes a year or more, the restoration to the natural fulness and softness of the respiration may take place ; but this is not to be antici- pated in the great majority of cases attended with a large effu- sion in which the inspiration will remain feeble, and we must therefore be satisfied with a slow and gradual improvement. Besides the physical signs, there are other symptoms of pleu- risy, which are, to a certain extent, quite conclusive. These are generally most decided in the commencing stages of the PLEURISY. 81 disease, and they may subside almost entirely, and be almost forgotten by the patient. The diagnosis of the disease is there- fore easiest, by the general symptoms, at its very commence- ment, when the physical signs are most obscure. We are also obliged to rely chiefly upon the rational symptoms in those cases in which the adhesions between the two surfaces of the pleurae are strong, and of course no effusion can take place ; this is always the case in pleurisy which has succeeded to a former severe attack of the same disease. *.- Of these local, but at the same functional signs, the most pro- minent is the pain. This is so acute in many cases of pleurisy, that the ideas of pain and pleurisy are very firmly associated in the minds of most persons, and they are apt to believe that all cases of pleurisy must be attended with pain: this is an error; for the pain may either be totally absent, or may be so obscure as scarcely to attract attention ; it is then limited to a mere sore- ness along the portion of the chest most affected. When there is severe pain, it is almost always felt near the nipple; it is acute and lancinating, similar to that caused by the prick of some sharp instrument; hence it is in many languages called a stitch in the side. It is increased by motion, cough, or even respiration. When the inflammation is very sudden and exten- sive, the pain may be agonising, and for a time effectually check the respiration. A large quantity of effused liquid rather dimi- nishes than increases the pain; and when it becomes very large, as in very chronic cases, the pain is often limited to a mere sore- ness, which is often seated in the loins, instead of the thorax. This seems to depend upon the great weight of the thick puru- lent liquid. In diaphragmatic pleurisy, especially when caused by rheumatic or gouty disease, the pain is difficult to localise, and is generally wandering about the lower part of the thorax, causing more distress than other varieties of the disease. We see, therefore, that the pain is an important symptom of the disease when it exists, but that it is never lasting in the slow and moderately severe cases of pleurisy, and may be either en- tirely absent or badly characterised throughout the disease. The cough is another local symptom : this is generally pre- sent in the milder cases of pleurisy, and is always short and almost insignificant. If the inflammation be very acute, the cough is almost entirely suppressed ; and even in moderately severe cases, it is in a great degree checked by the aversion of the patient to make the strong respiratory movement necessary to produce a full cough. It is not attended with expectoration in the simple inflammation of the pleura, for there is of course no secretion to be thrown off externally, unless the substance of 82 PLEURISY. the lung or the bronchial tubes are involved in the disease. Hence many of the remarks which we may find in some of the older writers upon this subject, are in reality applicable to pneumonia, and not to pleurisy. The more chronic the disease becomes, the less disposition is usually felt to cough, so that in cases of extensive empyema, there is often no cough. The mode in which the respiration is performed is sometimes of importance. In the beginning of the disease, when the pain is severe, the patient breathes chiefly with the healthy lung: this arises from the pain which is caused by the act of respira- tion, as well as coughing. When the disease is more advanced, the mechanical pressure upon the affected lung will prevent its expansion. Hence the patient throughout the disease breathes chiefly by the healthy side. The decubitus in pleurisy is sometimes of importance. When there is pain, you may state in general terms, that the patient does not lie upon the affected side, which is extremely sensi- tive to pressure. Even late in the disease, he will prefer the sound side, or the back; but when the effusion is so great that the weight of the liquid would press upon the mediastinum, and thus prevent the expansion of the healthy lung, he will naturally prefer lying upon the diseased side, and will thus re- lieve the lung which remains in a state fit for the performance of its proper functions. The rational as well as physical signs which I have just de- scribed, are those which belong to pleurisy considered chiefly as a local affection. There are many other symptoms which appertain to it in common with other inflammations of the serous tissues. These phlegmasia? present a number of charac- ters similar to those of other inflammatory affections, and some that are nearly peculiar to themselves. In general, the serous tissues, like other membranes, modify the ordinary characters of inflammation, rather than offer others which are strictly novel. At the commencement there is usually a chill, which varies in intensity from a slight sensation of coldness to a complete chill. This is generally felt at the same time with the pain,— that is, the pain in the chest seems to excite the chill; it may return at several different times throughout the disease ; but it then rarely offers the same intensity as on the first day. The chill is followed, of course, by heat, and by sweating, which occurs at irregular times, and is never very copious. During the disease the fever is generally persistent, and is characterised by a quick, tense, but rather small pulse. This is often called the pulse of inflammation of the serous tissue; and although PLEURISY. 83 not regularly present in all cases of these diseases, it is found in a large proportion of them. The sweats in pleurisy are some- times extremely abundant, especially in the varieties of the dis- ease that are complicated with a tuberculous development; but even in simple inflammation of the pleura they are sometimes extremely copious, and form a harrassing and alarming symp- tom. In empyema, the nature of the fever approaches the hec- tic type, and almost always assumes it when the operation of paracentesis has been performed, and a free communication is made between the external air and the purulent collection. In the latent form of pleurisy the fever may be quite moderate, rather a slow febricula than a perfect fever, and this is one of the causes which render this form of disease extremely ob- scure. The secondary irritation and inflammation of other viscera, which are so frequent in the inflammations of the mucous mem- branes and the parenchymatous organs, are very slight in pleurisy and serous inflammations in general. The disturbance of the alimentary canal is strictly proportioned to the intensity of the fever, and not to the gravity of the inflammation, which pursues a course almost unconnected with the viscera of the abdomen. The strength and the cerebral functions are usually just so far affected, as naturally results from the severity of the pain and the degree of fever; they are, in themselves, very little dis- turbed by the inflamed pleura. Hence pleurisy is a remarkably simple disease, if it be the primary affection; it frequently oc- curs as a complication, but has little power to give rise to dis- order of other tissues. This is explicable enough when we reflect upon the simple structure and few nervous relations of the serous tissues. There is, however, one exception, that is the tuberculous diseases, whose development is sometimes singu- larly favoured by pleurisy. The diagnosis of pleurisy is readily enough made in most instances : a well characterised case is always certainly known, and can be confounded with no other affection. That is, when the distension of the chest, the dulness on percussion, and feeble or bronchial respiration, coincide with dyspnoea, pain, and fever. If we restrict our diagnosis to the functional signs, we shall, of course, be somewhat puzzled in many cases: but with the aid of the physical signs, all decided cases can be mistaken for nothing else. In the slighter cases, where there is little or no physical change, this is not always the case : pleurisy may be confounded with pleurodynia, or simple rheumatic pain in the intercostal muscles and the adjacent fibrous tissues. The fever is a very uncertain test; but it has a collateral value, for it is 84 PLEURISY. more apt to accompany true pleurisy than simple pleurodynia. The nature of the pain is a better one ; for, in pleurisy, this is, to a certain degree, limited, and almost always is found about the anterior margin of the axilla ; but in pleurodynia it shifts about, and is often found on both sides at once ; very frequently it disappears for a time, but soon returns, displaying in this re- spect the peculiar changeable character of rheumatic disease. When severe fixed pain occurs during the course of inflamma- tory rheumatism, we need not trouble ourselves about the diag- nosis, — for in such cases there is almost always something more than a mere rheumatic pain, and the pleura is positively, though perhaps slightly, inflamed. As a general rule, therefore, if in the suspected pleurisy the pain is at all constant, we may regard it as a true inflammation. The mobility of the pain is therefore the only good proof of pleurodynia. There is no difficulty in distinguishing between simple pleurisy and pneumonia, or other diseases of the parenchyma of the lungs, with pleuritic complications; for the signs of true pulmonary disease are of course wanting in the one case, but present in the other. The inflammation of the pericardium frequently occurs in connection with pleurisy of the left side, when it is sometimes extremely difficult to recognise it; for the signs of one disease, to a great extent, obscure those of the other. If the pleurisy attack the right side, the distinctive characters of the two disease's are quite evident. In simple pleurisy our prognosis is almost always favourable if we see the patient rather early in the disease ; if the effusion is very large, or if the disease be chronic, it is then quite doubt- ful : the mortality is totally different under these circumstances. In the secondary pleurisy, or in that variety which is accompa- nied by tuberculous disease, the prognosis is of course much less favourable. When it precedes tubercles, it usually ends in recovery, but afterwards phthisis will occur. The treatment of the ordinary pleurisy,—that is, of the dis- ease as distinguished from those in which pneumonia plays the most important part, is based upon well established grounds. It is strictly antiphlogistic,— and, as in other inflammations of the serous membranes near the surface of the body, it is most effectual when we use local depletion in combination with or in addition'to general blood-letting. The latter remedy, how- ever, is always productive of great relief in the cases which begin with strong inflammatory symptoms, — that is, much pain and dyspnoea ; there is, then, no substitute for it. After we have taken a moderate quantity of blood, however, and have relieved the pressing symptoms, the indications are then PLEURISY. 85 rather to continue the treatment by local depletion and by dia- phoretics than repeated general bleeding. Cupping or leech- ing to the painful parts, repeated if necessary, two or three times, is then the best remedy. The effects of local bleeding are much more prompt in serous than in mucous inflammations, or in diseases of the parenchyma of organs. Cups or leeches may be repeatedly applied in either acute or chronic cases; but we will gain most from them if we choose the moment when the pain is most acute ; it will then often yield very quickly, and the disease improve after free local bleeding. There are several other local remedies which are effectual in relieving the pain and inflammation besides cupping and leeching; these are warm poultices of hops, sprinkled with a tea-spoonful or two of laudanum, and kept warm by plac- ing over them a bottle or tin vessel filled with hot water, which should lie on the bed by the side of the patient. The narcotic acts with considerable energy upon the part, and its action is favoured by the warmth and moisture. In slight pleuritic pains, as well as in the true pleurodynia, sinapisms are eminently useful; but they are of little benefit in severe pleurisy. This is not the case with blisters, which belong to that established class of remedies whose virtues have been tested by the experience of many generations; they-are used with two objects in view — to relieve the inflammation, and to favour the absorption of the effused fluid. While the inflam- mation is still advancing, the operation of blisters is uncertain, and sometimes seems to be positively injurious; but after the active inflammatory symptoms have been checked, they are productive of decided benefit, and are perhaps, of all remedies, those whose action is most unquestionable. The acute pain often subsides immediately after vesication, and the absorption of the effused liquid sometimes takes place very rapidly. The rapidity of absorption is not generally proportioned to the quan- tity of the serous secretion from the blister, although in a few cases a very copious discharge will pour from the vesicated surface, and the pleuritic effusions may disappear in a few hours. In chronic cases of pleurisy, blisters are amongst our most valu- able remedies; but they should be small and very frequently repeated. My own plan is, not to make them larger than two or three inches square, and to apply them every two or three days, dressing the surfaces with simple cerate ; you should, in this way, pass over a considerable part of the affected side by applying these small blisters successively to different parts of it. When the pleurisy has been entirely or nearly removed, the 8 86 PLEURISY. patient often complains of slight returns of the pain from expo- sure to damp, or to a cold wind. The only way of guarding against these slight returns of the inflammation is to cover the affected side with a Burgundy pitch plaster, and to direct your patient to clothe himself warmly. These, then are the directly depletory remedies, and such as act as local counter-irritants. The internal remedies suited for the treatment of pleurisy are numerous, and applicable either to different cases of the disease, or different stages of the same affection. They may be divided into three principal classes : — 1st. The antiphlogistic remedies, which are intended to relieve the inflammation, and check the fever. 2d. The reme- dies that promote absorption, which, however, are often fitted at the same time to check the inflammation. 3d. The anodyne, which may relieve the pain. Of course, in a strictly inflam- matory disease, the first class of remedies, and those which belong both to the first and second classes, are the most impor- tant. The tartarised antimony has long been used both in simple pleurisy, and in the disease complicated with pneumonia ; it is usually given as a diaphoretic, in the doses of a fourth to the eighth of a grain, — rarely in larger doses. In these doses its nauseating influence is but slight. In the early stages of pleu- risy, free diaphoresis is a powerful therapeutic agent, — but in the more advanced cases, sweating is productive of compara- tively little benefit; its good effects are most evident in those stages of the disease in which resolution is practicable before there is much effusion into the pleura; that is, it is a means of depletion from the vessels, and exercises comparatively little influence in promoting absorption. In chronic cases of pleurisy the tartar emetic should either be given up altogether, or restricted to very minute or merely alterative doses. The tartar emetic is almost the only remedy which is nearly exclusively antiphlogistic in its action ; most other internal remedies are more powerful from a combined action in promo- ting absorption, and checking inflammation. The most impor- tant are mercury, nitre, and digitalis ; squill and colchicum are also powerful remedies, and act like most other diuretics of a moderately stimulating character. Of these the most efficient is mercury. Mercury, given in moderate doses, so as not to disorder the bowels, produces two distinct effects ; one is directly antiphlogistic, the other is the influence which it exerts upon secretion and absorption. In the treatment of pleurisy in its active inflammatory stage, the first action of mercury is that which is most beneficial; in the advanced cases of purulent effu- sions, the inflammatory character of the disease is less marked, PLEURISY. 87 and the action of the mercury is chiefly limited to the absorp- tion and elimination of the effused matter from the body. In the more acute cases we may give mercury more rapidly, in the chronic cases more slowdy. Thus, I would advise a quarter of a grain to half a grain of calomel to be given every four hours, if we design it as an antiphlogistic : it will then produce its specific effect in a short time, and the disease will generally decline. The mercurial treatment is, of course, but a sorry substitute for blood-letting, which it should follow and assist, but not replace. If the mercury be used towards the decline, or in the advanced periods of the disease, when our object is more to promote absorption, than to remove the inflammation, we should give the calomel in much smaller doses, that is of an eighth or a sixth of a grain three or four times a day ; this ope- rates but slowly, and is much more effectual in increasing the power of other alteratives than larger quantities. The mercurials are usually combined with other remedies, which will work, as it were, in the same direction with them. Thus, in the early stages of the disease, Dover's powder, or the simple opium and ipecacuanha, may be given with them; if full diaphoresis is brought about by these means, the disease is more easily subdued. The Dover's powders should be given in doses of about three grains every four or five hours. The opium and ipecacuanha should be given in doses of a quarter or third of a grain of the former, and one grain of the latter. In the advanced stages, digitalis, and nitre, act admirably as diuretics. Digitalis should be given in doses of a grain of the powder three times a day, or the half ^of a grain to be taken more frequently. The tincture of digitalis may be given in doses of ten drops, three or four times a day. The nitrate of potash should be given in solution of it in flax-seed tea, in the proportion of about one drachm to a pint of the infusion. There are cases in which others of a more stimulating kind, as the juniper berries, or spirits of nitre, come in well; but these are chiefly such cases as approach very nearly to hydrothorax : there is then a feeble condition of the economy, and but little active inflammation. The diaphoretics of a vegetable kind are, like many other remedies, adapted for various stages of pleurisy. In the early stages, full diaphoresis acts admirably as an antiphlogistic remedy, while in the advanced stages it may increase in absorption, and remove the effused fluid. The latter effect is, however, very uncertain : for the disease naturally tends to produce sweating, and the perspiration seems an abortive attempt on the part of nature to throw off the disorder, — the 88 PLEURISY. curative action being quite disproportioned to the diseased one. Anodyne remedies in the treatment of simple pleurisy, are merely palliative, and, are therefore, rarely given alone. They consist almost entirely of some form of opium, except in those cases in which the patient is unable to take any preparation of this drug ; we are then compelled to resort to various substi- tutes. We must not, however, suppose that opium is insig- nificant, or of no value, because it is simply a palliative ; for in pleurisy, as in other inflammations, the relief of pain prevents the increase of the disease, and is indirectly one of the effectual aids towards its cure. The only objections to its employment are to be found in those cases in which the cure takes place chiefly by secretions which must be thrown off from the body : this is not the case in inflammation of the serous tissues, for in these the liquid is necessarily retained until it can be removed by absorption and the adhesion of the coagulable lymph. There is, then, no permanent therapeutic contra-indication to the use of the opiates ; if the skin be dry, they should be given in the form of Dover's powders, from eight to twelve grains of which may be given in divided doses during the day. If the sweating be copious, morphine will, as a general rule, be the best remedy, administered chiefly at night, in the ordinary doses of an eighth to a quarter of a grain. This is sometimes necessary for a con- siderable period. When we find the pleurisy nearly well, but the patient still complaining of some dyspnoea, or a little feverishness, and we discover on examination, that a portion of the liquid remains unabsorbed, nothing; is so efficacious as a journey, with its necessary consequence, change of air. Although the sea-air is not always adapted to pectoral diseases, it is often of decided advantage in chronic pleurisy, especially if combined with a voyage. But a course of this kind is necessarily attended with no little expense and inconvenience, and is totally beyond the reach of many of our patients: we will be obliged to resort more frequently to land journeys, as a less troublesome and sometimes as efficient a course. This is generally the surest means of dissipating the remains of the disease, and insuring a restoration to entire health. Of course, the usual hygienic pre- cautions as to the dress, should be adhered to. There is no disease in which the treatment is more influenced by a knowledge of its symptoms and pathological relations than pleurisy ; for, simple as it is, the success in chronic cases, depends chiefly upon steadily watching the physical condition of the chest, and persevering in our care until the disease is entirely dissipated. PLEURISY. 89 VARIETIES OF PLEURISY. Besides its simple form, pleurisy presents many varieties which are for the most part connected with various structural alterations of the lungs, or with peculiar symptoms of the dis- ease itself. I have already giving a passing notice to several of them; but they require something more, as they constitute the most difficult cases of the disease. There are also other varieties of the disease which differs from the usual form, but at the same time are not connected with an important change in the substance of the lungs; that is, latent and chronic pleurisy. These are sometimes closely con- nected together; thus, latent pleurisy with large effusions is almost always chronic, but chronic pleurisy is not necessarily latent. The same is not the case, however, at the commence- ment of the disease, for pleurisy may then assume the character of a latent disorder, and be even attended with a considerable effusion without showing the usual symptoms — but the large effusions of pus which are latent, and unattended with the usual symptoms always belong to the chronic variety of the disease. I shall first allude to the variety of it which follows a primitive acute pleurisy. It is difficult in many cases to say what renders an ordinary acute pleurisy chronic ; sometimes it is evidently a badly treated case of acute pleurisy, and the inflammation continues, although some of its symptoms may cease. At other times the inflam- mation has either entirely resisted the ordinary remedies, or it has recurred after having nearly ceased. Both of these varie- ties present the same symptoms ; the physical signs are similar to those of acute pleurisy, but there is evidently an increase in quantity and weight of the effused liquid ; hence the promi- nence of the chest, the displacement of the viscera of the abdo- men and thorax, and the flatness of the chest, are all much more decided than in ordinary pleurisy, while the bronchial respiration, as well as the egophony, gradually ceases. I have already stated that the general signs of acute pleurisy, such as the inflammations, fever, and severe pain, may gradually dis- appear ; but the fever is apt to recur, and changes its type, either resembling hectic very closely, or becoming perfectly identical with it. The fever is one of the most troublesome and alarming symptoms of this variety of pleurisy; for in other respects the patient does not suffer in a manner proportioned to the extent or the duration of the effusion. I once saw a patient who had performed the full duties of a sailor, going aloft, &c, 8* 90 PLEURISY. with an enormous pleuritic effusion ; when he returned from sea, it amounted to two or three gallons. This is an exceptional case; but it is very frequent to find patients who can perform many laborious occupations without much inconvenience : it is generally the case if the dyspnoea be not severe, and you will find that some patients complain of little difficulty of breathing with an extent of pectoral disease which will give rise to great distress in other individuals. The symptoms which so frequently characterise chronic organic diseases, are extremely variable in this variety of pleurisy: these are emaciation, loss of firmness of muscles, harshness and dryness of the skin, and slight oedema of the legs. Sometimes they are nearly as well marked as in tuberculous disease of the lungs, — in other cases they are very slight; hence they constitute a diagnostic sign of the disease, and if we find them well characterised, we will do right to regard the case as one probably complicated with tuber- cles ; if our impression be erroneous, we will soon rectify it, as the symptoms will gradually become more decided in the latter case, and slowly disappear if the pleurisy be followed by recovery. The diagnosis of chronic pleuritic effusion is often quite im- possible without the physical signs, for its symptoms are some- times nearly similar to those of phthisis. When the physical signs of the disease are present, there is no difficulty in ascer- taining it; if it be complicated with tuberculous deposit, the case should be regarded as one of great danger, and our diag- nosis is, as we shall afterwards see, much more difficult. I have already alluded to the prognosis in this variety when speaking of ordinary pleurisy; it is always doubtful, if the effu- sion be very large, for the liquid then consists nearly of pure pus, and of course the irritation caused by it may be sufficient to produce marasmus, and perhaps deprive the patient of the strength necessary for a cure. The disease may occasionally though rarely, prove fatal, from the mere obstruction to breathing. The liability of the disease to give rise to secondary tuberculous deposit, after the absorption of the pus, is also to be taken into our account: this forms a variety of the tuber- culous pleurisy, in connexion with which I shall presently treat of it. There is another way by which chronic pleurisy may terminate fatally, — that is, by producing metastatic abscesses in parenchymatous organs, as the lungs or liver; this result is, however, not common. The treatment of chronic pleurisy differs so little from that of the acute variety, that I have treated of it at some length in connexion with the latter disease. The inflammation is in both PLEURISY. 91 cases essentially the same: but, as it has become chronic, it requires chronic remedies, adapted to protruded cases: as a general rule, these should be such as are at the same time antiphlo- gistic, and favour the absorption of the pus. But in usingthese remedies we must not commit a common error, and attempt to force nature through a process which is essentially a slow one : thus, if we subject the patient to what is called a vigorous treatment, we rather impede than favour the cure, and the strength may fail in the attempt. It is on this account that I advise the repeated application of small blisters, warm clothing over a large portion of the body, which is a mild, but powerful means of counter- irritation, and the careful administration of the mercurials and other remedies favouring absorption. Sometimes tonics are ne- cessary in very old pleurisy, as in other diseases in which there is an abundant suppuration ; for the strength may fail at the critical point when the largest demands are made upon it. In these cases, the essential remedies are the chalybeate prepara- tions, which we may use from time to time, and occasionally, either combine or alternate them with the vegetable tonics; but as the influence of the latter is much stronger in restoring the state of the digestive functions than in producing a decided alterative effect upon the general system, they are rather secon- dary remedies. I have already alluded to the good effects of travelling, and even of a sea-voyage in the treatment of chronic pleurisy. There is another cutaneous tonic and alterative which may be properly combined with them,— that is, stimulating baths, especially the sulphur and salt-water baths. These are gener- ally taken at natural sources, by resorting to the sulphur springs or sea-bathing. They are much more powerful and more safe, taken warm, than cold, especially if we use the artificial baths. But sea-bathing, or bathing in cold sulphur-water, is sometimes, though rarely advisable as a mere tonic, when the patient is simply debilitated, and the inflammation has subsided; they are always remedies which require some caution in their management. In chronic pleurisy it frequently becomes a question whether the operation of paracentesis should be practised. This is, as is well known, one of the most simple operations in surgery, and no one can meet with the least difficulty in performing it, — but, at the same time, it is often very serious in its conse- quences. There is a rule in surgery which is here strictly appli- cable ; that is, that the exposure of a large suppurating cavity to the air, necessarily excites hectic fever, and sometimes favours the development of secondary abscesses. The chances of recovery are not, therefore, on the whole increased by the 92 PLEURISY. operation, — and it is one which we should not perform, unless it be to relieve excessive dyspnoea, which may in itself be severe enough to threaten life. LATENT PLEURISY. This is another variety of the disease : like all latent inflam- mations, it is not indicated by the usual functional signs. These are in pleurisy, pain, cough, dyspnoea, and fever, all of which may be either wanting, or so obscure as scarcely to attract notice. When the disease is slight and latent, it passes through its stages without notice, and the patient usually forgets the trifling indis- position under which he may have laboured ; it is in this way that adhesions are so frequently found in the pleura? of persons who have no recollection of the symptoms of the previous inflam- mation. When the latent pleurisy is more severe, it gives rise to more decided symptoms ; but these are very slow in their progress and formation, and increase very gradually, producing a disturb- ance of the general system, attended with slow wasting of strength and slight fever, rather than with any symptoms which point de- cidedly to the local inflammation. A disease which begins in this way is necessarily an obscure one, and may imperceptibly attain a degree of severity which will either render it fatal of itself, or as is much more frequent, give rise to other disorders, especially of the tuberculous kind. Indeed, many cases of tuberculous pleurisy are in their nature more or less latent; for the pecu- liarity of latent pleurisy consists merely in the absence of the ordinary local signs; it may or may not be complicated with tubercles. When these are found in pleurisy, the symptoms are generally less distinct than in the ordinary varieties, but not in other respects very different. The diagnosis of latent pleurisy is of course more difficult than that of any other variety of the disease. It depends upon the physical signs ol the local mischief, and the evidence of general disorder of the economy. When the disease is attended, as it often is, with considerable effusion, there can be no diffi- culty in deciding as to its nature, provided all the physical signs can be detected, — that is, the dull or flat percussion, feeble respiration, and egophony: if the friction sound be pre- sent, it is of course still more evident. But if the signs be limited to the mere feebleness of respiration and dulness of per- cussion, we must take care not to confound the disease with an enlargement of the liver, or a chronic consolidation of the lung. As a general rule, however, the physical signs of latent pleurisy are tolerably well marked in all severe cases, when we compare FLEURISY. 93 them with those constitutional symptoms which are commonly caused by the disease. These generally pursue the following order: — a patient previously in good or passable health is taken with a slight chill, which is sometimes so short that he is scarcely conscious of its occurrence ; this is followed by a slight fever, increasing a little towards the close of the day, but rarely severe enough to destroy the appetite ; this is, however, a little diminished, whilst the thirst and dryness of the skin are rather increased. There is often a slight hacking cough, but the ex- pectoration is altogether or nearly wanting. The strength of the patient is a little enfeebled, but not enough to prevent him from attending to his ordinary business. These symptoms are so slight that most patients are totally unable to localise their disease; this is indeed so difficult that I have known several experienced physicians, who were labouring under this affec- tion, without being able to make a positive diagnosis in their own case. If we remember, therefore, that latent pleurisy is rarely im- portant, unless it be discoverable by the physical signs, — for in no other case does the effusion take place to any great ex- tent, — we will rarely meet with much difficulty in recognising the disease. The common source of error is in distinguishing between it and pulmonary phthisis, which is sometimes exces- sively difficult, for the one may often be complicated with the other. This is particularly true of tuberculous pleurisy, in which there is an actual deposit of tubercles, either in the pleurae, or the lungs, and yet the ordinary symptoms of pleurisy are present. As this subject rather belongs to phthisis than proper pleurisy, I do not wish at present to enter more at length into this matter. It is one of those things which are most diffi- cult to describe; the diagnosis depends upon a number of cir- cumstances, which, in themselves, are unimportant, and acquire value only from their combination. The prognosis of this form does not differ from that of other varieties of the same disease,—that is, of those which are equally chronic ; and except in the cases in which the disease passes into the tuberculous form, it generally terminates favour- ably : if it be long neglected, however, the disease is sooner or later transformed into pulmonary phthisis. The treatment of latent pleurisy does not differ in any respect from that of the ordinary chronic forms ; and I need not, there- fore, repeat what I have already sufficiently entered into. The treatment is continued until all physical signs of the disease are passed away, and the general healthy appearance of the patient is entirely restored. 94 PLEURISY. SECONDARY AND COMPLICATED PLEURISY. Pleurisy is secondary to many other diseases : these may be either the affections of the lungs proper, or of the economy in general. When pleurisy occurs during the course of a disease of the lungs, it is most apt to develope itself w-hen the external portions which are nearest to the serous membranes are affected : thus, pneumonia, gangrene, and phthisis, which are the diseases most frequently followed by pleurisy, are often not complicated with it until the disease has advanced from the central parts of the lung, where they generally begin, to the surface ; hence the pleuritic stitch or pain may not be felt until a comparatively late period. As a general rule, all affections of the lungs which approach the pleura, will give rise to pleurisy, which is the surest safeguard against perforation of the pleura. These cases of secondary pleurisy are generally classed with the diseases of the parenchyma with which they are connected; for these are much more important disorders. The treatment is especially directed towards the pleurisy only so far as it is designed to remove pain. In other respects, the same mode of treatment which is proper for the removal of the inflammation of the paren- chyma, will usually relieve the disease of the serous membrane. The serous inflammation may occasionally prove more severe than the parenchymatous disorder ; thus, there may be but little disease of the substance of the lung, and rather a large effusion into the pleura: this variety is then called pleuro-pneumonia, and it becomes very little else than a pleurisy aggravated by the pulmonary disease. The tuberculous pleurisy is a disease of some importance: in certain cases it is consecutive to the tuberculous deposit in the parenchyma of the lungs, and is then strictly secondary; in another class of cases the tuberculous deposit takes place in the pleura, and is followed by the inflammation ; and in a third the inflammation occurs in an individual who is previously in good health, or at least free from evident tuberculous disease of the lungs, which does not occur until the inflammation has taken place. The first two varieties belong exclusively to the subject of pul- monary phthisis ; the latter is rather a cause than a consequence of it,— hence it merits some notice in this place. The third class, observe, I divide into two subdivisions, — in one of them, the tuberculous disease of the lungs occurs after the pleurisy has lasted for some time, or the effusion has perhaps been partially or entirely absorbed. It is difficult to say why a simple pleurisy should be more frequently followed PLEURISY. 95 by tubercles than pneumonia, yet such is the fact; or at least there are many cases of pleurisy in which neither attentive ob- servation nor careful reasoning can lead us to suspect the occur- rence of tuberculous disease during the active period of the in- flammation, although it is developed in its declining stage or at its close. If I were to hazard a theory, I should say that the singular analogy between the irritative fever from pleuritic in- flammation with purulent effusion and that resulting from the acute tuberculous disease, shows that there is a close alliance between the two kinds of morbid action. This explanation, however, even if its correctness were perfectly proved, does not entirely solve the difficulty ; but it is certain that the very dif- ferent ways in which tubercles accompany pleurisy, prove that the mere absorption of pus will not account for it in a large pro- portion of cases, although the transmission of the purulent fluid through the system must be more or less deleterious, and, like all enfeebling agents, it will break up the constitution, and favour tuberculous diseases. The second mode in which tubercles seem to arise from pleu- risy is probably rather more frequent than that which I have just described; the pleuritic inflammation occurs in healthy indi- viduals, or those who are apparently healthy; and in the serous membrane as well as in the coating of coagulable lymph or false membrane, we find a great number of minute granulations of various size, some barely visible, others of the diameter of half a line or a line, each surrounded by a beautiful net-work of vessels passing to them. The granulations are, as a general rule, most numerous where the vessels are most developed, al- though this is not invariably the case. In this variety, it would be an abuse of reasoning to conclude that the tuberculous granulations had existed in a latent state, and were followed by the serous inflammation ; for they are, for the most part, equal in size, and evidently of extremely recent origin, some of them often appearing in the false membranes, which are necessarily consecutive to the pleurisy. There is, of course, something besides the pleurisy ; for all cases of inflammation do not give rise to tubercles, although the exciting causes of the disease, when complicated with them, are the same as of ordinary in- flammations. This variety of pleurisy has been little noticed by writers ; indeed, we will not, I believe, find that its true value as a cause of tuberculous disease of the parenchyma of the lungs, is anywhere pointed out. The varieties of tuberculous pleurisy which are consecutive to pulmonary phthisis, belong more properly to the history of 96 PLEURISY. the latter disease than to that of pleurisy proper. The other anomalous products which occasionally take place in the lungs are often complicated with pleurisy; and in a few rare cases we shall find that the cancerous or melanotic substance is se- creted with the serous inflammation: this disease is similar in many respects to tuberculous pleurisy, but possesses little or no practical interest. BRONCHITIS. 97 CHAPTER VII. BRONCHITIS--ACUTE VARIETIES — SIGNS AND TREATMENT OF ACUTE VARIETIES--BRONCHITIS OF THE OLD--CHRONIC VA- RIETIES --PECULIAR VARIETIES. Having concluded the subject of pleurisy in its various forms, I might now pass to that of pneumothorax, as in this affection the same membranes are involved ; but inasmuch as bronchitis is of more frequent occurrence, and, like pleurisy, in very many cases complicates or gives rise to affections of the parenchyma of the lungs, I think it comes in very well in this place, and I shall therefore now proceed to treat of this disease. The term bronchitis is, in common parlance, applied to various affections of the respiratory organs, as laryngitis, several affections of the lungs, &c.; but it should never be used in this way by physi- cians, as it is vague and unphilosophical. The term should be confined to inflammation of the mucous membrane of the bron- chial tubes. Bronchitis, like all other inflammations, is divided into acute and chronic. The acute has been subdivided in reference to the greater or less quantity of the secretion, and its epidemic or sporadic nature. The first division is of very little importance; but the second is well founded, as the disease is much more serious when it occurs in an epidemic form. In the epidemic bronchitis, to which the name influenza has been given, the severity of the constitutional symptoms is by no means propor- tioned to the intensity of the local lesion, — the latter in many cases being very slight, while the former are sufficient to con- fine the patient to his bed for several days. The constitutional symptoms are pains in the back, &c, high fever, and extreme prostration. We have no opportunities of examining the anatomical lesions in simple acute bronchitis, as the disease is seldom or never fatal. On this account we can only study them in cases in which it is secondary to other grave diseases, and in these cases we often meet with every stage of bronchitis. In this disease the mucous membrane itself is chiefly involved, and not the subjacent tissue, as is the case in serous inflammations. The 9 98 BRONCHITIS. lesions observed are injection of the mucous membrane, ecchy- mosis, thickening, and induration. The last mentioned lesions may perhaps occur in primary acute bronchitis, although it can- not be demonstrated ; but in cases where the affection is second- ary to some other disease, we frequently meet with it. The lesions are found to be more marked in the minute than in the large bronchial tubes, although the signs of inflammation of the larger tubes may have been very decided before death. In anemic patients, the mucous membrane, instead of present- ing increased redness, is found to be pale ; the only change which is perceived is that the membrane becomes more opaque, while, in a healthy state, it is almost transparent. This appear- ance is not at all uncommon in persons whose blood is deficient in red globules at the time of the occurrence of the affection. . In acute bronchitis ulceration rarely takes place, although it is by no means infrequent in the chronic form of the disease. In the more acute variety it is almost entirely confined to those cases which have a specific character, such as bronchitis, com- plicating rubeola and variola. In these cases the ulcers are at first confined to the follicles, although they sometimes extend themselves until these acquire an irregular outline, involving the surrounding membranes. Ulceration affects principally the trachea and larger tubes, where the follicles are well developed, and rarely extends to the minuter ramifications of the bronchial tree. I shall not dwell upon this lesion at present, as it does not deserve much attention in this place. There is, however, another modification of much more importance, viz. the effusion of lymph and formation of false membrane. This form of in- flammation which has been termed diptheritis, occurs also in severe cases of croup. It is not met with in the usual forms of the disease, but occurs chiefly at particular seasons and in cer- tain localities. When bronchitis commences in the small tubes, and extends upwards towards the larynx, it is sometimes though not fre- quently fatal; but when it follows the opposite course, begin- ning at the larynx, and extending downwards, it may be ar- rested, and the disease will almost always terminate favourably. Inflammation of the bronchial mucous membrane is in some cases attended with a serous effusion, which, occurring under the membrane, gives rise to oedema: when this takes place in the upper portion of the larynx, it constitutes oedema of the glottis. Bronchitis tends, in most cases, to get well without the formation of pus. Its progress is as follows: at the com- mencement of the inflammation the membrane is injected and thickened, and its secretion is arrested. An increased secretion BRONCHITIS. 99 then takes place, which is intended by nature to relieve the turgescence of the vessels: if the inflammation continues, the secretion then becomes opaque; if it be not arrested at this stage, but still goes on, purulent globules are mixed with the mucus, and in more protracted cases pure pus is secreted. The expectoration, however, is never found to consist of pus alone, because, although certain parts of the membrane secrete pure pus, yet before it is expectorated, it is mixed with mucus from other portions. Bronchitis may occur as a primary disease, or as secondary to some other affection of the lungs. When it occurs as a pri- mary affection, it may either terminate in perfect recovery, or may give rise to the development of some lesion of the paren- chyma of the lungs, such as pneumonia or phthisis. The for- mer is the more common termination, but the latter is not un- frequent. In other cases the bronchitis supervenes on one of these affections, which may promote it or rather involve the bronchial tubes with the parenchyma. This distinction is of the greatest importance in forming a prognosis ; for when the disease is secondary, it is merely a part of the tuberculous disease ; when it precedes this affection, it may proceed to a certain length, and the tubercles may then be arrested. We now come to the signs which indicate acute bronchitis. These may be divided into general and local. The general signs are febrile excitement, with its attendant symptoms of enfeebled strength. The local signs are cough, expectoration, soreness of the chest, with the physical changes in the respira- tory sound. In treating of the local signs, I shall first consider those connected with obstructions to the passage of air through the tubes. The sonorous rhonchus is generally heard in the first stage of acute bronchitis : it is produced by the thickening of the mucous membrane of the larger portions of the tubes, which contracts their calibre, and thus impedes the passage of air through them. I described this rhonchus in a previous chapter, and pointed out its distinctive characters. As it often occurs first at the root of the lungs, where bronchial respiration is loudest in pneumonia, we may, without we are attentive to the distinctive characters which I laid down, mistake it for the latter sound : it is important to bear this in mind. The sono- rous rhonchus is heard in the larger tubes; but when the in- flammation extends to the smaller tubes, a sibilant rhonchus is produced, which is caused by the same physical condition as the sonorous, but differs from it on account of the smaller calibre of the tubes in which it occurs. 100 BRONCHITIS. Although these rhonchi are very frequent, yet if we expect to meet with them in all cases of acute bronchitis, we will be egregiously mistaken, because the thickening must reach a cer- tain point before the sound is developed, and therefore if it does not proceed thus far, no rhonchus will be heard. Feeble- ness of respiration is a more constant sign in bronchitis : it re- sults from the air not passing freely through the tubes ; but, like the rhonchi themselves, this sign is extremely variable, shifting from one portion of the lung to another, as it is temporarily in- fluenced by the efforts of breathing, which force the air into the lungs, and for a time clear the tubes. In this affection, the chest sounds perfectly clear on percussion in the first stage; it, however, becomes somewhat dull in the second, but the altera- tion is very slight. In the second stage of the disease, secretion takes place into the bronchial tubes, which gives rise to the moist rhonchi, mucous and subcrepitant. The former, like the sonorous rhon- chus, is produced in the larger bronchial tubes, — the latter in the smaller. The mucous rhonchus is not, however, constant, but it appears and disappears in various portions of the lung, even after the patient expectorates freely, and it will only show itself, and that too, afterwards, in the slighter turns of the disease. In some cases in which there is an abundant secre- tion, the moist rhonchi, both mucous and sub-crepitant, are almost always permanent, and they usually extend through the whole or a great part of the lungs, never ceasing entirely, notwithstanding the patient has expectorated with some fa- cility. The sub-crepitant rhonchus resembles very much the crepitant, which is peculiar to pneumonia: this renders the diagnosis somewhat difficult, as the cases in which it occurs, simulate pneumonia very much. When, however, the bron- chitis is of considerable extent, it does not resemble pneumonia so closely, for the latter disease scarcely ever extends to a large portion of both lungs, as is often the case with bronchitis. After the secretion from the mucous membrane occurs, the thickening subsides, and the respiration gradually returns to the normal state, but, for a time, it may be more or less mixed with moist rhonchi, — that is, the mucous and sub-crepitant. These gradually cease as the resolution of the disease ad- vances. The expectoration in acute bronchitis is very variable : at first, as the cough is dry, there is little or no expectoration; but as the disease advances towards resolution, or passes into a more chronic variety, the expectoration becomes much more abundant, and consists of sputa which are almost peculiar to BRONCHITIS. 101 this disease. When the disease is still slight, or if it remain stationary, the sputa are generally transparent, and consist merely of thin mucus. As soon as it tends decidedly towards resolution, or if, instead of tending towards resolution, it as- sumes a sub-acute form, and becomes chronic, the character of the sputa changes, — they become more thick and opaque, and of a whitish colour. If the disease be very intense, a small quantity of purulent matter is sometimes mixed with the sputa, and they assume the muco-purulent character. In these cases their form is irregular, and the thicker portion is generally dif- fused in irregular shreds through the thinner part. As the dis- ease declines, the sputa gradually become less and less abun- dant. If the inflammation be very violent, the secretion from the bronchial tubes becomes almost of the consistence of coagulable lymph, and is firm, and moulded into the form of the bronchial tubes ; these tubes, or polypi, as they are sometimes called, indicate a high degree of inflammatory action. The general signs of primary acute bronchitis, differ but little from those of other forms of the disease, such as the chronic, &c, but the general signs are somewhat different, — they are generally very well developed in epidemic cases, and are very slight in the sporadic. The patient is first taken with a chill, which is followed by febrile excitement, thus resembling other inflammations, as well those of serous membranes and of the substance of the lungs, although it is of much less intensity. The patient, then, has slight fever, and sensations of chilliness occurring at different times, restlessness, heat in the palms of the hands, &c. The condition of the pulse is in perfect cor- respondence with the moderate fever, rarely exceeding eighty or ninety in the minute. In epidemic bronchitis the condition of the patient may be very different; the pulse is often small, compressible, and frequent; there is great prostration and dis- turbance of the nervous system ; and, consequently, the tole- rance of loss of blood is much less than in serous inflammations. There are other symptoms depending upon the febrile excite- ment, such as anorexia, thirst, and headache. There is another set of symptoms which is secondary, and belongs to affections of the other tissues, principally the serous : of these the inflammations of the pleura is the most common, producing pain, which is increased during the act of inspiration. The pleurisy which sometimes though rarely supervenes on, or complicates bronchitis, is very slight, and is usually dry ; when the pleurisy is considerable, it is looked upon a.s a pri- mary disease, of which the bronchitis is a complication. This accidental pleurisy may prove a cause of death in certain cases; 9* 102 BRONCHITIS. when, for instance, there is hypertrophy of the heart, or when the patient is loaded with fat, it produces this catastrophe by increasing the dyspnoea which usually attends bronchitis, when it attacks the same individuals. The danger in these cases arises chiefly from the pain which impedes the respiration : in simple bronchitis the pain is slight, and often limited to a mere soreness. Acute bronchitis generally lasts but a few days, and its ter- mination is in most cases favourable. It sometimes, how- ever, runs into the chronic form. This may depend upon the peculiar susceptibility of the patient to inflammation of the mucous membrane, or the unfavourable hygienic circumstances in which he is placed. In some cases it leads to the develop- ment of tubercles in the lungs ; this, most commonly, is owing to a decided tuberculous diathesis of the individual affected with it. The diagnosis of acute bronchitis is generally quite easy. Beginning, as the disease generally does, as an acute affection, it can only be confounded with pneumonia or pleurisy. In some cases, indeed, bronchitis is merely the commencing stage of the pneumonia, which soon marks its symptoms, and then becomes the principal affection. The distinction between these diseases, is to be looked for partly in the expectoration, which is very different, and then in the absence of the characteristic signs of pneumonia,— such as bronchial respiration and crepi- tant rhonchus. In pneumonia, too, the patient is generally very ill, and obliged to keep his bed, but in bronchitis he is still able to walk about his room, if not to get out of doors. There is sometimes, however, a difficulty in distinguishing cases in which the bronchitis is extensive and is followed by a limited pneumonia, but in these cases, the last distinctive marks must be sought in the characteristic physical signs of each of those affections. The distinction between bronchitis and pleu- risy is in general quite easy, — the symptoms of the two affec- tions, as well as the physical signs, may be totally different. Phthisis, in some cases, is with difficulty distinguished from bronchitis ; much attention must be given to the general symp- toms of the two disorders, and the progressive emaciation and the frequency of the pulse will generally point out those cases of phthisis in which the physical signs are not very evident. WThen there is much physical obstruction at the summit of the lungs, the case is evidently phthisis, although it may be implicated with catarrh, that is, with slight bronchitis. The prognosis of bronchitis is, as a general rule, quite fa- vourable; there are, however, exceptions, to this rule. These occur chiefly in the aged and in young children. We there- BRONCHITIS. 103 fore always feel more uneasiness about the disease when it is seen in an aged person; it is in this class of individuals, how- ever, more dangerous, because it is apt to terminate in pneu- monia, than from any immediate symptoms in the acute forms. In young children, the danger depends almost entirely on the same disposition to inflammation of the parenchyma of the lungs. As a general rule we may state, that when the oppres- sion is but moderate, and the expectoration continues to be free, there is little danger with the aged. In children, if we find the respiration continues free, we know that there is but little danger ; but when the oppression becomes considerable, the child is almost always on the point of passing into pneumo- nia, a disease in which the prognosis becomes much less fa- vourable than in ordinary catarrh. The treatment of bronchitis is simple, and will occupy us but a short time. We find in the books generally, a regular course laid down for the treatment of this affection, — the first step of which is, in severe cases, the abstraction of blood. Bleeding is unquestionably a most useful remedy ; but it should not be prescribed for all patients indiscriminately, for the milder cases get well very rapidly without it. We should only resort to it in severe cases, for there are other means by the use of which we may cause the disease to abort. These consist chiefly of the nauseating and stimulant expectorants and diaphoretics. In most cases I prefer the vegetable diaphoretics, aided by hot pediluvia, and generally make use of an infusion of eupatorium and sanguinaria, or eupatorium and seneca, after the following formula: R. Eupator. Perfol, gss. Rad. Senegse, 5'ss. M., et infunde in aq. bull. Oj. A tablespoonful or two may be given every hour, or a larger dose less often. Ipecacuanha and tartarised antimony produce a decided effect on the disease. The latter is not always well borne, and ought to be used in large doses only in severe cases, as it may cause much irritation of the stomach. I give it usually in very small doses, sometimes in lemonade or neutral mixture, the object not being to excite severe nausea, but to produce a sedative effect. Dr. Physick has the credit of originating a remedy which was much used in this city some years ago. It consists of tartarised antimony gr. ij., bitartrate of potassa ^ij., dissolved in one quart of flaxseed tea, to be taken in divided doses, in the course of twenty-four hours. This remedy is not altogether safe ; for if the patient should drink a large quantity of it through mistake, it would probably produce very unplea- sant symptoms, as tartarised antimony diffused in a large quan- 104 BRONCHITIS. tity of any fluid is very apt to bring on violent inflammation of the mucous membrane of the alimentary canal, though the quantity taken be not very large. It may be advantageously combined with opium. Some give a dose of opium alone in the commencement of the affection; — I prefer, however, a combination of this kind, which produces diaphoresis, and often affords very speedy relief. You may give a fourth of a grain of tartarised antimony, with one-sixth of a grain of sulphate of morphia, or you may vary this to suit the case. When the disease does not subside at once, after active treat- ment, the patients generally ask something for their cough. In these cases many cough mixtures are used, most of which are beneficial in their effects. They contain a narcotic, nauseating, or stimulating ingredient, and sometimes a combination of these, commonly mixed with mucilage of gum arabic, which fulfils the indication of allaying the irritation about the throat. A remedy in very general use is the Brown mixture, the composition of which every one is well acquainted with. Another common mixture is one, of the syrups of seneca and squills, to which opium may be added if necessary ; but you should be very cautious about giving opium in mixtures to children, as the accumulated effect of repeated doses may arrest the secretions, and produce other dangerous results. Certain stimulants are frequently given with advantage towards the close of acute cases, and are very useful in the chronic forms of the disease ; these are gum ammoniac, balsam of Tolu, balsam of copaiba, &c. The precautions necessary to be observed in convalescence, are the same as in other acute diseases. The general indica- tions, therefore, in the treatment of bronchitis, are, if possible, to bring about a cure of the disease by resolution ; this rarely takes place without a secretion of mucus from the membrane. Hence, if you prevent the fever and local inflammation from running sufficiently high to impede secretion, either by blood- letting, or nauseating, or stimulating diaphoretics, you produce nearly the same effect. After this object is attained, the local stimulants which tend towards the lungs favour very much the secretion of mucus, which is almost essential for the removal of the disease. There are several circumstances which modify this affection to a considerable degree. The most important of these is age, — the bronchitis of children and of old men being very differ- ent from this disease as it occurs in adults. BRONCHITIS OF CHILDREN. The bronchitis of children is particularly interesting ; it ex- tends usually from the trachea down to the tissue proper of the BRONCHITIS. 105 lungs, involving the whole mucous membrane of the large and small bronchial tubes. Its chief peculiarity is its tendency to pass into lobular pneumonia ; indeed, if the bronchitis continue for a considerable length of time, this affection is almost cer- tain to supervene. Secretion takes place very early, and con- sequently the dry rhonchi do not make their appearance, or continue for so short a time that they escape observation: this is another point in which it differs from the affection as it occurs in adults. As the smaller bronchial tubes are usually affected, we almost always find the subcrepitant rhonchus, which can be heard at all times, for children do not expectorate, but throw off the accumulated secretion by an effort of vomiting or simply swallow it. The chest usually gives a clear sound on percussion, though it is sometimes rendered dull by the accu- mulation of mucus in the small tubes, and of blood in the tissue of the lungs. These signs are more marked, and more early developed in the right lung, which is more commonly the seat of pneumonia than the left. Besides the physical signs, we meet with a loose cough, orthopncea, and flushing of the face ; the redness, instead of being circumscribed as in the case of adults, extends over the whole face, and is of a purplish colour, which is to be ascribed to the imperfect aeration of the blood. There is also at times great febrile excitement, with cerebral symptoms. The treatment is also modified by the age. In bronchitis attacking adults, bleeding from the arm is the best means of depletion, — while in children its advantages are very ques- tionable, and it may sometimes be positively injurious. Local depletion is decidedly preferable. Children, who have passed the age of two years, may be treated by general bleeding; but before this age, it should almost never be practised. I have very rarely found it necessary to bleed an infant suffering with disease of the chest; indeed, in these affections I only bleed as an exception. Nauseating expectorants are the remedies which have been found most generally beneficial in these affections. Among these, ipecacuanha holds the first rank; this is given in the form of a wine, or, what is still better, a syrup. When much mucus is present in the tubes, it is sometimes useful to give it in doses sufficient to produce vomiting, thus favouring the ten- dency which already exists ; by this act the mucus is thrown off, and it is the only way in which children can rid themselves of it, as they cannot expectorate. It is generally, however, used in small doses, which act upon the skin and other secre- tions without producing much nausea. Antimonial wine is also 106 BRONCHITIS. used in the treatment of this affection, but I prefer the wine of ipecacuanha in the greater number of cases. Ine tormer is a more powerful remedy, and in very severe cases more reliance can be placed on it, but it is, on the other hand, more liable to induce inflammation of the mucous membrane of the stomach and intestines. Squills is also a remedy in common use in the pectoral affections of children, and is usually kept in families in the form of syrup. In cases which do not yield at once, we have recourse to other remedies as adjuvants, such as mild sinapisms applied to the chest, legs, and ankles. A very good one is readily prepared by wetting a cloth with vinegar, and sprinkling it with mustard ; blisters I do not consider to be so efficacious as the milder stimulants long continued. Another very important point in the management of this affection is, that the child be not suffered to remain too long on its back, as this position promotes the development of lobular pneumonia, in consequence of the mucus gravitating to the inferior portion arid accumulating in the small tubes, which renders aeration imperfect, and thus favours if it does not pro- duce, the congestion of the lung which ends in pneumonia. The child should not be allowed to lie on its back for a longer period than two hours. This direction may appear to be trivial, but it is of much importance, for I have known death to occur from a neglect of this precaution. As regards the quantity of blood, one or two ounces may be taken from a child under two years of age ; as a general rule, an ounce for a year will answer very well. In judging of its immediate effect, we must be guided by the paleness of the patient, and not by the pulse. Sometimes a very small loss of blood produces a very decided effect upon children ; therefore they should not be leeched or bled except under our imme- diate inspection, for cases of death from leech-bites, have often occurred among them. Cups are better than leeches, after the child has passed the age of seven years. BRONCHITIS OF OLD MEN. The bronchitis from which those advanced in age so fre- quently suffer, is an affection presenting much variety of form. In the first place, it varies as regards the affected portion of the bronchial tubes. It sometimes atttacks the smaller tubes, and then it sfimulat.es pneumonia. Indeed, it is often called peri- pneumonia notha. The patient suffers excessively from dyspnoea, which is much worse when he already labours under emphysema, or any other disease of the respiratory organs, which of itself BRONCHITIS. 107 occasions a difficulty of breathing. The treatment of this affec- tion varies according to the condition of the individual attacked by it, and the form of the disease which it assumes. If the patient be robust, and we are called early, wTe will find it advantageous to resort to pretty free depletion from the arm. Great caution, however is necessary in the use of this remedy after the disease has advanced to a certain point. As a general rule I think it best to abstain from blood-letting except at the earlier periods of the disease. When secretion has taken place, and the patient is reduced in flesh and strength, the bleeding often causes dyspnoea by preventing free expectoration. Vegetable emetics, in small doses, and expectorants, especially those of a stimulating nature, are the most valuable remedies in these cases; and in this disease you will again find that the senega is one of the best expectorants of its class. If the patient be weak and debilitated, some carbonate of ammonia must be added to it; but the balsam of copaiba does not answer so well in this variety. If I were to select the diseases in which carbonate of ammonia is decidedly useful, I should place the bronchitis of old men and feeble subjects at the head of the list. The ammonia keeps up the strength of the patient, and pro- motes the natural process of cure ; that is, evacuation from the bronchial mucous membrane. It therefore acts directly upon the affected part; blisters and sinapisms exercise a much more indirect influence upon it, and do good rather as revulsives in removing the inflammation, and as stimulants to the nervous system, than as direct curative agents. In some cases of bronchitis there is a viscid secretion with deposit of lymph, which causes great dyspnoea on account of the formation of a membrane in the tubes ; sometimes this mem- brane has a tubular form, and these tubes have been ridicu- lously termed bronchial polypi. This formation I have observed more frequently in old persons than in children. It causes dyspnoea by protecting the mucous membrane of the tubes from the contact of the air, and by obstructing the passage into the air-cells. The lymph is detected by its presence in the expec- toration, as well as by the orthopncea. Emetics and expec- torants, as those of a nauseant or stimulant kind, are appropriate to this disease, according as inflammation is present or not; but mercurials which are the most efficient of all known medicines in preventing the formation of lymph, are sometimes required, if the affection be highly inflammatory. 108 BRONCHITIS. SECONDARY BRONCHITIS. Although acute bronchitis is in many cases an idiopathic affection, it also occurs frequently as a complication of other diseases. Almost no acute disease attended with fever is entirely exempt from it; and as a general rule, the degree of fever is proportioned to the frequency and severity of the secondary bronchitis. It is thus an almost invariable attendant upon measles, typhoid fever, and in fact many of the exanthe- matous diseases. The secondary inflammation is most frequent at the same season of the year as the primary bronchitis ; that is, in the early spring, and in the winter months, when febrile diseases are peculiarly liable to this complication. There are also many chronic diseases which singularly favour the develop- ment of acute bronchitis; these are diseases of the heart and of the lungs. I have already alluded to the connexion of this disease with tubercles ; this is the variety most difficult of recognition, but scarcely more frequent than the acute bron- chitis which occurs during the course of the chronic variety, or in emphysema. In these cases the distress and difficulty of respiration are much greater than in the simple form of the disease. The treatment of this variety of the disease is similar to that of the acute idiopathic bronchitis, and consists in the use of depletion, stimulants, expectorants, and diaphoretics. After the secretion from the mucous membrane has set in, local deple- tion may be used according to the necessity of the case. Cups are more beneficial than leeches, as they produce greater irrita- tion with a smaller abstraction of blood; they are generally applied between the scapulae. Stimulants applied externally often produce a good effect; sinapisms, and other remedies of this kind are usuallly placed upon the anterior portion of the thorax. They act as counter-irritants. CHRONIC BRONCHITIS. I have still to speak of the chronic and specific varieties of bronchitis, and shall commence with the chronic. Chronic inflammation of the serous and mucous membranes may originate in two ways: 1st, it may be chronic from its commencement; 2dly, it may follow acute inflammation, which frequently passes into the chronic form. The latter is the more common in the case of bronchitis. Chronic bronchitis presents several varieties: the common BRONCHITIS. 109 chronic mucous catarrh ; chronic catarrh, with a thin glairy secre- tion ; and the dry catarrh, with thickening of the bronchial mucous membrane. There is another form described by some authors, viz. the pituitary ; but this is very rarely met with so strongly characterised as to be distinguished from the second variety, or chronic catarrh with a glairy secretion, and there- fore it may be considered as a mere modification of it. The first variety, or the common mucous catarrh, is the most common. It is characterised by a secretion of white mucus, sometimes puriform, generally in irregular shreds, and but rarely moulded to the form of the tubes. It consists of mucus rendered albuminous or purulent in the progress of the inflam- mation. The febrile excitement in this affection is various, being sometimes very decided, but in a majority of cases com- paratively mild. It is usually greater at night than during the day. The appetite, and other constitutional symptoms, vary very much. The diagnosis is based upon the presence of certain physical and functional symptoms, and the absence of other physical signs which are found in analogous affections of the chest. The positive signs are, in the first place, the rhonchi; these are of the moist variety, and vary very much, the subcrepitant being heard at one time, and the coarse mucous rhonchus at another. The respiration is sometimes loud and rough, at other times fee- ble; the latter state is much more common. These are the positive signs. Our diagnosis is rendered certain by the absence of signs which other diseases of the chest always present. Thus, it is distinguished from phthisis by the absence of flatness at the summit of the lungs, (which we almost always find in this affec- tion,) and of the bronchial or cavernous respiration. Although these signs are absent in the commencement of the affection, we not unfrequently find them supervene after it has continued a certain time, as chronic bronchitis is often a precursor of phthisis. This change in the condition of the lungs is shown by consti- tutional as well as local signs. An increase of febrile excite- ment takes place, and the patient becomes more emaciated. Emaciation sometimes occurs without the supervention of phthisis; from the alimentary canal being involved, and from the febrile excitement; but this is of rare occurrence, and'we scarcely ever meet in our practice with cases in which the diag- nosis is rendered obscure on this account. After the tubercu- lous disease has taken place, it is exceedingly rare that the patient recovers. Sometimes the change that is about to take place seems to be indicated by the constitutional signs before the development of tubercles has occurred, by the febrile ex- 10 110 BRONCHITIS. citement, by the other symptoms being decidedly increased, and by a change in the complexion and countenance. This is a time when a correct diagnosis is of very great importance, as a proper plan of treatment may retard or prevent the develop- ment of a disease which is almost always fatal. Treatment. — The treatment of this form of chronic bronchitis is somewhat similar to that pursued in the acute varieties. General blood-letting is not often indicated ; but the abstraction of small quantities of blood, by means of cups, often repeated, produces very good results ; the cups are usually applied in the axilla, between the scapulae and under the clavicles. If the disease at any time assumes a more acute form, general bleed- ing comes in very well. Leeches are sometimes used, but cups are preferable on several accounts ; they produce a greater degree of irritation, without so great a loss of blood, and are cheaper and more convenient. Counter-irritants to the chest are very good adjuvants. These are numerous, and various in the degree of irritation they produce. I generally prefer the milder ones, such as Burgundy pitch, croton oil, &c, which being applied over a large surface often produce, I think, a better effect than blisters and tartarised antimony, which must be limited to a comparatively small portion of the chest. Lini- ments of a stimulating character have been much recom- mended ; these consist of ammoniacal and terebinthinate mix- tures. The noted empiric St. John Long, was in the habit of treating thoracic diseases solely by applications of this character. Flannel worn next to the skin, and woolen stockings to the feet, are essential as adjuvants. As internal remedies the stimulant expectorants should be used, except in those cases in which the disease approaches the acute form, when the antiphlogistic and sedative medicines are much more effectual. These are ipecacuanha, tartarised anti- mony, &c. Of these I prefer the ipecacuanha, as it is much milder in its action, and more easily borne than tartar emetic, which, after it has been employed for a few days, is apt to affect the mucous membrane of the stomach and intestines. In the more chronic cases the balsamic expectorants are employed with great advantage. Of these the balsam of copaiba is the most efficient, but it is a very disagreeable remedy, and cannot be taken by persons who are at all dyspeptic. The success in the employment of the remedy with patients of this class de- pends very much upon our mode of administering it. The fol- lowing formula is a very good one: BRONCHITIS. Ill R. Balsam Copaibae 3j vel 31J. Tinct. Cardamom. Comp. gii. Gum. Acac. q. s. Aq. Menth. Svss. M. d We should commence with half a drachm of the balsam in 24 hours, which quantity is to be gradually increased up to one or two drachms in the same period. If it produces much purging after administering it for some days, its use must be stopped, as this is an evidence that it has made an impression on the system, or we may sometimes arrest this by adding a few drops of laudanum to this mixture. This remedy is only to be re- sorted to when others have proved ineffectual, as it is exceed- ingly disagreeable to the patient. There are other remedies of a milder nature, which can be taken with more facility; they are generally given in the form of syrups or lozenges. Most persons prefer the former, as they have been accustomed to the use of cough mixtures, which are generally in the form of syrup. Syrup of seneka is one of the best in the very chronic cases ; syrup of ipecacuanha is also frequently used, and many prefer a combination of the two, which answers a very good purpose. I often use a combination of seneka and Prunus Vir- giniana, or seneka and sanguinaria, but more frequently the former. The following formula is one which I generally pre- scribe : R. Senegae. ? -- z • • r aa ^ss Prun. Virgin. 3 3 Aq. Bullient. Oj. M. Macera per horas xij, dein cola et adde saccharum album, q. s. This quantity may be taken in two days, and in the manage- ment of the disease is a most effectual remedy. Gum ammoniac is a remedy much used by some physicians, and in its action nearly resembles the balsam of copaiba. Assa- foetida is also an excellent expectorant, but its taste is objec- tionable to many adults; it may be given in the form of lac assafcetidae. For children it is peculiarly adapted. Opium, as a remedy in bronchitis, has many advocates, and it is certainly very beneficial in some cases; but I am very cautious as regards its employment in those affections for the relief of which a secretion is necessary. I only use it as a means of procuring sleep when me cough is troublesome at night, espe- 112 BRONCHITIS. cially when there is much irritation about the trachea and larynx. If we prefer the form of lozenges, one of the best prescrip- tions will be that of the balsam of Toluy which may be made into lozenges, each containing from half a grain to a grain of ipecacuanha, to which a small portion of morphine may be added if necessary. The next point in the treatment is the hygienic condition under which the patient should be placed. And here the ques- tion occurs, should the patient be confined to the house or not? I would not, as a general rule, enjoin this upon him ; but where there is a certain degree of acuteness in the symptoms, I think it necessary. In other cases he would lose much by keeping within doors in mild and pleasant weather, although during the cool, damp weather which is common in the spring, he should by no means expose himself. We should therefore direct our patient to take gentle exercise in the open air in good weather, unless he should find it to disagree with him. A sea voyage to a warmer climate will often remove a bron- chitis of long-standing; but it is often very inconvenient for the patient, and in many cases it is not in his power to try it. In proportion as the disease becomes more and more chronic, the patient may increase the amount of exercise, and endea- vour to stimulate the muscles and the skin, arid thus produce a general but mild revulsion from the interior organs. This treatment is not only of great service in removing the bronchitis, but it is the best means of obviating the danger of pulmonary phthisis. The rules as to clothing and warmth are obvious enough; the great secret of the treatment consists in diffusing the action and nutrition throughout the muscular and tegu- raentary tissues, and thus giving to the bronchial mucous mem- brane an opportunity of regaining its normal condition. The medicinal treatment is more complex ; but if we separate it from the hygienic management, it will be found to be less efficacious than the latter. The second variety of chronic bronchitis resembles the pituitary catarrh of Laennec. It is distinguished from the preceding by several peculiarities. It does not usually follow the acute affection, but commences with its peculiar characteristics. It generally occurs at irregular periods; but in many individuals it takes place at regular seasons; in this climate usually at the close of the summer, about the month of August. It is quite frequent too in Great Britain. The local signs of this affection consists of the various rhonchi, both dry and moist, the lafter being found usually at BRONCHITIS. 113 the lower part of the chest, the former in the upper portion ; there is, however, a predominance of the moist rhonchi over the dry, and of the sibilant and subcrepitant over the coarser varieties, as the smaller tubes are more affected than the larger. Sometimes all the rhonchi are heard at once, and produce a singular confusion of sounds, to which Laennec has applied the term omnium avium cantus. In some cases the air cells are dilated, which renders the respiration feeble, and gives rise to much dyspnoea, resembling asthma, and indeed it may be set down as one of the varieties of this disease. The dyspnoea complicating the affection, however, more frequently arises from thickening of the tubes preventing the passage of the air into the vesicles. These attacks of dyspnoea are sometimes perma- nent, sometimes transitory. The fever attending this variety of bronchitis is very slight, and there is very little emaciation. When this disorder assumes a periodical character, and oc- curs at a particular period, it lasts several weeks, and in gene- ral cannot be cut short by treatment. The duration of this variety of the disease is less than that which occurs at irregu- lar intervals, and it resembles in many respects the more ordi- nary forms of acute catarrh, but is much more intractable. Treatment. — Bleeding in a majority of cases is not well borne ; but when the symptoms are acute, it may be prescribed with advantage. The remedies to be used are those which are calculated to relieve the dyspnoea. These are principally the nauseating expectorants, of which I think lobelia to be decid- edly the best, given so as to produce slight nausea; it thus favours secretion and expectoration. Balsam of copaiba is also a very good remedy ; but the same objections apply here as in the other forms of bronchitis. Venetian turpentine has been very much used, and is an excellent remedy. In the periodical form of the affection, after the paroxysm has commenced, no treatment has yet succeeded in cutting it short. There is, however, one point which demands our atten- tion, viz., the prevention of the occurrence of the paroxysm. In one case for which I prescribed cold affusions and the ex- hibition of quinine, previously to the attack, the disease ap- peared much later than usual, was milder in its character, and its duration was much less. Dry Catarrh.—The third variety is perhaps as frequent as either of the others, and is by a strange contradiction in terms called dry catarrh, because there is little or no expectoration, differing in this respect from the other varieties. The promi- nent lesion in this form of bronchitis is a thickening of the mu- cons membrane. This, though rendered evident by the local 10* 114 BRONCHITIS. signs, is not always found after death : in this respect it is analo- gous to other congestions of the mucous membranes. It is at- tended with very little febrile excitement; and the functions of the alimentary canal are but slightly, if at all impaired. The cough is short and dry, thus differing from the cough which attends the other varieties, the latter being loose. The chest is sonorous throughout, and in some cases preternaturally so, on account of the emphysema, which is a frequent attendant. The respiration is generally feeble, and sometimes a rough rustling sound is heard, arising from the friction of the air-cells against the pleura. The dry rhonchi are usually heard, though not in all cases, as the thickening must proceed to a certain point in order to pro- duce them; they, of course, vary according to the particu- lar part of the bronchial tube which is affected. But, it generally occurs that the sibilant rhonchus is chiefly confined to the anterior part of the chest, and the sonorous rhonchus to the neighbourhood of the larger tubes. Besides emphysema, there is another complication which is frequently met with, and which, like it, is produced by the violent efforts made in coughing,— I allude to hypertrophy and dilatation of the heart. These three affections frequently coincide ; and the heart disease, the dry catarrh, and emphysema, form a triple lesion. The dura- tion of this variety of chronic bronchitis is greater than that of the other two. It continues to an indefinite period, — the patient often labouring under it for several years, unless some acute affection of the lungs should supervene, which is then ren- dered more grave by the previous existence of the dry catarrh. When, for instance, pneumonia attacks a person who is affect- ed with dry catarrh, the dyspnoea which, under ordinary circumstances, attends the acute affection, is rendered more severe by the existence of the chronic: this, of course, renders our prognosis much more unfavourable than it is when the dis- ease is not complicated with an acute inflammation, or when the dyspnoea is not severe. Treatment. — Very little advantage results, I think, from the employment of medicines in this variety of chronic bronchitis. It is, however, of importance to attend to the hygienic con- dition of the patient. His clothing should be warm, and his chest and extremities protected by flannel; and he should not expose himself in damp and inclement weather, while he should take exercise when the weather is dry and pleasant. The pa- tient, however, sometimes insists upon having medicine, and it is as well to gratify him in this respect. The balsams and tur- pentines have been much used ; also alkalies, which are highly recommended by Laennec. BRONCHITIS. 115 I have not spoken of the use of mercurials in the treatment of chronic bronchitis. They have been used from time to time ; but the results have not been such as, in my mind, to warrant their employment. There is an affection which resembles very much the dry ca- tarrh, that is, the cough which occurs in some cases of dys- pepsia ; it is usually dry, and sometimes attended with rhonchi, although in general they are not heard. The diagnosis here depends upon our knowledge of the previous affection of the stomach. In other cases, however, a bronchitis, previously ex- isting, is aggravated by the occurrence of an affection of the sto- mach : here the priority of symptoms must be your guide. We can generally succeed in arresting this cough by the use of tonics, alkalies, and other remedies adapted to the state of the stomach. Chronic bronchitis may arise from a variety of causes, as a fever, an acute attack of disease of the lungs, &c. It is fre- quently found co-existing with tuberculous phthisis, which may either have preceded or followed it; and it may follow any other disease of the lungs, or it may be the cause of such affec- tion. Indeed, we seldom meet with a disease of the paren- chyma of the lungs unaccompanied by bronchitis, which we might naturally suppose would be the case, since the bronchial tubes constitute so large a portion of the respiratory organs. The disease receives the name of bronchitis when the affection is confined to the tubes ; when the parenchyma is attacked, the bronchitis is looked upon as a mere complication of the more serious affections, and the designation of the disease accords with the principal lesion. This rule should be adhered to, otherwise you will confound together many different affections, and may include phthisis, laryngitis, and pneumonia, under the common designation of bronchitis. PECULIAR VARIETIES. Besides the modifications of bronchitis which depend upon the duration of the disease, and the age or other pe«uliarities of the individul, there are other varieties which are specific in their character, and depend upon a peculiar condition of the system, produced by a constitutional disorder. Of these varieties one of the most frequent is pertussis, or whooping cough. This is an affection of the nervous system accompanied by bronchitis, in which sometimes the one, sometimes the other predominates ; the affection of the nervous system being in some cases very- severe, with but little cough, whereas the cough is frequently very bad, with comparatively slight nervous symptoms. We 116 BRONCHITIS. almost always meet with this disease in children, though adults are occasionally attacked by it. It is a self-limited disease, and therefore cannot be cut short by treatment, although its complications may be removed or palliated. Though the in- flammation of the bronchial tubes is merely the local part of the disease, yet it is in one sense the most important, for when the disease proves fatal patients generally die of the bronchitis and its immediate effects. The secretion from the mucous mem- brane is much greater than in ordinary varieties of bronchitis ; and in children it tends constantly to accumulate in the inferior parts of the tubes: they are in this way gradually enlarged until permanent dilatation results. The thickening and con- gestion of the mucous membrane do not differ from the same alterations in ordinary bronchitis. When a fatal termination occurs, it generally arises from the feebleness of the patient, and a consequent inability to expectorate, or as is the case with children, to discharge the secretions by vomiting. The parenchyma of the lungs may become congested and in- flamed, and produce a pneumonia which may prove fatal. The principal sign of this disease is the peculiar whooping character of the inspiration: this is caused by the forcible ex- pulsion of air from the chest, in fits of coughing, and sometimes occurs in other forms of bronchitis, which, however, do not often possess the paroxysmal character of pertussis. In addi- tion to the cough we meet with the rhonchi, both dry and moist, sometimes with a gurgling caused by the collection of fluid in the dilated bronchi. That is, the mucous, the subcrepi- tant and the sonorous rhonchi, are generally heard at one and the same time. The cough usually lasts for several weeks ; it then declines by degrees, and the rhonchi disappear. It is gradual in its attacks, being at first slight, and then becoming violent. It comes on in paroxysms, of which, in mild cases, there are usually five or six during the day, the patient being free from cough in the interval. In severe cases the number of paroxyms is much greater. They sometimes occur as often as once an hour, and occasionally there is only an interval of a few minutes. In such cases the patient generally dies of exhaustion. The secretion in the bronchial tubes con- sists of thick, glairy mucus; when it has continued for a long time, it sometimes contains a small portion of pus, intermixed with blood. Sometimes blood is effused, and a partial he- moptysis occurs. The secretion is usually thrown off by vomit- ing, especially in young children, who cannot expectorate. The appearance of the face in this disease is peculiar, being of a bluish colour, accompanied by puffing of the eyelids. This is BRONCHITIS. 117 the effect of the violent efforts made in coughing, and the con- gestion consequent upon them. It is in some degree a measure of the severity of the affection. When fever occurs it indicates the existence of inflammation of the lungs, and when high, it is a symptom of much gravity. When the. development of tubercles takes place towards the close of the disease, the fever continues, with a quick, irritable pulse. It is usually the milliary form of tubercles which occurs under these circumstances, and is almost always fatal. The diagnosis is pretty clear after the second week; the paroxysmal character of the cough, with its whooping inspiration, its complete intermission, and the recurrence of the paroxysm during any disturbance of the mind, are sufficient to charac- terise it. The prognosis is generally favourable in the simple forms of the disease, but becomes less so in proportion to the severity of the complications. Treatment. — As the disease cannot, as a general rule, be arrested, we should palliate its symptoms, and assist nature in the means which she has pointed out for its relief, we should therefore promote the secretion in the tubes, and favour its removal. Therefore, we should employ mild emetics, which tend to bring about both these ends. They should be given once or twice a day, for a week or two. In this affection there is always a disposition to vomit; and as this action, brought on by artificial means, is milder than when it occurs spontaneously, emetics afford very great relief. After this treatment has been continued for the time above specified, we should make use of remedies whose action is slower but analogous to that of emetics, for this is the means pointed out by nature for the cure of the disease ; and it is a maxim in therapeutics, that when a secre- tion is intended by nature to remove any diseased state of the economy, we should favour or moderate it, and not arrest it. Ipecacuanha, in the usual expectorant doses, may be used for this purpose, and answers very well,—but one of the best reme- dies in this affection is assafcetida, as it favours expectoration, and also controls the disorder of the nervous system, which con- stitutes so large a part of the disease. It may be given to children of eight or ten years, in doses of two or three grains, increased to four or five, several times daily. However, it cannot always be given internally, as it is so repulsive to the senses ; applied externally in the form of a plaster, it acts very well, producing an impression on the nervous system, and moderating the paroxysms. Ammoniac, galbanum, &c, are used in the same manner. Revulsives to the chest are useful, 118 BRONCHITIS. but not always necessary ; when required, I prefer sinapisms to blisters or moxas. There is another remedy which is much more powerful than these, — that is, the extract of belladonna ; this must of course be used in very minute doses. Still we cannot be too cautious in the administration of this medicine, which is certainly always attended with some risk. The success which attends its administration in whooping cough, is stated to be greater than any other remedy. The clothing should be warm, and flannel should always be worn around the chest. The complications are various affections of the lungs, which when very acute, are to be treated by general and local blood- letting, and other remedies required in the affections occurring idiopathically. Phthisis occurs as a* sequela of this disease, and does not require medication ; it is best treated by a change of air, which is advantageous in the declining stages of all severe cases of pertussis. As pertussis rarely occurs with adults, we are apt to make an incorrect diagnosis when it does thus occur; this should be borne in mind, as we might confound it with a variety of bron- chitis resembling pertussis, which is exceedingly difficult to get rid of. Ordinary bronchitis may be complicated with the ner- vous spasm; but the disease should not be confounded with pertussis, unless the spasms are disproportioned to the bronchial affection. This constitutes the peculiarity of the disease, and gives to it, a mysterious difference between it and other varieties of bronchial inflammation. BRONCHITIS DEPENDENT UPON A CONSTITUTIONAL TAINT. There are certain cases of bronchitis which depend on a particular diathesis, or a peculiar condition of the system, induced by a specific affection ; to this class belong the syphilitic and scrofulous bronchitis. But you will sometimes find that the syphilitic variety is singularly similar to phthisis in the emaciation and other constitutional symptoms ; so much so that the deterioration of the health is such as to end in phthisis. The scrofulous bronchitis is attended with a very abundant secretion, of a thick, glairy mucus, and is in most cases com- plicated with an inflammation of the upper portion of the respi- ratory tubes, so that the nasal cavities are sometimes more affected than the bronchi; it must be treated with remedies calculated to correct the morbid state of the system, such as mercury, iodine, sarsaparilla for the syphilitic variety ; iodine, iodide of iron, and other chalybeates, may be used in the scrofu- lous varieties of the disease, besides resorting to local remedies. BRONCHITIS. 119 General remarks. — Although bronchititis, as a disease, presents many varied characters, yet there are certain features which are common to every form of it. In all, the turgescence of the bronchial mucous membrane with blood gives rise to the chief difficulties in the respiration, and when this congestion extends to the smaller tubes, the dyspnoea becomes excessive, and may be a source of immediate danger. This simple con- gestion of the membrane occurs in the early period of acute cases, and in the dry catarrh it becomes a chronic condition, and lasts for an indefinite period. The most easy and frequent termination of the congestion is by direct secretion from the bronchial tubes ; that is by the formation of a mucous and muco-purulent discharge ; but in many cases the general circu- lation may be restored, and the congestion removed, by the free discharge from the capillaries of the skin, or some other tissue. If this relief does not follow, the tendency of all cases of dry bronchitis is to congest the heart, and to distend the vesicles of the lung : hence emphysema of the lungs, and dila- tation of the heart frequently depend upon this cause. The other varieties of bronchitis, whether acute or chronic, are those in which secretion takes place; if this secretion be of a natural, healthy kind, the inflammation ceases; thus the thin albuminous secretions are replaced by a more consistent mucous or muco-purulent expectoration, which again gradually passes into a more transparent mucous discharge, which in time ceases. But, although this is the course of the disease when it termi- nates favourably, in many cases the secretion of mucous and muco-purulent matter will continue, while the inflammation does not abate. These are the chronic cases of mucous catarrh. In this variety the discharge is analogous to what takes place in chronic dysentery, when the inflammation is not relieved by the secretion. The difference appears to arise from a modifica- tion in the mucous tissue, by which the vessels remain perma- nently enlarged, and recover with difficulty, unless a stimulant is administered which should excite this new action. Hence we use what are called the stimulating expectorants so largely in these forms of bronchitis ; these remedies supply the excitement necessary to the relief of the disease by a new and more health- ful secretion. The inhalation of the vapour of water, of tar, ether, &c, act much in the same way, but are more direct stimulants of the membrane. The depleting remedies, which are often necessary in severe bronchitis, act, of course, very differently from the stimulating expectorants; they merely equalise the circulation of the bronchial vessels, and thus lead towards health by removing the vascular excitement which 120 BRONCHITIS. keeps up the disease. The result of this mode of treatment will, of course, be essentially the same with those derived from the stimulating expectorants, but the modus operandi is totally different. The revulsive means are more analogous to the directly antiphlogistic remedies, and produce very nearly the same effects. Bronchitis is therefore a multiform disease and varies both in symptoms and treatment with almost every modification of the body; it may be highly inflammatory, and require the most vigorous depletory means, or it may degenerate into a mere chronic oozing of the mucus from the vessels. The object of the physician is to vary his treatment according to these differ- ent conditions, and, at one time, to resort to vigorous antiphlo- gistic measures, and, at another, to a course of treatment which is totally different. I have laid much stress upon the latter practice, because it is suited to a greater number of cases, but I am not the less convinced that in the cases which are de- cidedly inflammatory, the most effectual relief is produced by the depletory practice; it may afterwards be followed by any other remedies that the case may seem to require. DISEASES OF THE LUNGS. 121 CHAPTER VIII. DILATATION OF THE BRONCHIAL TUBES. There are two lesions of the bronchi, arising from long-con- tinued bronchitis, which differ very widely, however, in their physical condition, viz, dilatation, and contraction of the bron- chial tubes. The former of these lesions is by far the more important, and also the more frequent. It prevails in pro- portion to the number of cases of long-continued chronic bron- chitis, with abundant secretions. Acute bronchitis will occa- sionally produce the same dilatation, provided the mucus be copious, and be expectorated with difficulty after violent efforts of coughing; hence it is not infrequent in pertussis, which is about the only disease of children that gives rise to this lesion. As dilatation of the bronchial tubes is a mere lesion, which is produced by diseased action, but is in itself of little import- ance, it must necessarily require less attention than the diseases of the lungs, properly so called : nevertheless, it may be readily confounded with these affections, — and even if it were not liable to this chance of error, there would still remain sufficient reason for studying the symptoms of it. Lesions of this kind should never be confounded with the diseases which give rise to them; but they offer interesting points of relation, and require therefore some attention, in order to recognise them, and to discover the best means of obviating the mischievous effects which necessarily arise from their occurrence. Dilatation of the bronchi assumes several different forms: the most frequent is an uniform enlargement of several bronchi of a lobe which, after branching off from the principal trunks, re- main nearly of their original size, or even enlarge as they approach the surface of the lung. This variety results very frequently from whooping cough, and the spasmodic bronchitis which resembles it most nearly. The mucous membrane, at the same time, is thickened, and loses its transparency. The other varieties, which are less common, are merely par- tial dilatations in the course of a bronchial tube, There may be only one single enlargement, or several successive dilatations of a large bronchus, which aftewards recovers nearly its natural 11 122 DISEASES OF THE LUNGS. size. The enlarged portions are thus distinct cavities, and physically speaking, present nearly the same peculiarities as the cavities which arise from the softening of tuberculous matter. There is therefore necessarily cavernous respiration and pec- toriloquy, and the condensed pulmonary tissue which surrounds the enlargement may cause a decided dulness on percussion. The condensation of the tissue apparently arises from chronic inflammation, which causes a deposit of new matter in the pul- monary substance. The precise nature of this substance is not ascertained ; but it is probably albuminous, like similar deposits in other parts of the body. In the variety in which the bron- chial tubes are generally dilated, there is rarely cavernous respiration ; for the air, in diffusing itself through the lung, does not, of course, present the sharp, clear reverberation, which is essential to the formation of cavernous respiration. Hence there is very little difference between the respiration in this variety of dilatation, and that heard in the second stage of pneumonia, when the hepatisation occurs around the larger tubes. But in dilatation of the bronchi, the bronchial rhonchi, as the mucous and sub-crepitant, are much more frequent than in pneumonia ; and the permanency of the signs in the former alteration, and their rapid changes in the latter, will prevent all danger of confounding the two lesions together. The diagnosis between dilatation of the tubes and phthisis is much more diffi- cult, as it depends not upon the physical signs, which differ but little in the two cases, but upon the progress of the general symptoms. If the symptoms be those of chronic catarrh, that is, if they are attended with severe cough, and but slight emacia- tion, the disease is probably chronic bronchitis; but if the fever and emaciation be much more decided, the probabilities are of course greatly in favour of phthisis. Practically speaking, the chances of error are very slight; for those cases of chronic cough, in which the dilatation of the tubes is sufficiently great to simu- late a tuberculous cavity, are almost always connected with very general bronchitis, in which the signs of a general thick- ening and inflammation of the mucous membrane are very evi- dent, and totally unlike those of a tuberculous disease. There is, however, another variety, in which it is impossible to dis- criminate accurately between these two affections, for the tuber- culous disease then coincides with the dilatation of the tubes. In this case the dilated tubes either pass through the masses of tubercle which are deposited at the summit of the lungs, or they terminate as soon as they reach these masses. If the tubercles have advanced to the period of softening, the cavities which are thus produced often communicate directly with the enlarged DISEASES OF THE LUNGS. 123 bronchi, and form as it were, a continuous tube. When the dilatation is connected with a cavity, it is often preceded by a deposit of tuberculous matter in the bronchus, which is in this way gradually enlarged, and remains dilated after the softening of its contents. There is, of course, no peculiar treatment for the dilatation of the bronchi; it is strictly a lesion, not a disease, and being placed beyond the reach of the mechanical means of treatment which are adapted to remove an external alteration, it neces- sarily must remain with the patient. The object of the physi- cian is to remove, as far as possible, the protracted bronchitis which generally produces the dilatation. The lesion then ceases to give rise to much mischief, and even a partial cure may take place. 124 EMPHYSEMA OF THE LUNGS. CHAPTER IX. EMPHYSEMA OF THE LUNGS.--ANATOMICAL CHARACTERS.— SYMPTOMS. --DIAGNOSIS.--PROGNOSIS.--TREATMENT. This is an alteration which is closely analogous with dilatation of the tubes. In fact, it is the same disease attacking a different part of the structure, — that is, the terminating vesicles of the lungs. In their normal state, these cavities are very minute, but may still be discovered by a good eye; but when diseased their size may increase much beyond their natural dimensions, and they then very frequently attain the bigness of a small pea, and in some cases are even much larger. The vesicles, as they enlarge at the same time, become thickened in their parietes, and press upon those adjoining, of which some are atrophied, and others appear to form a direct connexion with the distended ones. It is in this way that the very large sacs, of the size of a pigeon's or even a hen's egg, seem to originate, not from a single vesicle, but from the junction of a number of distinct ones, which have gradually broken into each other. The tissue of the lung which is the seat of the emphysema, becomes pale, and crackles under the pressure of the fingers like a piece of dried lung,—the walls of the vesicles losing their elasticity, and becoming much more rigid. The size of the dilated part of the lung is necessarily increased ; hence it presses upon the intercostal spaces, and can no longer be con- fined in its usual limits. As a necessary consequence of this increase, the walls of the chest are enlarged to an extent cor- responding with the distended part of the lungs, so that they form a decided protuberance. The quantity of blood contained in an emphysematous lung is rather less than natural in those portions of it which are the espe- cial seat of the disease,—that is, the anterior margin of it,— but the posterior parts contain as much blood as usual, and some- times become congested on account of the dyspnoea, which is a necessary attendant upon all severe cases of the disease. The congestion frequently passes into pneumonia, and cases which prove fatal, for the most part terminate in this way. The mucous membrane of the bronchial tubes is rarely perfectly EMPHYSEMA OF THE LUNGS. 125 healthy in emphysema, if it be of severe character. There are two forms of bronchitis which commonly complicate emphy- sema,— the chronic and the acute. The former is a regular, and almost necessary complication ; the latter is often absent during nearly the whole course of the disease, but it is more apt to occur in patients labouring under this disorder than in those who are in the enjoyment of perfect health. When it takes place as a complication, the distress of the patient is vastly greater than in cases of simple bronchial- inflammation. The chronic bronchitis which so commonly attends emphysema, is nearly always of the dry variety, or as it is often termed, it is in fact the dry catarrh. In this case the membrane is perma- nently thickened to such a degree as to impede the passage of the air, and constantly react upon the disease itself. The bron- chitis is then doubly connected with the emphysema, and may be regarded both as cause and effect; either of the disorders may occur first, and will be almost necessarily followed by the other. Chronic dry catarrh produces Of itself sufficient dyspnoea to distend the air-cells, and favour the development of emphy- sema ; while if the anatomical condition exists, either as the result of original structure, or of some peculiar cause, the slightest obstruction to the freedom of the respiratory function may cause a severe attack of dyspnoea, and thickening of the bronchial membrane is then almost a necessary result. Signs. — The physical signs of emphysema are extremely well-marked in severe cases ; but, of course, there are many instances in which the alteration deviates so little from the normal standard as to render the signs of doubtful value. When there is much distension the physical signs are all present, and may be referred to the three following heads: — 1. Distension of the portion of the chest. 2. Clearness of sound on percussion. 3. Feebleness of respiratory murmur. These are the only regular or constant signs, but there are occa- sionally a number of others perceived. They are sibilant rhonchus, from the frequent complication of dry catarrh, in which this rhonchus is heard along the anterior margin of the lungs; and subcrepitant, or mucous rhonchus, at the posterior part of the lungs, when they are much congested, or the bron- chial tubes are attacked with acute inflammation. There is another sign which is occasionally met with, — the dry subcre- pitant rhonchus, which is nothing but the slight rustling sound produced by the bubbles of air either forcing themselves into the cellular tissue and forming little bags which rub against the pleura, or the dilated vesicles themselves, which are sometimes 11* 126 EMPHYSEMA OF THE LUNGS. sufficiently rigid to give rise to some friction and cause a sound. 1. Dilatation of the Chest. — This is necessarily most evident in those portions of the thorax where the dilatation of the vesicles is greatest; that is, at the anterior margin of the lungs. The anterior plane of the thorax is rounded, and gradually assumes a convex shape, the most prominent portion of it being near the margin of the sternum : the form of the dilated portion is generally oval, the long diameter of the oval corresponding to the axis of the body: but as the extent of the altered portion of the lung is very variable, the form of the chest differs ex- tremely. The dilatation is more evident in the intercostal spaces than at the level of the ribs, which are but slightly thrown out from the general plane of the body. There is at times a general distension of the chest; the shoulders are then elevated, and rounded, and the thorax approaches very nearly to the cylindrical form. This extreme distension takes place only in those who have been long subject to emphysema, especially those who have inherited a predisposition to the disease. In speaking of the dilatation of the chest in emphysema, we must remember that it is moderate, and never attains the degree which we find in large pleuritic effusion, or in pneumo-thorax. 2. Resonance on percussion. — The anatomical condition of the lungs in emphysema necessarily admits more air into the lung, — in fact, the tissue is permanently distended with air,— and if percussion be made over the part, the sound is of course, clearer than in a lung which is perfectly in the normal condi- tion. This clearness is extremely great in thin persons who are affected with emphysema: if the patient be corpulent, and sufficiently advanced in life for the elasticity of the chest to be diminished, a moderate degree of emphysema does not render the percussion very sonorous. The clearness of sound is of course, greatest at the spot where the dilatation is most percep- tible ; and when the chest is generally dilated, the percussion retains its character of great clearness throughout. The reson- ance in a few patients is sufficiently great to resemble a little, that produced by pneumothorax, but it never has the tympanitic sound produced by the latter lesion. 3. The feebleness of the respiratory murmur is the third pecu- liarity of emphysema. The dilatation of the cells prevents a free circulation of air; they even remain permanently dilated when removed from the dead body. This immobility probably arises from the thickening of the walls of the vesicles, which always follows their permanent enlargement. The respiratory EMPHYSEMA OF THE LUNGS. 127 sound is not only enfeebled : but if the emphysema be extensive, it is apt to assume a peculiar rustling tone, which is probably in part produced by the motion in the vesicles themselves, and in part by their friction against the parietes of the chest. The functional symytoms of emphysema are less characteristic than the physical signs, but are always sufficiently marked to increase the certainty of the diagnosis, — sometimes to indicate of themselves the character of the disease. One of them is much more constant than any other, — that is, the dyspnoea. The other symptoms depend in a great degree upon the com- plication of chronic or acute bronchitis, which so often attends the disease ; hence they vary according to the intensity of this affection. They are cough, expectoration of thick, pearly sputa, which are small in quantity, or of a large amount of thin glairy, and transparent matter, which occurs in the paroxysms of the dyspnoea, or during the complications of acute catarrh. There is no fever or disturbance of other organs than the lungs or heart, which is necessarily connected with dyspnoea; when other affections occur, they may be set down as complications which may acquire additional severity from the pre-existence of the emphysema, but do not arise necessarily from it. The dyspnoea is in part permanent, and in part comes on in paroxysms. The permanent dyspnoea is developed by any exercise which hurries the act of respiration, such as ascending a flight of stairs or a high hill, or indulging in any unwonted exercise. The subject of the disease then complains that he cannot take as much or as long-protracted exercise as other people ; and this inability, if it be not accounted for by decided organic disease of the heart or lungs, is one of the best diagnostic characters of the disease. It is very regularly pro- portioned to the extent and severity of the emphysema, and in slight cases may escape notice. The dyspnoea which occurs in paroxysms is not frequent until the disease has become compli- cated with bronchitis, or as is still more frequent, with a disease of the heart. In the lafter case, a disturbance of the circulation is frequently produced by slight causes, and then the paroxysms of difficulty of respiration become extremely severe and intense, until the patient is partially relieved by a free expectoration of glairy mucus from the bronchial membrane, or until he remains for a considerable time in a condition of perfect repose. If the patient be extremely corpulent, the frequency of the paroxysms is of course proportionally increased, and they become more and more severe as the disease continues longer, for the dilata- tion in the majority of cases tends to increase, — and each sue- 128 EMPHYSEMA OF THE LUNGS. cessive attack, by distending the vesicles, may act as a new exciting cause of a further enlargement of them. The diagnosis of severe cases of emphysema is readily enough made, for the physical signs are then pathognomic of the affec- tion; but in slighter cases they are not always clearly enough developed to render the diagnosis quite certain. This is the case when there is little or no dilatation of the chest, but merely an increased resonance on percussion, and a diminished loud- ness of respiration. We are then obliged to resort to the diag- nosis by way of exclusion; and if we find that no other disease which can account for the permanent dyspnoea exists, we should ascribe it to emphysema. When emphysema is complicated with another disease of the lungs, or with one of the heart which in itself is capable of producing a corresponding dyspnoea, it is difficult to ascertain the precise influence of the two affec- tions. If the dyspnoea be excessive, emphysema alone is rarely capable of producing it; but if it be more moderate, the proba- ble share of each affection is extremely difficult to ascertain. The prognosis in this disease is favourable, so far as the chances of death are concerned, — for it is scarcely possible for a patient to die merely of emphysema. But on the other hand, a complete recovery is scarcely possible, unless in very recent cases of the disease, when the distension of the air-cells has succeeded an acute disorder. In this case the disease tends gradually to recovery, although the restoration is rarely perfect; for the constant dilatation to which the vesicles are subjected prevents them from resuming their natural size. The treatment of emphysema is in a great degree nugatory, so far as the removal of the lesion itself is concerned ; but the paroxysms of dyspnoea may be checked, and the attacks of acute bronchitis relieved. The remedies most useful in check- ing the dyspnoea are sinapisms applied between the shoulders to the dorsal spinal vertebrae, and the use of lobelia in doses sufficient to excite slight nausea. If the tincture, which is the preferable form, be used, the dose should be twenty or thirty drops every two or three hours : some patients, however, will bear or even require a much larger dose, but for the greater number that just specified is sufficient. Opiates are also useful in some varieties of emphysema; they should be repeated often enough to quiet the cough; and in emphysema, as in common bronchitis, their effect is much enhanced by combining them with a nauseant. From a quarter to half a grain of opium will in general be found sufficient, if combined with the same or half the quantity of tartarised antimony. If ipecacuanha be EMPHYSEMA OF THE LUNGS. 129 used, of course the dose should be larger. The remedies which are most serviceable for ordinary bronchitis, are in general equally applicable to that variety which complicates emphy- sema ; it does not, therefore, require any specific direction for the treatment. It is to these cases that the physician is chiefly called; for in the large majority of patients the emphysema itself is not a sufficiently severe disease to attract much notice from the subject of it. 130 ASTHMA. CHAPTER X. ASTHMA—NERVOUS ASTHMA—FALSE ASTHMA—PAROXYSMS—DIAG- NOSIS--TREATMENT. The term asthma is extremely vague, and is still used in a very loose sense. It is commonly applied to any condition of the respiratory system in which there is much oppression, especially if the dyspnoea comes on in paroxysms, and is attended with a wheezing noise during the inspiration or expiration. In many of these cases there is sufficient evidence of organic disease in the lungs or heart to account for the difficulty of breathing; hence the term asthma is then applied merely to a symptom, and does not designate a specific disease. In other cases there is no evidence of any organic alteration ; and the asthma then becomes a peculiar disease, characterised by regular symptoms, but without definite lesions ; it is therefore to be classed amongst those diseases to which the common designation, nervous, is applied. The term is a vague one ; but if we restrict it to functional disorders which present a sufficient regularity of symptoms to identify them, there is little practical objection to it. In the present state of the science, therefore, we are com- pelled to admit a nervous asthma, and a periodical dyspnoea without organic lesion. The diseases of the lungs which are attended with paroxysms of difficulty of breathing, are a variety of bronchitis, emphysema, certain rare cases of miliary tubercles, and the presence of large tumours upon the trachea or the larger bronchial tubes. This variety of bronchitis I have already treated of under its appro- priate head ; it is one of the most painful and harassing to the patient, but at the same time is the most curable variety of asthmatic diseases, for it often yields to the continued use of ipecacuanha, and other remedies of the kind, with appropriate counter-irritants. The probabilities of cure are of course much enhanced by a voyage to a milder climate. Emphysema may be palliated, if not cured ; but miliary tubercles is generally the most intractable, and often the most rapidly fatal variety of phthisis. The tumours which give rise to periodic dyspnoea at first, ASTHMA. 131 will cause a permanent difficulty of breathing if they increase much in size ; they are sometimes scirrhous growths, but more frequently aneurism of the arch of the aorta in adults, and scro- fulous enlargement of the bronchial glands in children. The dyspnoea is at first not permanent in these cases, because the obstruction to the passage of the air is not sufficient to cause great difficulty of-the respiration without some congestion of the bronchial mucous membrane ; this is more and more apt to re- cur as the disease continues to advance, and the case may readily be mistaken for one of nervous asthma. After striking those cases of false asthma from the list, we next come to the diseases of the heart which simulate the same disorder. These are quite numerous; indeed, any serious dis- order of the heart, which impedes the circulation, may congest the lungs, and, as a necessary consequence, great dyspnoea will result. The oppression will be very nearly in proportion to the difficulty of the circulation through the heart, and must of course be greatest in those cases in which the valves are most ob- structed. These diseases constitute some of the most severe cases of those classed under the general head of asthma. There remains, then, a nervous asthma, which cannot be classed under these heads. This disease, like most other chronic affections, is in a great degree hereditary, and often passes through several members of a family ; all, or a large number of the children of one family, are often subject to at- tacks of it upon exposure to slight exciting causes. These causes are extremely various; but they are in general such as act particularly upon the nerves of the respiration, and produce a slight oppression, even in individuals who are not at all asth- matic ; such as the inhalation of deleterious gases, certain per- fumes, a heated, and especially a crowded room, changes of temperature, or changes in the barometrical conditions of the air, will all occasionally produce the same results. The effects of atmospheric changes which are not connected with tempera- ture, and can only be recognised by a delicate hygrometer or barometer, are very peculiar; a very little difference in the moisture, or in the altitude of a particular spot above the level of the sea, being often sufficient to bring on, or to remove a severe attack of asthma. The change from a lower and more crowded to a higher and more airy part of the same town, will often produce the same effect. These attacks of nervous asthma are often periodic, or at least especially apt to recur at particular seasons of the year, which are not always the same, although the summer is in general more apt to favour the de- velopment of the disease than colder weather. But there is 132 ASTHMA. no disorder which is proverbially so peculiar in its time and mode of attack as asthma,—the most opposite conditions will modify the action of the nerves of respiration. These condi- tions do not, however, vary much in each individual; they are generally sufficiently regular, but they are extremely different with different persons who might at first sight seem to offer the same variety of the disorder. This idiosyncracy is not more remarkable than that which is observed in relation to many otrnr functions of the body, especially the digestive, and is of course equally inexplicable. The symptoms of nervous asthma are similar in this respect, that all who are affected with the disease are liable to sudden and violent paroxysms of dyspnoea, or to slighter derangement of the respiration; at the same time there are no decided signs of bronchial inflammation. If the respiration be examined, the inspiratory sound is feeble, but there is generally no rhon- chus ; the wheezing which is occasionally heard at a distance from the patient is produced almost exclusively in the larynx. The rhonchi, and other signs of bronchial irritation, are heard if the attack is accidentally complicated with acute bronchitis. Paroxysms of true asthma terminate by a gradual decline, or as in the variety termed asthmatic bronchitis, the attack is not relieved until a free secretion of glairy liquid from the bronchial membrane takes place ; in either case the disorder is singularly apt to return in a short time upon a renewal of its exciting causes. The diagnosis of the disease is, like the prognosis, exceed- ingly simple. The disorder may always be recognised by the presence of the periodical dyspnoea, and the absence of any de- cided evidence of structural change. The prognosis is, on the whole, highly favourable ; for few cases of the kind termi- nate unfavourably, but, like the asthma which arises from em- physema, the disease is exceedingly difficult to remove. At the same time the affection is so peculiar in its nature that it often ceases abruptly, without the slightest assignable cause ; and at other times, an apparently insignificant impression made upon the nervous system, either directly on the nervous expan- sions, or indirectly through the medium of the imagination, will often stop a paroxysm, or postpone one for a long period. The prognosis, therefore, is peculiar ; and it is very necessary to be guarded in our promises of cure, or in ourjanticipations of an unfavourable result when the case is most unpromising. In most patients asthma may be greatly relieved by attend- ing to the exciting causes of the disease, and carefully avoid- ing them when practicable. This is often less difficult than it ASTHMA. 133 would appear to be at first sight; for a very slight change of residence from one situation to another in the same city, or district of country, will often suffice. Sometimes a more dis- tant removal becomes necessary, at least at the season of the year when the disorder is most apt to recur. Every patient is not however fitted to decide as to the proper change of situa- tion. In the same way a change of occupation, or even the avoidance of certain departments of a particular business, will often succeed. If these attempts fail, and the patient is will- ing to make the sacrifice, a more decided change is advisa- ble ; and, in making it, the warm, moist regions of the sea- side, will generally be found preferable to the drier and more hilly country. The hygienic precautions not connected directly with the condition of the air, are less certain in asthma than in most other diseases ; and we must here also rely chiefly on the ex- perience of the patient. Those causes which tend to produce bronchitis, favour the development of asthma, although they do not cause it. Hence the avoidance of cold and unnecessary exposure is essential, unless the experience of the patient should teach him that a cold atmosphere agrees better with him than a warmer one. In either case, however, the impression of pro- longed cold upon the surface is almost always deleterious, whatever may be its direct influence upon the bronchial mu- cous membrane. Excesses in diet are also often exciting causes, and the particular perfumes or stimulants of the bronchial mem- brane which act unfavourably upon the disease, are generally well known to every patient. There are many modes of arresting the paroxysms, and for the most part the remedies resemble each other only in their general power of producing a decided action upon the nerves of respiration. Frequently these remedies are the narcotics ; at other times a mere counter-irritant applied between the shoulders will prove effectual in cutting short the paroxysms. In some cases a galvanic plate applied upon the nucha, and communicating with another placed at the point of the sternum, will instantly check an attack of this disorder; and although the cure is not always permanent, yet in some instances the disease does not return. The nauseants and antiphlogistics, which are often useful in emphysema, are sometimes equally effectual in arresting the paroxysms. Amongst them the tinc- ture of lobelia is one of the most certain and convenient, but with some stomachs it is oppressive and irritating. The various narcotics which are from time to time resorted to, for the relief of asthma, may be administered in the usual 12 134 ASTHMA. way, or be inhaled into the lungs, and thus brought directly in contact with the bronchial membrane. Thus stramonium, tobacco, and other remedies of this class, are often smoked with great benefit; and a method recommended lately by M. Raspail, is sometimes of advantage. This consists in inhaling the vapour of camphor ; a few pieces of it are placed in a quill, and the patient may breathe through it. The slow volatilization of the camphor brings it directly in contact with the lungs. These means are, however, all palliative, and there is some- times no certain relief for the disease. A careful study of the exciting causes, and attention to some very simple hygienic pre- cautions, are the most promising means of treatment. PNEUMONIA. 135 CHAPTER XL PNEUMONIA -- ANATOMICAL CHARACTERS -- PHYSICAL SIGNS — SYMPTOMS--TREATMENT. In the last chapter I concluded the subject of diseases of the mucous membranes lining the bronchial tubes. As I had pre- viously described the inflammation of the investing membrane, it now only remains for me to give an account of the affections of the parenchyma of the lungs. It was necessary to treat of the diseases of the membranes first, because the parenchyma is very rarely, if ever, diseased, without the inflammation extend- ing to them, for the tendency of disease of the lungs is to pro- duce inflammation of the mucous membranes connected with them. What, then, is the parenchyma ? To answer this ques- tion, it will be necessary to reflect upon the anatomical structure of these viscera. The bronchi continue to divide and sub- divide, the ramifications becoming smaller and smaller after each division, and terminating in vesicles arranged in lobules ; the vesicles of each of them communicate with one another, but not with those of the adjoining lobules ; and each lobule receives a blood-vessel, which ramifies within it, and is dis- tributed to the vesicles in the cellular tissue, which invests and unites them together. The parenchyma may, then, be said to consist of the air-vesicles, the blood-vessels surrounding them, and the cellular tissue ; or the term may be extended further, so as to include the ramifications of the tubes within the lobules, yet not the tubes which lead to them. The latter definition answers better in a pathological view, inasmuch as the smaller tubes are always involved in diseases of the portion of the pa- renchyma through which they pass. The term parenchyma being then understood to include these finer tubes, we designate the disease as- bronchitis when the inflammation attacks the large bronchial tubes, but extends no further than the tubes which lead to the lobules: as pneumonia, when it extends to the smaller tubes within the lobules, and to the air-cells of the part affected. Pneumonia, which is an inflammation of the parenchyma of the lungs may commence in two ways, —either as a bronchitis, the inflammation in this case extending to the smaller tubes 136 PNEUMONIA. and air-vesicles ; or it may originate in the vesicular structure, and subsequently involve the* larger tubes, just as dysentery may commence in the form of diarrhoea, and pass into dysen- teric inflammation, or originate in the latter form, and present the symptoms of dysentery from the first. When the bronchial tubes only are inflamed, as soon as a secretion takes place, it is removed from the body, and the inflammation is partially re- lieved, so that the disease rarely does much harm ; but when the lobules are inflamed, the exit is closed, and the fluid accu- mulates in the lung, thus increasing the congestion, and im- peding the respiration, but not relieving the inflammation by a natural depletion. This fluid consists at first of a bloody serum, and is often of a reddish colour. It afterwards passes through the stages of lymph and pus. In hemorrhage, the blood con- tained in the cellular tissue is arterial in its character ; in apo- plexy, it is venous, and in inflammation it partakes in a mea- sure of the nature of both. The lung at this stage of the disease, yields readily to pressure with the finger, and the fluid can be expressed from it. In post-mortem examinations the sound appearance may be confounded with engorgement pro- duced after death, in a dependent portion of the viscus; and there is frequently some difficulty in making the distinction between the two, — but the redness of inflammation is always brighter, and the softening of the tissue is more decided. Still the two conditions are not very dissimilar, for the congestion, if it occur during life, may readily pass into inflammation. Pneumonia passes through several stages between its com- mencement, which I have described, and termination ; and its symptoms, in accordance with the changes of structure, are divided into four stages. The first is characterised by engorge- ment of the tissue ; the second by induration, which has received several names, as hardening, red softening, hepatisation. It is called hardening, on account of the increased consistency which is perceived when it is slightly pressed ; softening, on account of the facility with which it is broken, if the pressure be in- creased ; hepatisation, from its resemblance to the tissue of the liver. The vesicles of the lung being deprived of air, and en- gorged with blood, resemble the acini of the liver, their colour being thus changed to a brownish-red. In the case of children, this resemblance is so close, that I have known a bystander to mistake a piece of lung for liver, although both tissues were before him. A small piece of lung in this stage of the disease will sink in water, although a large mass of it may float on ac- count of some portion of it containing air in its cells ; whereas, in the first stage, the whole of the tissue is lighter than water. PNEUMONIA. 137 The bronchial tubes are red, and filled with a fluid containing a large portion of lymph, which in many cases closes the smaller tubes, thus reducing the lung to an uniformly solid mass. If the lung be torn, or even if simply cut, it presents an irregular granulated appearance, which arises from the vesicles being separately hardened and enlarged, while they still retain their individual form. They therefore project above the level of the adjoining cellular tissue. In the third stage the lung remains indurated, but assumes a yellowish colour. In this stage the lung contains a considera- ble quantity of pus, diffused through the cellular tissue, and deposited in the vesicles. The tissue loses its granular appear- ance, and becomes more smooth and polished, the vesicular structure having been completely obliterated. It yields readily to pressure, and breaks under the finger, affording a puriform liquid, which at first consists of a mixture of pus and blood glo- bules floating in serum, and afterwards of pure pus. By placing the diseased lung under a stream of water, the parenchyma may be completely removed so as to leave nothing but the bronchial tubes. The bronchial mucous membrane is not so red in this as the second stage, and the tubes contain purulent liquid. We may admit a fourth stage, in which the parenchyma is softened down and removed by expectoration, and an abscess remains, resembling an abscess in the other tissues of the body; a pus-secreting membrane is formed, and pus ;s thrown out, which becomes less and less in quantity until cicatrisation takes place, and a cure is effected. This stage of the disease is rarely met with ; but when it does occur the patient usually recovers, which termination might not be expected, as an abscess in the lungs appears to be a lesion of great gravity. However, if the patient has strength enough to go through the first three stages of the disease, he will generally survive the fourth, though he may require the aid of artificial stimulants. The symptoms are generally somewhat relieved by the formation of an abscess, as the inflammation is thus circumscribed in its locality. If, how- ever, instead of there being a circumscribed abscess, the pus is diffused through the lung, a fatal termination will generally take place. The physical signs of pneumonia, like the lesions, occur in a regular series. The signs in the first stage are obscure, but in the second, they become very plain ; hence they are looked upon as the pathognomonic signs of the disease. In the first stage, the lung is infiltrated with a thin liquid ; this produces a sort of rustling respiration, and not unfrequently the respira- tion at the time is rude ; that is the vesicular murmur loses its 12* 138 PNEUMONIA. natural softness and fulness, and the air rushes abruptly into the cells. Subsequently we meet with another sign, which is said to be pathognomonic of the first stage. This is the crepitant rhonchus. It is indeed, pathognomonic when it does exist, but it is not present in all cases: for when the inflammation is seated near the centre of the lung, the engorged vesicles cannot dilate ; as this rhonchus is produced by the expansion of the diseased vesicles, of course it cannot be heard. Besides the healthy tissue, which is to be found between the ear and the diseased lung, gives rise to a healthy vesicular respiration, and prevents the crepitus from being heard after it is formed in the inflamed portion. But when the seat of the inflammation is near the surface it always occurs. There is also slight dulness on percussion, which is caused by the secreted liquid partially dis- placing the air in the tubes. The dulness is of course not considerable, for the air is not completely expelled from the dis- eased portion. The signs of the second stage are more strictly pathogno- monic of the disease. In this stage the tissue of the lung is completely altered, and this alteration is attended with corres- ponding physical signs. On percussion we find complete flat- ness, as the cells are filled with fluid, and no air whatever is contained within them. Auscultation gives us, 1st, a bron- chial respiration, which is more marked in the second stage of pneumonia than in any other affection of the lungs, as the tissue is perfectly consolidated without any obliteration of the tubes. It is that variety of bronchial respiration, which on account of its loudness, has been denominated tubal; it is most distinctly heard at the root of the lung, where the tubes are of the greatest calibre. Bronchial resonance of the voice, or bronchophony, is also heard, and in fact it always co-exists with the bronchial res- piration. If the patient breathes rapidly, the crepitant rhonchus is also heard in many cases co-existing with the bronchial respira- tion ; this arises from a portion of the lung remaining in the first stage of inflammation. It is then heard in trains, like the crackling of wet powder, in the tissue which has not been indurated, and which surrounds the solidified portion. This state of things is very frequently met with. These signs are present in all cases except when the patient breathes too feebly to impel the air through the tubes, when, of course, they are not heard ; but as they are so constantly met with, they are usually described as the pathognomonic signs of pneumonia. The patient should always be directed to cough when you suspect that he is in the second stage of pneumonia ; PNEUMONIA. 139 and you will then find that the bronchial respiration is made much more distinct, and the air is driven so suddenly into the smaller tubes during the following inspiration, that a very char- acteristic crepitus is produced either in the same spot as the bronchial respiration, or very near it, for the lung can never be completely solidified. The signs of the third stage are not so characteristic of the disease ; but, if you have followed it through the previous stages, you cannot be at fault, nor can you, if the signs of the first and second, or of the three stag'es be present at the same time. But if you see the patient for the first time in the third stage, you may, by relying on the general symptoms, mistake the disease for an affection of the brain, which it sometimes much resembles. The signs are, in the first place, those con- nected with percussion, which is perfectly flat, as the lung re- mains solid, and very little air is contained in the tubes. The results given by auscultation are obscure, as the current of air has by this time been diverted from the diseased lung, just as the blood is diverted from a gangrenous limb, and therefore little or no sound is heard. The respiration, when heard, is feebly bronchial; a mucous rhonchus is also present. We have, then as signs of the third stage, flatness on percussion, feeble bronchial respiration, and mucous rhonchus, The reso- nance of the voice is proportional to the respiration, and is of course feeble. These signs are all very obscure, and therefore we may often be foiled when called to a patient in this stage of the disease. There may still be heard in very strong inspi- rations a decided crepitant rhonchus ; but this is rather owing to a portion of the lung which remains still in the first or second stage, and admits the air in very strong inspirations. The signs of the fourth stage, or that of abscess, are the usual signs of formation of a cavity, viz., at first a mucous rhonchus becoming more loose and large, until at last a well developed gurgling is heard, produced by the passage of air through the pus contained in the cavity. The following table will give you a condensed view of the physical signs connected with the dif- ferent stages of the disease : 140 PNEUMONIA. First stage, or en-gorgements. Rude or harsh re-spiration ; crepi-tant rhonchus. Percussion clear, or nearly so. Second, or hepa-tisation. Bronchial respira-tion ; broncho-phony ; crepitant rhonchus around it.. Percussion flat, or very dull. Third, or purulent infiltration. Bronchial respira-tion in large tubes, feeble or absent elsewhere; mu-cous and subcrepi-tant rhonchus; bronchophony im-perfect. Percussion flat. Fourth stage, or abscess. Cavernous respi-ration, gurgling. Percussion flat. In practice, several of these stages may co-exist in the same lung; but the signs of each may be recognised without diffi- culty, and the proportionate extent marked out with tolerable precision. When the disease terminates by recovery, it gradually retraces its steps until it returns to a healthy state. The signs connected with ^this return to health are called the signs of return, or of recovery: their regularity depends upon the stage which the disease had previously reached. If the disease advance no further than the second stage, it will regularly return to the first. When first the crepitant rhonchus of return is heard, it is looser or more moist than the true crepitant; this gradually subsides, and the vesicular respiration re-appears, but remains for a long time much more feeble than it was previously to the attack. The bronchial respiration and dull percussion do not suddenly cease, but remain in some degree for a considerable time after the cessation of most of the symptoms of the disease. This depends upon the consolidation of the lung, and the difficulty with which the tissue returns to its vesicular expansive con- dition. When, however, the disease has reached the third stage, this series of changes does not occur. The mucous rhonchus is the first sign of improvement observed, it depends upon a PNEUMONIA. 141 large quantity of fluid which is poured into the tubes. The crepitant rhonchus of return is not heard, because no air passes through the smaller tubes. The fluid, which is produced in the bronchi, consists of mucous and purulent matter, resulting from the breaking down of the diseased tissue, and the secre- tion from the tubes passing through the inflamed mass. The secretion of this fluid contributes very much to the relief of the disease. The liquid gradually becomes more and more mu- cous, until it is perfectly natural. The return from the fourth stage is marked by the secretion of pus becoming less and less, and at last disappearing with the cicatrisation of the parts involved in the abscess, while the se- cretion becomes entirely mucous in its character. These stages belong to pneumonia of a perfectly frank char- acter ; they are, however, liable to be modified by various cir- cumstances which are necessarily attendant upon the disease. There are some lesions of other organs than the substance of the lungs, always found in pneumonia, — that is, inflammation of the pleura, and of the bronchial mucous membrane. The pleurisy is at first dry, and merely produces slight pain and a feeble sound of respiration. When the pleurisy is slight, the affection is simply called pneumonia; when the pleurisy is severe, and attended with a large effusion, it is called pleuro- pneumonia ; and when the pleurisy is considerable, with very slight inflammation of the parenchyma, it is merely termed pleurisy. When the pleuritic effusion is considerable, the signs of one or the other affection predominate according to the re- lative stage of each disorder ; the pneumonia is apt to decline sooner than the pleurisy, which may remain for an indefinite period after the cessation of the inflammation of the substance of the lung. The bronchitis which attends pneumonia may be confined to the tubes which lead to the lobules which are inflamed, or it may extend throughout the bronchial tree. That which is con- fined to the inflamed portion of the lung is always present to a greater or less degree ; but the bronchitis which extends fairly throughout the tubes is extremely variable, and generally takes place under two different circumstances. In one the bronchitis occurs as an ordinary catarrh, and the pneumonia occurs after- wards during its progress. In the other the bronchial affection comes on late in the disease, and generally in the third stage of it, when the purulent secretion is copious, and passes into the bronchial tubes. Having mentioned the physical signs of frank pneumonia, I shall now proceed to consider the functional signs of this affec- 142 PNEUMONIA. tion. These are of three kinds —local, secondary, and general. The local comprise cough, expectoration, frequency and mode of performance of the respiration, and the pain produced by the act of breathing. By secondary signs we mean the affections of the brain, alimentary canal, the assistant chylopoietic viscera, &c. The general signs are those which are common to all in- flammatory affections, as the condition of the circulation, &c. Local signs, cough, &c. The cough is usually at first the ordinary cough of acute bronchitis, which is either hoarse, or a loose mucous cough. In this case the bronchitis is the pre- dominant affection ; as soon, however, as the parenchyma be- comes seriously affected, the cough changes its character, as- suming the form which is called pneumonic. The pneumonic cough is short and suppressed, which results partly from the pain felt during the act of coughing, and partly from the im- possibility of inflating the lungs completely ; hence the force of the column of air, which is expired during the act of coughing, is not sufficient to cause a loud and distinct sound. The pneu- monic cough begins from the first, if the disease attack the parenchyma and pleura before passing through ordinary bron- chitis. The cough sometimes exhibits this character from the first. In some cases of pneumonia the cough is wanting through- out the course of the disease, which is then said to be latent; in such cases the patient is generally aged, or the pneumonia succeeds another affection. As the disease proceeds, secretion takes place, and the cough again becomes loose ; when an ab- scess is formed, it becomes exceedingly loose and rattling. The frequency of respiration is increased in pneumonia, and the degree of this increase is a tolerably exact indication of the extent of the affection. The frequency of respiration arises from the diseased lung being rendered unfit for the performance of its functions, so that a smaller portion of the blood is ex- posed at once to the action of the air, and a smaller quantity of the air is inhaled during an inspiration. Therefore it must be changed more frequently. Besides the inflation of the healthy portion is less complete than natural, because the motion of the lung is suspended, and the action of the respiratory muscle is less complete. Where only one lung is slightly diseased, the frequency of the respiration is but very little increased. If the disease embraces the whole of one lobe of the lung, it is increased to forty or fifty a minute: and when both lungs are involved, the respiration will be as frequent as fifty or sixty in the minute. Should it be more frequent, the extent of mischief is very great. It must be evident, then, that this sign is impor- tant for the prognosis of the disease. The mode of performing PNEUMONIA. 143 respiration differs from that observed in the healthy state. The patient breathes irregularly ; the respiration is usually high, and is performed chiefly by the side of the chest which is not inflamed. At first it is not strictly abdominal: but after pneu- monia has continued for a time this character is developed, and then the ribs remain nearly motionless. The pain is very variable, and is proportioned to the inflam- mation of the pleura. When the inflammation is situated near the surface of the lung, the pleura is necessarily much involved, and the pain is consequently acute ; but when it is deep-seated, there is, generally speaking, little or no pain. In the old and feeble the pain is scarcely felt, whatever be the portion involved. Therefore, as in many cases it is wanting, and as, when present it does not indicate the extent of the pulmonary inflammation, it is a sign of comparatively little importance. The expectoration at the commencement of pneumonia con- sists of mucus, such as is observed in ordinary bronchitis, and differs but little from the healthy secretion. As the disease is developed, it becomes viscid and transparent, and in some cases is of a rusty colour, the viscidity and transparency are considered as the characteristic properties of the pneumonic sputa. It is sometimes so viscid that it will not flow from the vessel con- taining it, although the latter be turned bottom upwards. It is small in quantity, generally from one to four ounces in twenty- four hours; its becoming more abundant is generally a sign that the disease is retrograding, sometimes it is mixed with yellow sputa from some other portion of the lung or tubes. As the disease passes from the second into the third stage we observe an admixture of pus, which renders the liquid muco- purulent, it is at the same time much more abundant than it was previously; when it declines the sputa become thinner and more mucous in their character. If an abscess form, the sputa become decidedly purulent, and a large quantity is either sud- denly discharged or expectorated in a very short time. This is to some extent the case, when the third stage is so far ad- vanced that a considerable portion of the lung is softened into a pulp, even if there be no large cavity. The secondary signs may be divided into those connected with the lungs, and those dependent upon other organs. Affections of the lungs. — Bronchitis and pleurisy almost always attend pneumonia, but their severity varies exceedingly. Tubercles are sometimes formed in the lung during the course or in the decline of pneumonia, which, though it is not pro- bably the sole cause of their formation, it in many cases hastens their development. Their formation, of course, increases very 144 PNEUMONIA. much the gravity of the prognosis. Emphysema is sometimes produced during an attack of pneumonia, principally in children. This lesion is not so important when it is an affection owing to pneumonia, as when it has existed previously to the occurrence of the latter affection, in which case, by increasing the dyspnoea, it renders the prognosis more unfavourable. The heart is very often secondarily affected in this disease, sometimes from the general diffusion of the inflammatory action, and sometimes from the imperfect performance of the function of respiration, the blood becomes congested in the right ven- tricle, and in some cases a coagulum is formed in the ventricles in consequence of the imperfect circulation, and of the highly fibrinous state of the blood. But, often in addition to this, we find inflammation of the lining membrane of the left ventricle, which is more frequently affected in this manner than the right, in consequence of the general law, than the arterial system is more subject to inflammation than the venous. This occurs in a large proportion of the severe cases of pneumonia. This affection of the heart varies in intensity— sometimes the mem- brane is merely reddened, sometimes it is opaque and thickened, partly by the deposition of lymph, and occasionally it is ulcer- ated ; the ulceration is generally seated at the valves. These cases of endocarditis are sometimes distinguished with difficulty, because the symptoms are in a great extent, masked by those of the pneumonia. They always constitute a grave complica- tion of the disorder. The brain is very often affected in pneumonia, and when the inflammation of this organ occurs, it is attended by delirium, such as takes place in common arachnitis. The medullary cerebral substance is not often the seat of the inflammation, which in almost all cases is confined to the membranes, and to the cortical substance. Dr. Louis says, that one-sixth of the cases of pneumonia which he saw, were complicated with an affection of the brain ; like the inflammation of the heart, it occurs most frequently in the very severe cases of pneumonia. If the cerebral symptoms should be severe, the primary affection is generally masked by the secondary, which often gives rise to an error in diagnosis, as the signs of arachnitis remain very evident while the functional signs of pneumonia are obscured, and, therefore, liable to be overlooked. The cough may cease almost entirely and the expectoration disappear; and, in fact, all the thoracic symptoms may be concealed by the occurrence of the meningeal inflammation. Cases of this kind are some- times distinguished with difficulty, they are not, however, very frequent. This complication adds very much to the gravity of PNEUMONIA. 145 the prognosis ; and unless active treatment be resorted to at the commencement of the attack, the disease is very apt to prove fatal. The liver is sometimes involved in pneumonia, but the fre- quency of this complication varies at different seasons, and in different localities, being much more common on our southern Atlantic coast than it is at the north. This inflammation of the liver is distinguished by some authors from bilious pneumonia, although it closely resembles it, and as it seems to me, differs only in the bilious pneumonia described by Stoll, being an epi- demic disease. Its signs are jaundice, pain in the side and shoulder, and cerebral symptoms, such as stupor and somno- lency, which are dependent upon it. Bilious pneumonia, though in some years common amongst us, is now very rare. It differs from pneumonia in which the affection of the liver is a mere secondary complication, by the liver being attacked in bilious pneumonia, simultaneously with the lung. The right lung is the one which is always most inflamed in pneumonia complicated with the inflammation of the liver, and the transmission of the inflammation from the lung to the liver, in the simultaneous attacks of the two organs, shows that there must have been previously a disorder of the liver, which favoured at least, the extension of the disease. Hence the affection is so frequent in warm climates and miasmatic situa- tions. This complication certainly adds much to the difficulty of diagnosis without the physical signs, especially as the cere- bral symptoms, such as stupor or delirium are generally so well marked as to suppress, in a great degree, the cough. Inflammation of the stomach and bowels, of the oesophagus and pharynx, have all been observed in pneumonia, and also inflammation of the kidneys; but these complications are not more common in this than in other inflammatory diseases. They may be known by their proper local signs, and I shall therefore, not enter into a minute account of them. General signs — Capillary circulation.— A sign which may be called general, although confined to very narrow limits, is the appearance of the face, for this depends upon the capillary circulation. In acute cases we meet with a circumscribed flush of a circular form, and which is sometimes confined to one cheek, sometimes found in both. When one cheek only is affected in this manner, it is more frequently, though not inva- riably, that which corresponds with the diseased lung. In some cases the whole face is flushed, the colour varying from a light to a deep red ; sometimes it is still deeper, and may be almost of a bluish colour. The whole countenance is generally changed. 146 PNEUMONIA. These various tints depend upon the greater or less obstruction of the circulation of the blood through the heart and lungs, they are darker when the difficulty of the circulation is greater, and often become bluish about the lips and nostrils, while the rest of the face is pale, if a coagulum should form in the heart. Dilatation of the nostrils in each inspiration, is another symp- tom ; this depends upon the dyspnoea, and its extent is in pro- portion to the latter. General circulation. — The disease makes its appearance in the following manner : The patient is almost always first seized with a chill; this lasts half an hour or more, and sometimes two or three hours, and when it goes off is succeeded by a fever, which continues during the whole twenty-four hours, but usually increases at night, and is rarely attended with extreme heat of skin. The pulse is full, hard, and developed at the commence- ment of the disease; in the latter stages it is frequently feeble. It is very generally from one hundred to one hundred and twenty, and rarely becomes more frequent, except in the termi- nating stage of the disease. It is in most cases a good measure of the intensity of the inflammation, and a correct indication of the propriety of blood-letting; but the pulse is sometimes con- tracted, and at the same time the inflammation is violent; if bleeding be practised it rises and becomes softer. A careful bleeding, if the general symptoms be inflammatory, is the best guide in this matter. The alteration of the strength is another sign which is con- nected with inflammatory diseases. In general the degree of dimi- nution depends upon the importance of the part affected, and the extent to which the inflammation proceeds. Thus, a patient with pleurisy, will continue to walk about until the effusion causes so much dyspnoea that he is compelled to keep his bed ; whereas a slight pneumonia, with scarcely any local signs, will enfeeble him so much that he will be unable to sit up. Diagnosis. — Although the physical signs are the most im- portant in the diagnosis, as they indicate the extent as well as the nature of the affection ; yet there are certain rational signs, which, taken together, may be considered as pathognomic, namely, the expectoration, flush, and dyspnoea: these are, how- ever, often obscure at the commencement of the attack. The physical signs are often only required to ascertain the extent of the disease, as its character is rendered sufficiently apparent from the rational signs of sthenic pneumonia. Prognosis. — The prognosis is very variable in all diseases of this kind, as it often depends upon circumstances uncon- nected with the disorder itself. In ordinary frank pneumonia the prognosis is favourable where other things are not unfavour- PNEUMONIA. 147 able; that is, where it attacks a person previously in good health, and the treatment is commenced early, for this modifies the disease very much, when begun at an early period ; but after it has continued a few days, the prognosis is very little affected by it. When it is complicated with an affection of the brain or liver, the prognosis is more unfavourable. When this dis- ease occurs in very old persons, it is always much more danger- ous than when it occurs in the young or the middle-aged. The danger seems to increase very nearly in proportion to the ad- vance in years, aged patients dying often of the complicated in- flammation. Duration. — A mild case of frank pneumonia without treat- ment usually lasts from 10 to 21 days, but if it has reached the third stage, it will last much longer. If it has continued a few days before the commencement of the treatment, it rarely ends before the tenth day. If you treat it from the first, you may frequently produce a partial jugulation of the disease, and shorten somewhat its duration. The observations made at Paris coin- cide in this respect with the experience of Dr. Jackson, of Bos- ton, and the results obtained in this city. When the disorder terminates fatally, death usually occurs early in the third stage, or just in the passage from the second to the third stage. This stage is reached in different periods, sometimes in three or four days, but generally about the beginning of the second week. Treatment.—The treatment of frank pneumonia is that of ordi- nary inflammation modified by the peculiarities of the organ affected. Hence bleeding is the most efficient remedy, and should be practised freely at the beginning of the disorder. The method which has of late years been revived by Dr. Bouil- laud, consists in repeated bleedings, which are prescribed again and again for several days. This method is reduced to a regular formula, and in the hospital practice there are not so many ob- stacles to this system as in private ; but it must be obvious to every one that no one method of treatment, or at least no regular formula, is applicable to all cases, and I do not, therefore, ad- vise a uniform method of blood-letting. The best directions must be gathered from a knowledge of the disorder, and from the present symptoms of the patient. Thus, in the commence- ment, a very large bleeding, pushed to the verge of syncope, is certainly best in a plethoric individual, or a moderately strong person, previously in good health, if the pneumonia is of a highly inflammatory kind — that is, if the evidence of vascular excite- ment be decided ; for it is in these cases that the inflammation tends necessarily to diffuse itself, as it were, over a large sur- face, and to attack several organs, especially the serous tissues 143 PNEUMONIA. of the circulating system. A large bleeding is of course the surest means of checking this tendency, and is the most com- forting remedy for the patient, as it at once diminishes the head- ache and the oppression which are amongst the most disagreeable symptoms. A general bleeding produces much more effect than a local one, which is almost nugatory in its action upon the highly inflammatory cases of pneumonia, although very power- ful in the later stages, or in the slighter forms of the disorder. The venesection may be repeated on several successive days, or in the after-part of the days in which the first bleeding was practised, if it seem necessary from the excitement of the pulse and the vascular action. That is, if the pulse should rise again, and especially if it should become more developed after the first bleeding. It is, as you may readily suppose, impossible to lay down positive and unvarying directions for conditions of things which are in their nature changeable. But by reflecting on the condition of the lung, which at first is merely that of engorgement or commencing hepatisation, and on the stimulant properties of the inflammatory blood, it is easy to see that seve- ral bleedings may become necessary, although in the majority of cases one single bleeding will suffice, especially if the seda- tive effects of it be kept up by other remedies, particularly the antimonials. The appearance of the blood drawn, is, of course, highly in- flammatory,— that is, much buffed, with a very firm crassa- mentum ; this is a tolerably correct, but not a sure guide for the repetition of venesection. The blood will generally remain buffed, even in that period of the disease when bleeding is no longer of benefit. A physician is frequently called to a patient late in the dis- order, when the inflammation has either not been treated by bleeding, or the disease continues very severe. It is very dif- ficult in these cases to decide as to the propriety of general bleeding; my own impression is, that bleeding is in these cases apt to produce a double influence, which is partly of mischief, and partly of benefit. The inflammation, which is generally commencing in certain parts of the lung, or at least is much less advanced than in others, may be, to some degree, checked by the blood-letting; but those portions of the tissue in which the blood is completely stagnant, and, as it were, incorpo- rated with it, are restored with more difficulty if blood be drawn from the general system. This is still more strongly the case, if the pneumonia has in part passed into the third or suppurative stage. The effect of blood-letting upon the general circulation is also in these cases often productive of PNEUMONIA. 149 evil, for the coagula which begin to form in the heart may be- come a greater obstacle to the circulation if the strength of the patient be lessened. The latter effect is difficult to demonstrate ; but it has struck me in a number of cases that it was founded on good grounds, and I therefore state it for what it may be wrorth. The action of local depletory means in acute sthenic pneu- monia is much more limited than that of general bleeding; the be- neficial effects of these remedies are most important in the latter stages of the disorder, when a portion of the lung remains in the first or second stage of the inflammation, but the greater part of it has passed into the third stage. The local bleeding, then, seems to get rid of the remaining inflammation with less exhaustion of strength. When we meet with patients who have been neglected during the greater part of an attack of pneumonia, we are often obliged to limit our depletory measures to cups or leeches. The cups should be applied to the poste- rior parts of the chest, immediately over the inflamed lung. They should be used in considerable numbers, say six or seven and may be repeated once or twice if the disease does not abate. Blisters, or tartar emetic ointment, are not necessary as a general rule in acute pneumonia; for the disease belongs to those inflammatory disorders, for the earlier stages of which blisters are not adapted. They are useful, however, at the beginning of the third stage, when the benefit from them is scarcely equalled by that from any other remedy in the treat- ment of pneumonia. The blisters then act with great power in checking the inflammation, at the same time preventing the collapse which is so frequent at this stage of the disease. The blister should be rather large, and in general the best place for it is under the axilla, or between the scapula and the spine. Tartar emetic ointment applied so as to produce a very rapid pustulation, has been recommended under similar circum- stances ; but I do not in general regard it as possessing any ad- vantages over blisters, while it is for many reasons inconvenient. Sinapisms, or other rubefacients, are often useful within certain limits,— that is, as stimulants to the general strength, and as remedies which have a powerful influence upon the dyspnoea which attends the disorder. Next in importance to general blood-letting as a remedy in pneumonia, is the tartrate of antimony : this medicine may be given in several ways, either as a simple diaphoretic expecto- rant or as a direct arterial sedative. In the former case it should be given in doses from a twelfth to a quarter of a grain 13* 150 PNEUMONIA. every two hours ; in general a sixth of a grain is borne at first, and afterwards the patient should take a quarter of a grain, either alone, or combined with nitre or calomel. The medi- cine is, in these doses, quite free from danger, except in a very- few individuals of extremely irritable temperament; for there are some patients who cannot bear antimony in any dose, or in any form. In most cases, however, these small doses of a sixth of a grain are attended with a disposition to sweating, and a diminution in the excitement of the circulation, which, on the other hand, always coincides with a diminution of the general inflammatory action, which plays so important a part in the pathology of acute pneumonia. The antimony should gene- rally be continued during the earlier stages of ordinary acute pneumonia, but it must be given in less doses when the strength of the patient becomes notably diminished, or the irritability of the stomach should be excessive. Of late years the contra-stimulant, or Italian method of giving antimony in very large doses, has been often resorted to in the treatment of pneumonia. This method has been perfected in France, and rendered much more safe. In my own practice when I have followed this method, I have adopted very nearly the usual formula of the French hospitals ; it is as follows : Tart. Antim. gr. vj.; Aq. Menthae. ^vj.; Gum. Acac. gij. M. Of this a table-spoonful may be taken every two hours. It is not always customary to add the gum arabic, but the irritation of the stomach is certainly lessened by it. The antimony, taken in this dose, frequently produces no other effect than purging, which does not invariably follow. If the purging is severe, it is readily checked by adding a few drops of laudanum to each dose. In itself opium is rather objectionable, but it may be properly used, if there is a decided tendency to purging. The medicine should be continued in this dose for twenty- four hours, and not increased until the next day, when eight grains may be given instead of six ; either in the same or in a larger quantity of vehicle. Itis better to avoid giving it in too con- centrated a form, for it then would probablyproduce much vomit- ing or at least retching. If the tolerance has been established the first day,—that is,if the remedy has not produced decided puking or purging, or very debilitating sweats,it maybe safely taken dur- ing the second day; and if the disease does not abate, the dose for the third day should be the same as that for the second. But, after the third day, there is some danger in continuing the anti- mony in a high dose, unless the patient is perfectly conscious, and his brain entirely clear; if the remedy be then attended by no uncomfortable sensations, there is little danger in its admin- istration. But if the patient is comatose, or even slightly stupid, PNEUMONIA. 151 very extensive inflammation and other structural lesions may follow the administration of the tartarised antimony without any symptoms to indicate them. If the cerebral functions are unimpaired, the condition of the nervous system is a very faith- ful guide for the administration of tartarised antimony. The good effects of the medicine are shown by the diminu- tion of the local signs, and of the oppression and fever; this is especially obvious in the local signs of the pulmonary inflam- mation, for the antimony seems to act more quickly upon the parenchyma of the lungs than even general bleeding. When the symptoms have declined, the remedy should be gradually diminished, and not suddenly discontinued ; about two grains should be taken from the dose, each day, until the whole amount is withdrawn. There issome danger or at least inconvenience in attempting to give antimony in these doses to certain individuals who possess a peculiar idiosyncrasy with regard to the medicine ; for there are some persons who cannot bear it in any form, or even in small doses, without great nervous distress and extreme prostration. To such persons the remedy should never be given, at least not in any other than in very minute doses. Besides these peculiar cases, the antimony will occasionally produce in- jurious effects from the mere purging or excessive emesis which it occasions, — chiefly from the former cause. It is true that the addition of a small quantity of opium, or even the mere persistence in the remedy without an opiate, will often suffice to arrest such a tendency ; but if the patient should not lose this extreme susceptibility to the antimony, it becomes neces- sary to discontinue it. The remedy which is next in power to antimony is mercury, although its effects are somewhat different; When given in the period of hepatisation it acts in two ways, — as a directly antiphlogistic remedy, and as possessing a peculiar power in preventing, or at least checking, the formation of lymph, — in other words, it is antiplastic. Hence, when given after bleed- ing, it is directly opposed to the progress of the inflammation, and modifies the products which result from it. Mercury should be given in such doses as to produce a full impression upon the general system, not amounting to ptyalism, but producing a slight action upon the gums, as an evidence of its constitutional effect. The proper dose is from a quarter to half a grain of calomel every two hours if it be desirable to make a rapid im- pression ; from a third to half a grain three times daily if the mercury be designed to act more slowly. Even less doses pro- duce at times a good effect. 152 PNEUMONIA. The calomel is often combined with ipecacuanha or opium ; but the latter remedy should be given with great reserve in acute inflammatory pneumonia : the ipecacuanha is free from danger, and is generally of service by its power of facilitating the operation of the mercurial and promoting secretion from the lungs. It should be given in doses of about one grain, every few hours : generally the patient will bear it well. The mercurial impression is usually followed by a rapid decline of both general and local symptoms. If it should fail, the disease assumes one of two forms, — it either remains in the highly inflammatory condition, or it passes into the third stage of the disease. In the first case it may become necessary to recur again to depletory measures ; in the second, blisters to the chest, with stimulating expectorants, and sometimes wine whey, or in persons addicted to the abuse of alcohol, milk punch may become necessary. The expectorants which are of most value when the anti- phlogistic treatment has failed, are the eupatorium and senega, or the sanguinaria. These may be given in the form of infu- sion — half an ounce of eupatorium, and two drachms of senega in a pint of boiling water— of which from a table-spoonful to a wine-glassful, accordingto the susceptibility of thepatient, should be taken every two or three hours ; or the senega and sangui- naria may be combined in the dose of two or three drachms of senega, and one of sanguinaria, in half a pint of boiling water, and a table-spoonful may be given every two hours, unless it should excite much nausea. In a few cases the dose may be increased. After the acute symptoms of pneumonia are dissipated, the patient will often continue to cough a little; and on ex- amination it will be found that the bronchial respiration has not entirely ceased at the root of the lung. This state of things depends upon the very slow absorption of the substance which is effused into the cellular tissue of the lung. It requires no special treatment, and in a little while will cease ; still the patient should avoid exposure to the cold damp air, and to pro- mote the resolution he may wear a Burgundy pitch-plaster, or some similar covering over the part affected. LOCAL PNEUMONIA. Besides the highly inflammatory cases of pneumonia, there is a variety of the disorder which is also simple and inflammatory, but more local in its action, attacking only a small portion of the lung, and therefore not producing the general inflammatory PNEUMONIA. 153 action of the severer cases. The local signs of pneumonia are present in these cases, such as bronchial respiration and crepi- tant rhonchus; but the fever is moderate, or may not exist at all, and the prostration is but slight. These cases cannot be distinguished from ordinary catarrh, except by the local signs and the expectoration, which is generally, but not invariably, characteristic. The duration of these cases rarely exceeds a fortnight, but in general it does not extend beyond ten or twelve days. The patient is not often confined to his bed, and in some cases he feels so little inconvenience that he will insist upon going out and following his usual employments. The prognosis is always favourable, unless some unexpected aggravation of the disease should take place. The treatment in this form of local pneumonia is extremely simple. The disease tends so universally to recovery that there is little difficulty in its management, and the large majority of cases would get well under any treatment. It is, however, quite possible to hasten its course. For this purpose the best remedies are, at the very commencement, a moderate bleeding, or after the first few days one or two applications of cups to the affected parts. These remedies will relieve the lung, and facili- tate the cure, which is brought about by exciting secretion from the inflamed surface. If the secretion takes place readily, or if the inflammation is very slight, blood-letting in every case is not at all necessary ; but if the pulse be excited, the symptoms are more or less relieved by venesection to some twelve or fifteen ounces, and no inconvenience at least will result. Bleeding, however, is never followed by the same decided benefit as in the cases of highly inflammatory pneumonia. The secretions from the lungs are promoted by the same treatment which is applicable to the declining stages of the last mentioned variety, — that is, the infusion or the syrup of senega or ipecacuanha, or the infusion of eupatorium or sanguinaria, or combinations of these with the senega. Small doses of the an- timonials are also productive of prompt relief when the patient is feverish, but I do not regard the antimonials as so generally useful as the vegetable expectorants especially the ipecacuanha. Towards the decline of local pneumonia the case requires some attention to distinguish between those cases which are really simple, and those in which there is a complication of pulmo- nary tubercles : in the latter case the disorder may pass into phthisis ; in fact, it is then only one of the modes of attack of the latter disease. 154 PNEUMONIA. ASTHENIC PNEUMONIA. Inflammation of the lungs does not necessarily assume the sthenic form ; it may be connected with symptoms of depres- sion, which may either come on from the beginning, or at an after-period of the disease. In the third stage this naturally occurs to a certain extent; that is, when the suppuration has extended to a considerable portion of the lung, the patient sinks into a prostrate or asthenic condition, very different from the false or apparent prostration which may arise very early in ordinary pneumonia from the dyspnoea produced by the exten- sion of the inflammation to a large surface. But the secondary asthenia is not altogether similar in its symptoms to that which occurs much earlier in the disorder, and in its progress differs altogether from it. The causes which render pneumonia asthenic at the earlier stages of the disorder may be referred to three classes: ad- vanced age, previously enfeebled health, and certain epidemic causes, which are not known. Neglect, and exposure to con- tinued cold, favour the transformation of ordinary pneumonia into this variety, and have some influence over it at the begin- ning. The local signs and the expectoration of .asthenic pneumonia do not differ from those of the inflammatory variety, except that as it passes more quickly into the suppurative stage there is but little viscid expectoration ; it very soons takes on the characters of the third stage, and in some cases the viscid in- flammatory sputa are totally absent. There are, however, many exceptions to this rule, and the sputa are sometimes perfectly well characterised, and similar to those in ordinary pneumonia. The general symptoms are more unlike those of ordinary inflammation : instead of the forcible pulse, and the active ex- citement of the capillaries, there is a feeble pulse, a diminished action in the smaller vessels, and a rapid sinking of the strength. In the worst cases the prostration is as great as in the typhoid varieties of fever, and the pneumonia is then frequently termed pneumonia typhoides. The epidemics of asthenic pneumonia are often of this character, and the disease is then extremely fatal. This is especially the case with the disease when it occurs among soldiers, who are much exposed to its causes. Gangrene of the lung frequently supervenes in the third stage of this variety of pneumonia; and in all cases there is a close connection between the two affections, so that it is often ex- tremely difficult to draw the dividing line between them, unless the gangrenous sputa should make the case clear. PNEUMONIA. 155 The treatment of asthenic pneumonia is a matter of much difficulty ; general bleeding is almost never borne with advan- tage, and in most cases it is directly contra-indicated by the exhaustion of the patient; cupping or leeching is very often of benefit, and in all cases it is easy to try the effects of a small local abstraction of blood, and to abstain from it, if its effects should be injurious ; in general, this kind of depletion, if borne well, is in such cases of decided benefit. If either the local abstraction of blood should not be tolerated, or the disease should continue but little improved after the patient has been cupped, blisters must be applied ; they are much more certain in their action than in ordinary pneumonia, and may be used much earlier. The blister often requires to be re-applied if the part should heal very soon, or a new one may be placed over an adjacent part of the thorax. Other contra-irritants, such as sinapisms, are of more benefit as general stimulants to the ner- vous system, than as revulsives against the pneumonia. The internal remedies demand more attention, it is often very difficult to determine upon their administration, they must be pre- scribed and again discontinued according to the state of the patients strength, and the degree of the oppression under which he suffers. Antimony should, as a general rule, be proscribed ; but there are some cases in which the inflammatory action is acute enough to justify a recourse to this remedy, —that is, in small doses; in large quantities, it is always of danger. The times for its administration must be carefully chosen. It should never be given if there is much sweating, or a small and feeble pulse. The combination of opium, calomel, and ipecacuanha, is much more frequently prescribed, and as a general rule, it answers well. The dose, may be varied in this form of the dis- ease, just as it is in the advanced stages of ordinary pneumo- nia ; and the opium should be given in minute proportions, not exceeding one grain, or at most a grain and a half in twenty- four hours. In a considerable number of cases I exclude the opium altogether, — that is, if there should be much oppression and difficulty of expectoration. The stimulating expectorants, and in some cases even wine, or stronger stimulants, are useful, and even necessary, in this disorder. The senega and eupatorium may be given at first nearly in the same doses, as in the third stage of ordinary pneumonia ; but they are, in some cases, tolerated for a very short period before it becomes necessary to substitute for them the milder alcoholic preparations, with some nutritious food,— that is, either wine whey, or, in a few extreme cases, milk punch. 156 PNEUMONIA. In the form of pneumonia which occurs in persons of intem- perate habits, and is nearly always asthenic, alcoholic stimu- lants are often indispensable; this is especially the case if the inflammation should be complicated with delirium tremens. If stimulants be omitted in this class of individuals, the mor- tality of the disease will be very great; but if they be com- bined with local depletion and blistering, the local inflammation will be relieved, while the nervous asthenia, which is so apt to occur in these persons, may be prevented. Carbonate of ammonia is another remedy which is often of extreme importance in this disorder; it is peculiarly adapted to those cases in which the secretion into the tubes is considera- ble, and the patient expectorates with difficulty. It may often be combined with small doses of ether, or Hoffman's anodyne. The usual dose is five grains of carbonate of ammonia, and from twenty to fifty drops of the ethereal preparation, every two hours ; when the depression is very great, the medicine may for a short time be given even in barger doses. Asthenic pneumonia sometimes prevails as an epidemic, and is attended with so much prostration of strength and alteration of the blood, that it has received the name of typhoid pneumo- nia, or even of typhus fever. These cases require more decided stimulation than those of the same variety in which the inflam- matory symptoms predominate over the general feebleness, and will often scarcely bear even the local abstraction of blood. Blisters, with stimulating expectorants, especially ammonia, and sometimes wine, or other alcoholic preparations, become necessary. LOBULAR PNEUMONIA, OR PNEUMONIA OF YOUNG CHILDREN. These terms are used as nearly synonymous, although lobular pneumonia is not strictly confined to children. It is, however, much more frequent in them than in adults. It differs from the ordinary pneumonia both in its progress and pathological con- ditions. Instead of the disease occurring in one lung, and in a limited portion of the tissue, it is scattered over a large ex- tent, and throughout both lungs, but it attacks isolated lobules, leaving for a time the intermediate tissue in a healthy state; these inflamed lobules become more and more numerous, until the greater part of the parenchyma is gradually consolidated. It is this progress of the disease which gives to it the term lobular pneumonia ; the lobules affected are chiefly at the pos- terior part of the lung, for the gravitation of the blood towards this portion seems to favour the development of the disease in its cellular structure. PNEUMONIA. 157 The appearance of the tissue is different from that of ordinary pneumonia ; it is much darker, harder, smoother, and imper- fectly granulated ; it rarely presents the characters of the third stage, passing with difficulty to purulent secretion. The pleura covering the hardened tissue is sometimes, but not always inflamed, and if but few lobules are attacked, there is little or no accompanying pleurisy. The disease is rarely confined to a single lung; both are almost always attacked, but the right lung at an earlier period and to a greater degree than the left. The bronchial tubes are much more frequently inflamed than the pleura ; they contain the usual viscid mucus of the bronchitis of children. The affection of the bronchial tubes is often the first step in the series of diseased actions constituting lobular pneumonia, and the induration of the lungs follows at various periods of time after the commencement of the bronchitis. The induration then appears first at the posterior portion of the lungs, and sur- rounds the smaller and more numerous tubes ; it thence advances gradually towards the anterior part. In other cases the indu- ration of the lung takes place very rapidly, after the impression of cold or some other cause of pulmonary congestion. The difference in the mode of attack naturally establishes two varieties of lobular pneumonia ; one is acute and primary, the other more chronic, or at least less acute, and secondary to bronchitis, or to some general disorder of the economy. In either case the symptoms of the disease are nearly the same. The physical signs are at first merely those of the ordi- nary bronchitis of children; that is, a sub-crepitant or mucous rhonchus, the percussion remaining at first clear, but gradually- becoming dull as the disease advances. The dulness is not confined to one side of the chest, as in ordinary pneumonia, but is nearly equal on both sides, hence it is difficult to draw the line of distinction between the sound and that yielded by a healthy lung. The only method of doing this is to fix in the mind a correct idea of the average sound yielded by the healthy chest in children of the age of the patient, and then to institute the comparison. The dulness does not, in the majority of cases, pass into complete flatness, for there is rarely a perfect consoli- dation of the parenchyma. The respiration is also in most cases not completely bronchial, for the same reason that the percus- sion does not often become perfectly flat; but it approaches this character more and more nearly as the disease advances, and sometimes offers it to a very decided degree. Previously to reaching this stage, however, it assumes several intermediate changes, becoming gradually harsh and incomplete. 158 PNEUMONIA. The other signs of this affection do not differ from those of ordinary bronchitis of children ; there is in both cases cough, but no expectoration, and the dyspnoea gradually increases as the disease advances from point to point of the lung. There is fever, which is sometimes intense; and the disturbance of the circulation extends to the capillaries, which are much congested, especially those of the face, where the redness is in the early stages of the disease extremely marked, forming circumscribed patches on each cheek. This peculiar colour, with the dilata- tion of the nostrils caused by the dyspnoea, forms one of the best indications of the disease. The accidental symptoms are those connected with the abdo- men and brain ; these are, from their nature, very variable. There is almost always more or less disturbance of the digestive functions ; sometimes vomiting, and either diarrhoea or consti- pation. The very irregularity of these symptoms proves their little importance for the diagnosis, and that they are only of value in the prognosis of the disorder. The cerebral symptoms are more constant; the obstruction to the circulation neces- sarily produces congestion of the brain, which is shown by de- cided stupor. In bad cases, this passes into coma, or even active delirium. Now, if these cerebral symptoms become ex- tremely severe, they may, to a great extent, conceal the pec- toral signs; for cerebral disorder produces, as its inevitable consequence, a more or less complete obliteration of the symp- toms of other organs, or at least it causes a decided diminution of them. The diagnosis of this disease is obvious enough from the symp- toms which I have described, excepting in one respect. As it arises insensibly during the course of bronchitis, there is no pre- cise dividing line between the two disorders. In practice this is of but little moment, for when these diseases approach so nearly, they generally require a treatment which differs but little. There is also a difficulty as regard the diagnosis with one other disease — that of tubercles in the lung; these begin nearly in the same way as lobular pneumonia, and the local, as well as the strictly physical signs, are very similar. At first they can- not always be distinguished with entire certainty ; but, after a short period, the softening of the tuberculous matter will ren- der the distinction very clear. The prognosis in this variety of pneumonia is, as a general rule, favourable in its early stages; and, indeed, in all cases where it occurs as an acute disease, but is not from the commencement sufficiently severe to cause extreme dyspnoea. In those cases which are strictly secondary, and succeed to chronic, exhausting diseases, the en- PNEUMONIA. 159 feebled state of the patient's health renders the probability of re- covery much less. Under all circumstances the disease is attended with more danger than ordinary acute pneumonia, which is very rarely fatal in children more advanced in age, in whom it often occurs. The treatment of lobular pneumonia varies according to the manner in which the disorder commences. If it begin as an acute disease, with much oppression, and other evidence of active excitement from the beginning, it may require active treatment, — that is venesection in a few cases, and very fre- quently leeching to the chest; these remedies are not, however, in most cases imperatively necessary, but they relieve the pa- tient more rapidly and certainly than any other. Blood-letting, in any form, is to be avoided, as a general rule, in cases of the lobular pneumonia of children; and it is only in those stages of inflammation in which the natural secretory efforts of the system seem to be insufficient for its relief, that it should be resorted to. The external revulsive remedies are, to a certain extent, useful in this form of pneumonia, but are less so than in the same disease as it occurs in adults; hence blisters, and other depletory revulsives, although they do relieve, are rarely of benefit until the advanced stages of the pneumonia, and even then are uncertain. Revulsives that act upon a larger surface, and at the same time are slightly stimulating, are much better, such as large mustard poultices. These should be applied not only to the thorax, but also to the lower extremities, especially to the soles of the feet and ankles. A convenient way of making them is to soak thick pieces of bread in vinegar, and to sprinkle them with mustard. In the declining stage, or in the milder forms of the disorder, a simple onion or garlic poultice is an excellent application. The natural cure of lobular pneumonia is, like that of bron- chitis, by secretion from the bronchial membrane; hence, in mild cases of the disease, nothing more is required than to prevent everything that may have an injurious influence with the use of a few simple remedies, which may favour the natural ten- dency to bronchial secretion. These are the wine of ipecacu- anha, graduated so as to keep just within the point of exciting nausea, either given alone or with a slightly stimulating expec- . torant; of these, one of the best and most simple is the domestic syrup of onions, or the lac assafoetidae. If the mucus becomes very abundant in the bronchial tubes, it will often much relieve the patient to increase the ipecacuanha to a dose sufficient to produce vomiting. There is, however, in general, little diffi- culty on that score, — for the tendency to vomiting is in these 160 PNEUMONIA. cases so great, that very small doses of ipecacuanha will excite it, or it may occur spontaneously. Vomiting is of course to be avoided if the congestion of the lung should extend over a large portion of the parenchyma. Tartar emetic may be substituted for ipecacuanha if there is much fever ; but it is not, as a general rule, equal to this remedy, nor is it as safe. Still, there is no important objection to it, provided it be given in small doses to produce a secretory, rather than a contra-stimulant effect. The other expectorants to which I have alluded under the head of bronchitis, are often advisable in lobular pneumonia; but the rules for their em- ployment present nothing remarkable. There is a hygienic precaution, which is essential both in acute and chronic lobular pneumonia: the child should never be allowed to remain long upon its back, nor, if the disease be severe, should it be permitted to sleep more than half an hour at a time. If this be neglected, the congestion of the lungs is greatly favoured, and the disease may prove unexpectedly fatal. The child should be gently carried about, or allowed to sit up in bed, or be simply inclined a little towards one side or the other. It is evident, therefore, that lobular pneumonia differs chiefly from the ordinary disease in its seat, and in its frequently assum- ing more of the congestive than inflammatory form. But there are many exceptions to this, in which the circulation is excited, and decided depletory means are indicated. PNEUMONIA OF THE AGED, AND LATENT PNEUMONIA. In old age, as in early childhood, pneumonia assumes cer- tain peculiar characters, but in the former case it approaches more nearly to certain stages of ordinary pneumonia. The only important difference is the great tendency of the disease to be- come latent, that is, to lose the ordinary functional signs of the acute inflammation, and to offer merely the feebleness and pros- tration which occur in most severe diseases, with little cough and little or no expectoration. Hence, the disease is often scarcely suspected, and in a number of cases it is not recognised unless the obscurity of the general symptoms and the dusky purple tint of the face should lead the physician to explore the chest. When the disease is not strictly latent, it is never so well marked by the ordinary pectoral symptoms as in more vigorous individuals, and passes rapidly through the first and second stages to suppuration. This peculiarity leaves little room, or at least but a short space of time for antiphlogistic treatment, PNEUMONIA. 161 and obliges us to resort, at a comparatively early period, to the more stimulating remedies which are appropriated to the third stage. At the commencement, however, the antiphlogistic treatment is directly indicated, and may sometimes be pushed with nearly the same vigour as in younger persons; but the period for this is short, and sometimes from the first, hardly discernible. SECONDARY AND INTERCURRENT PNEUMONIA. Pneumonia is naturally enough of common occurrence as a sequel to many diseases of the lungs, especially bronchitis and consumption. In the former case the original disease is in a great degree absorbed by the more severe but secondary affec- tion ; but in the latter the inflammation will go through its stages, and leaves the tubercles nearly as they were at the first. This is, however, not always the case; even if the tubercles are not advanced, their progress is occasionally hastened by the pneumonia, and after an attack of this kind, we often find that gurgling or crackling is heard when there was merely a slight bronchial respiration previously to the pneumonia. In more advanced cases the pneumonia is not unfrequently the imme- diate cause of death by invading the portions of the lungs which remained free from tubercles, and were therefore, essential for respiration. The inflammation may also form an exciting cause of new tubercles in a portion of the lung of a con- sumptive, or may give rise to them in one previously free from them, but of a tuberculous predisposition. In this case the gray granulations are found thickly disseminated through the part most inflamed, and are evidently of recent origin. If there be not, however, a strong tendency to this disease, pneumonia has less influence in developing -tubercles than pleurisy, notwith- standing there seems to be a more natural connexion between the former disease and phthisis. There is nothing peculiar in the management of these com- plicated cases, except that they bear a less decided antiphlo- gistic treatment than pure pneumonia, and mercurials must be used more sparingly. The rules for their management are essentially the same as those which I have already laid down. 14* 162 GANGRENE. CHAPTER XII. GANGRENE OF THE LUNGS — PATHOLOGICAL LESIONS--SYMPTOMS --CAUSES--DIAGNOSIS--TREATMENT. There is a disease which though not very frequently met with requires a notice in this place ; I refer to gangrene of the lungs. This, like gangrene in other parts of the body, may occur either as a primary or secondary affection. When primary, it is probably owing to an alteration in the condition of the blood, which, being rendered unfit for nutrition, can no longer support the vitality of the parts. It occurs as a secondary affection in cases of asthenic pneumonia. The anatomical characters of the gangrene are nearly the same in both forms, although, when it is in its secondary form, the tissue is at first hard and congested, and is seated in the midst of an inflamed parenchyma, while, in the primary form, it is at first merely infiltrated with a thin serous liquid, which is evidently in a state of incipient gangrene, and gives rise to the fcetor of the breath met with even in the first stage of the affection. In the second stage, the tissue begins to break down, and gangrenous matter is expectorated ; next, the bronchial tubes slough off, and nothing is left in a sound state but the vessels; these resist the destructive process for a long time; and on examination after death they are usually seen traversing the cavity ; however, after a while, they too are destroyed, and their destruction sometimes gives rise to a haemorrhage which destroys the patient, although generally the blood has ceased to circulate through them before they slough, and little or no haemorrhage ensues. The sputa and breath in this stage of the disease are pathognomonic ; they are both exceedingly foetid, and the disease can, on this account, be easily distinguished from any other. There are two principal varieties of the gangrenous sputa ; one consists of a dark thin liquid, which somewhat resembles tobacco juice, or the infusion of liquorice, occasionally containing small pieces of black, gangrenous lung ; the other consists of a grayish-yellow pasty fluid, which is pro- bably a mixture of pus and gangrenous liquid. The latter occurs most frequently in cases following pneumonia; both, GANGRENE. 163 however, are extremely foetid, though the odour differs slightly. In some cases of phthisis the sputa resemble the second variety, and it is probable that in these cases the tuberculous portion of the lung becomes gangrenous. The third stage begins with the formation of a cavity, which continues to increase for some time, and may go so far as to involve a lobe, or even nearly the whole of one lung. After the formation of the cavity, the sputa are nearly the same, con- sisting of a thin, foetid liquid, frequently stained with blood, which flows from the sphacelated vessels. When the case termi- nates fatally, the sputa increase in quantity, and the patient gradu- ally sinks, until he is completely exausted, and death ensues. But when the disease terminates favourably, the following changes take place :— the gangrenous portion of the lung is first circum- scribed by a membrane which separates it from the surrounding healthy tissue. As the gangrenous portion sloughs away, this membrane is left as a lining to the cavity, and secretes pus ; therefore, we find the latter fluid at first mixed with the gangre- nous sputa, and supplanting it entirely, when the whole of the diseased portion has been removed. As the inflammation sub- sides, the membrane assumes the character of a mucous mem- brane, and at last becomes similar to that lining the smaller tubes and air-vesicles, which resembles very closely the serous mem- branes in the delicacy of its texture. If the cavity ceases to communicate with the bronchi, the lining membrane being no longer exposed to the stimulus of the air, loses its mucous character entirely, and we find a cyst lined with a membrane, which is almost serous, and nearly similar to that found in the brain and elsewhere after cicatrisation; this may continue during the remainder of the existence of the individual, or be gradually obliterated by the formation of cellular tissue. After the entire cure of the gangrehe, the tissue which was involved, becomes more or less dense, and contains less than the natural proportion of air. The local signs of this disease are the cough, expectoration, and fcetor of breath. The cough at first resembles that of ordi- nary catarrh, but as the disease advances, it becomes looser and paroxysmal in its character, a change, which is produced by the accumulation of fluid in the bronchial tubes requiring a violent effort to throw it off. The effort ceases as soon as this is accomplished, and the paroxysm does not recur until the accumu- lation of fluid again renders this discharge neecssary. These fits of coughing are often extremely distressing to the patient. The physical signs are, in the first stage, feeble respiration and a moist rhonchus, generally either the mucous or sub-crepi- 164 GANGRENE. tant; the percussion is either natural or a little dull. The signs are not, therefore, characteristic. As the disease advances, we find the usual signs of a cavity, viz. : cavernous respiration, a loose gurgling and cavernous resonance of the voice, or pectoriloquy; the last, however, is not so clear as in phthisis, unless the cavity should be large, and near the surface of the lung, for the quantity of liquid in the cavity, and the softness of its parietes, deaden the reso- nance. When cicatrisation takes place, we find merely feeble- ness of respiration, which gradually diminishes, but does not entirely disappear after the patient entirely recovers. In a remarkable case which I attended some years ago, the respi- ratory sound became nearly as clear as in health after the patient had been for nine months perfectly restored, but for a long time it remained feeble, and more or less bronchial. If the liquid is discharged from the cavity in its early stages, the cavernous respiration and attendant pectoriloquy are rendered much clearer, but they are generally less loud than in cases of pulmonary phthisis. The general signs are the following: there is usually con- siderable fever during the progress of the disease, with a small, frequent, irritable pulse ; sometimes the pulse is exceedingly feeble. The fever is only important as it is connected with the prognosis, which is very unfavourable when the fever is high, and the gangrene is progressing ; but if the disease do not ad- vance, the fever is unimportant. There is an almost complete loss of appetite, produced by the nauseating character of the gan- grenous liquid which is swallowed by the patient, who often has diarrhoea from the same cause. The skin is pale, and usually lead-coloured in the advanced stage, this is observed in almost all cases of gangrene, whatever part of the body may be affected. Very often there is extreme dyspnoea. Prognosis.— As an average result, about one-half of those attacked will die. In hospitals the mortality is rather greater, amounting to three-fifths, while in private practice it is probably about two-fifths. Diagnosis.— The only pathognomonic characters of gangrene, are the foetid breath, and expectoration of the patient. When these occur as an acute disorder, or supervene suddenly upon a chronic one, they are quite characteristic of the disease. If they occur slowly, and continue for a long period, they may depend upon a vitiated secretion of the bronchial membrane, caused by chronic bronchitis; this either never occurs in acute inflammations of the lungs, or is so rare as not to be taken into the account. Numerous as are the cases of gangrene which I GANGRENE. 165 have met with in hospital practice, I do not recollect a case in which the foetid sputa came from simple acute bronchitis. The other signs of the disease are common to it and some other affec- tion of the lungs : but the rapidity of the softening, and the for- mation of a large cavity in a short period, occurs so seldom except from gangrene, that these signs are very good indications of the disease. Causes. — About these it will be proper to say a few words, before going farther. The proximate, and at times mainly pre- disposing cause of this affection, is an altered condition of the blood ; it becomes thin, and probably is vitiated in some un- known manner, wdiich frequently coincides with a local inflam- mation. The ultimate causes are intemperance, indulgence in food of an innutritrious nature, and any circumstances which break down the strength of the patient and thus predispose to gangrene. An attack of some acute disease, most frequently pneumonia, is the immediate exciting cause in rather more than half the cases : in others, the disease is general, and arises from the fluids alone, that is from such an alteration of these as tend to gangrene. In both cases gangrene of the lungs at times follows that of other parts of the body. Treatment. — This is not in most cases antiphlogistic, but supporting in its character, tonics and stimulants being required. When you detect the occurrence of gangrene, you must use all the means that you possess to support the strength of the patient, who is in a short time very much prostrated ; for this purpose you must administer stimulants and tonics, with the free use of porter, wine, and nutritious food. This is the best and almost only mode of treatment. There is a remedy, however, which I have used in addition, and, I think, with some benefit, viz. chlorine ; I give from ten to twenty drops of the solution of the chloride of soda every three or four hours ; if, however, there is disposition to diarrhoea in the patient, he will bear very little of it. In addition to the internal use of chlorine, I place near the patient's bed, vessels containing chloride of lime, which adds much to the comfort of the patient and his attendants. Opium is necessary in some cases of gangrene of the lungs, to check the violent paroyxsms which return so frequently as to fatigue the patient extremely ; but it should be given sparingly, for it has the disadvantage of checking the secretions of the lungs ; hence, it should be administered in the smallest possible quan- tity, and even then may be combined with senega and ipecacu- anha, unless the nausea should be excessive. Blisters should be applied in those cases in which the gangrenous action is 166 GANGRENE. developed by a portion of the lung which has been inflamed ; and in some ordinary cases in which the inflammation is more developed than usual, we may also apply cups to the chest in addition to the general treatment of gangrene. We must, however, as a general rule, abstain from all abstraction of blood when gangrene occurs, except in those cases in which the gangrene follows inflammation and seems to be in part at least caused by it. The indications for the treatment of gangrene are, therefore, extremely simple ; a generous, supporting diet and treatment, with blisters, and, in a few cases, cupping to the chest, to check the intercurrent and accompanying inflammation, constitute our main reliance, but the chances of success are greatly increased by the accessary remedies, some of which I have mentioned. The absolute antiphlogistic treatment is decidedly bad, and of the remedies which are classed under this head, none is more positively mischievous than mercury and its various prepara- tions. TUBERCULOUS PHTHISIS. 167 CHAPTER XIII. TUBERCULOUS PHTHISIS--NATURE OF THE DISEASE--ANATOMI- CAL CHARACTER--MODE OF ATTACK-- SYMPTOMS--PHYSICAL SIGNS--DIAGNOSIS--PROGNOSIS--TREATMENT. Tuberculous phthisis, or consumption of the lungs, is the most formidable disease of the thorax ; that is, a much greater number of individuals fall victims to it than to any other affection. It is natural, therefore, that we should study the disease with attention, and we should strive to acquire the means of detecting it in that early stage when treatment is often of decided benefit. In the later stages, unfortunately, we do not possess the means of arresting the progress of the disease ; wTe may it is true, to a certain extent, modify the symptoms, and thus alleviate the sufferings of the patient, but we can only in a few cases con- tribute to positive recovery. Even in these few instances we do not possess the same controlling influence as in many other diseases, but we must limit ourselves to acting strictly as the hand- maids of nature, and aiding the process of cure which she in- stitutes. It is possible that our power of control will be greater when the intimate pathology of the disease is more thoroughly understood, and the circumstances which favour the formation of tuberculous matter are completely known, but at present we are too often obliged to confess that our art is comparatively powerless in arresting so fatal a disease as pulmonary consump- tion. Consumption of the lungs is frequently regarded merely as a local disorder, but although the chief lesions are seated in the pulmonary organs, the essential characters of the disease de- pend much more upon its diffusion through the whole body than upon the local mischief, which is often comparatively- slight. The cause of the fatal termination is sometimes to be found in the local lesions, and the secondary exhaustion and irritation caused by them, and at other times in the general disorder which attends both the earlier and latter stages of pul- monary consumption. Hence consumption is to a great extent a complex disorder, and must be regarded in two distinct points of view; which must be kept steadily in mind, not only in the diagnosis but 168 TUBERCULOUS PHTHISIS. the treatment of the disease. On the one hand there is a local mischief which is often accompanied with inflammatory symp- toms, and on the other there is a vice or diseased action going on in the whole economy, which is brought especially into play in the lungs, but is rarely confined to these organs. This diseased condition of the whole body has received different names ; by some it is called the tuberculous diathesis or ca- chexia, and by others the scrofulous constitution ; but when the latent mischief is brought into action, it then receives a name from the organ, which is most decidedly attacked, and the original predisposition is almost lost sight of. Hence the tuberculous diathesis, that is, the general disorder, may be de- veloped to a very intense degree, and yet the local mischief may be slight, and tubercles may be scattered over a large number of organs. In these cases it is difficult to say whether the disease should be called pulmonary phthisis or not, for the disease of the lungs scarcely preponderates over that of the rest of the body, and the seat of the disorder is to be looked for in the fluids rather than in the solid tissues. At most the affec- tion of the lungs is important in such cases as a sign of the general disorder, not as a disease in itself, and the only means we possess of modifying the progress of the affection, consist in such remedies as are essentially general in their nature. In other cases the pulmonary affection either begins as the earliest point of the disorder, or it occurs very early in the dis- ease, and the functional disturbance of the lungs becomes so considerable that it necessarily attracts a large share of atten- tion. This is the case in a large proportion of tuberculous dis- eases, especially amongst adults, in whom the lungs are no* only the part which in most cases is earliest attacked, but it is that which is most deeply affected, and becomes the seat of the most extensive lesion. Just in proportion to the early appear- ance of these lesions, and to their inflammatory character, does the disease participate more in the characters of a local, and less in those of a general disorder; still the latter part of the affec- tion must in no case be lost sight of. Even in those cases which are most inflammatory, and which differ least from pneu- monia, there is something more than a common inflammation, for a secretion of tuberculous matter is added to the ordinary products of inflammation, and this secretion implies a peculiarity of constitution, either congenital or acquired, in the patient. If this peculiarity did not exist, it would be an ordinary local disease, which it evidently is not, either as regards its symp- toms or lesions. The essential character then of pulmonary consumption is, TUBERCULOUS PHTHISIS. 169 / that tuberculous matter should be deposited in the lungs, and the disease may begin with the local mischief, or this may take place as an evident sequel to the constitutional disorder. But in both these varieties, the constitutional mischief is present, and the evidence of this consists mainly in the formation of the tuberculous matter. It is very clear, however, that the mere presence of tubercles does not constitute the disease, and we must avoid falling into an error into which the exclusive study of pathological anatomy might lead us. The disease is essen- tially a morbid condition which either precedes for a long time the formation of tubercle, or it is more acute in its character, and is then accompanied or quickly followed by this product ; the local diseases which often precede tuberculous formations being, as we have often seen, merely an exciting cause. It is now agreed to restrict the term consumption of the lungs to the cases in which there are tubercles, although it was at one time used as synonymous with all chronic diseases of the lungs, attended with emaciation, which of course included chronic bronchitis as well as chronic pleurisy. Tubercle is the same in all its essential characters, in what- ever part of the body it may be formed. It consists of a white opaque or yellowish body which increases to a moderate size, rarely larger than that of a large almond, and generally much smaller, when it begins to soften and is finally converted into a very thick pasty yellowish liquid, of a dull yellow colour, and heavy but not foetid smell. As soon as this softening takes place, the delicate cellular membrane which always encloses tubercle like other morbid products of an analogous kind be- gins to assume the characters of a pus secreting membrane, and becomes thicker; ulceration of some portion of it, finally takes place and the matter finds its way towards the exterior of the body, generally by means of a mucous tube. At first, tubercles appear under several different forms, either that of a yellow opaque granulation, or of a grayish semi-transparent one ; in either case they are rounded, probably from the pres- sure of the adjoining tissue. In other cases the tissue affected is infiltrated with a grayish semi-transparent liquid, which does not at first reveal its peculiar structure ; little by little this dis- appears, and it is gradually absorbed as the quantity of the new substance increases. This infiltrated tuberculous matter is not always of a grayish semi-transparent colour; in some cases it is yellow and opaque from the very commencement, but in the greater number it passes through the changes of colour just de- scribed ; these are accompanied with a corresponding change in the intimate structure of tubercle; it becomes more granu- " 15 170 TUBERCULOUS PHTHISIS. Iar, more fragile, and less perfectly animalised. But in both cases the essential constituents of tubercle are the same, con- sisting chiefly of albumen, with a small portion of the salts of lime. There is, therefore, nothing peculiar in the chemical composition of tubercle, its characters depend upon its ten- dency to increase and finally to soften, and on the diseased condition of the whole economy which is necessary to its pro- duction. The gradual changes which occur in its structure, give rise to peculiar symptoms which are secondary to the disease pro- perly so called. Hence in the study of tuberculous disease in general, but especially in that of the lung, we have two sets of symptoms, one being primitive, and the other secondary, and not directly so much connected with the disease as with its effects. The patient may perish from either cause. Although in its regular progress, tuberculous matter ends in softening, and^in the formation of a pus-secreting cavity, this is not a necessary or invariable consequence. In many cases the tubercle ceases to increase after it has attained to a certain size, and becomes harder and drier; the earthy matter increases in quantity, and a calcareous mass is left in place of the tubercle, and is surrounded by a membrane ; in such cases the second- ary symptoms are either wanting, or are very slight. In a smaller proportion of cases, the tubercles do not even advance so far, but are actually absorbed ; this fact is difficult to prove, because tubercles are not in their earliest stages susceptible of physical demonstration, but there is every reason to admit it, for patients who have laboured under the decided symptoms of commencing phthisis, have on the one hand recovered, and on the other passed into the more advanced stage of the disease. We have, however, more direct proof of the curability of tubercle. That is the evidence derived from pathological examination, and of this there is no more striking illustration than the case of an eminent physician of this city, the late Dr. Parrish. It is well known that he regarded himself as labouring under pulmonary consumption at an early period of life ; he recovered vigorous health, lived to the age of sixty, and finally died of a disease of the kidneys. In his case there was undoubted evidence, not merely of the previous existence of phthisis, but of its ab- solute cure. At the summit of each lung were cicatrices and deposits of calcareous matter, proving that some portion of the tuberculous matter had passed to the state of softening, and that another portion has become dry and indurated. We learn from pathology that the more advanced tubercles are almost never met with, unless some gray granulations or incipient tubercles TUBERCULOUS PHTHISIS. 171 are found at the same time scattered amongst or around the larger tubercles; hence the inference is very conclusive, that the granulations had disappeared in those cases in which al- though there are evident indications of the larger tubercles in the cicatrices and in the calcareous matter, no trace exists of the granulations. Their cure probably takes place by ab- sorption. Phthisis is therefore strictly a curable disease, notwithstanding that in the majority of cases it terminates fatally, at an earlier or later period. This arises not so much from the effects of the first crop of tubercles as from the successive deposits of new ones in different parts of the lung, or rather from the accom- panying fever and irritation. Hence a patient rarely dies of one attack of phthisis, except it be of a very acute form. Anatomical characters. — These have been already described to a certain extent. As they essentially consist in the deposit and formation of tubercles, little need be added. The most frequent variety of tubercle in the lungs is that which com- mences by gray granulation, and gradually passes into a more developed stage: but the infiltrated tubercle is also extremely common, although rarely found alone, that is, without the gray- granulations. Both of these varieties begin at the summit of the lungs in the majority of cases, and are fouud with nearly equal frequency on the two sides. In other cases the tubercles are formed in a different way, that is, at the middle or lower portion of the organ, and they then begin more frequently as the formed tubercle, without being preceded by the gray granulation ; this is particularly the case where the general health of the patient is much vitiated, and the fluids of the body are much altered. In the latter case the tuberculous matter is softer, and less per- fectly eliminated : but it passes more rapidly through its course, and is, therefore, dependent upon a more severe form of the disease. The exact seat of pulmonary tubercle is difficult to point out. In fact, it is not always the same. In some cases, especially the last mentioned variety, the tuberculous matter is evidently found adherent to the mucous membrane of the bronchial tubes and small vesicles; but the gray granulations follow the usual rule upon this subject, and are formed in the cellular tissue of the lungs, as in that of the pia mater or the spleen, and are nourished by distinct vessels distributed to each granulation. These granulations as they enlarge, press upon the neighbouring vesicles, and gradually cause their atrophy, and finally give rise to absorption of the pulmonary tissue. The cysts are formed in the lungs, or in other organs, by the newly developed 172 TUBERCULOUS PHTHISIS. cellular tissue around the tubercle ; this gradually thickens as the softening advances, and, as I have already stated, it is then lined by a regular pus-secreting membrane. The process of cicatrisation is nearly the same as in other cases of cavities in the lungs ; as soon as the specific tuber- culous matter is completely discharged, there remains merely an ordinary cyst, which either becomes continuous with the mucous membrane of the bronchi, or is filled up by the deposi- tion of cellular tissue. The condition of the surrounding tissues is very various. If the case occur as a purely constitutional disorder without pre- vious local inflammation, the tissue remains pervious to the air, and nearly healthy ; but if the inflammation either precedes the formation of tubercle, or follows its development, the tissue is indurated, and of many shades of colour from a light gray to a decidedly reddish tinge. At other times the tubercular matter is infiltrated through the pulmonary tissue, and gives rise to an appearance similar to that of inflammation. When the inflamma- tion is of that kind which disposes to the formation of tubercle, — that is, when it occurs in an individual labouring under a highly developed tuberculous diathesis, the granulations are scattered abundantly through the most inflamed portion of the tissue, which in these cases, is often nearly similar to the local congestions, or lobular apoplexy, which occur in connexion with metatastic abscess of the lung. As this variety of phthisis is not so frequent as those in which the inflammation is com- paratively slight or doubtful, the appearance is by no means a very usual one : on the contrary, in most cases, the lung is vesi- cular, and respiration is carried on in the immediate vicinity of the tuberculous matter. Besides the lungs, the appendages of these organs are a com- mon seat of the tuberculous deposit; particularly in those cases in which the disease is more general or diffused in its character. These are the serous tissues and the lymphatic glands at the root of the lungs, or as they are called, bronchial glands. In children, they are more frequently the seat of tubercle than the lungs themselves, and even in adults are a common seat of this deposit, though to a less extent. But the pleurae are more im- portant as a seat of tubercle ; they are often deposited on the adherent surface of the membrane, causing little projections scattered abundantly over it; they are also very frequently formed in the thickness of the false membranes thrown out in the pleurae. This subject belongs, however, more properly to the accompanying inflammations of phthisis. Tubercles are of course, not confined to the thoracic organs ; on the contrary, PULMONARY PHTHISIS. 173 I have shown in the preliminary remarks, that the disease is eminently constitutional, and that, like all cachectic disorders, the development of the peculiar product in the organ primarily affected, favours its formation in other parts: and therefore, many organs suffer from the same cause. Of these complica- tions, the most frequent, and perhaps most important, is the formation of tubercles in the follicles of the intestinal canal. At least, this is the most important consequence of advanced tuberculous disease of the lung, for although there are other diseases of the same kind in which the mischief is more consi- derable, they are not simple sequelae of phthisis, but are earlier manifestations of tuberculous disease, the lungs generally remaining healthy until the other organs are attacked, or pre- senting but a few scattered tubercles, which develope them- selves slowly. For a more full account of the relative frequency of tubercles, I must refer to Andral's pathological anatomy, in which the tubercle is treated at some length. It is, however, imperfect, because it is founded upon observations made by physicians who were studying chiefly a single variety of tuber- culous disease, or at least did not extend their observations to a sufficiently large number of subjects, or to a sufficient variety of age and condition. MODE OF ATTACK. Pulmonary phthisis, like other forms of tuberculous dis- eases, occurs either as an acute or chronic affection. A certain number of symptoms are common to both varieties ; but others are peculiar to each, or at least, are so much modified that it is difficult at times to recognise the identity of the two affections. The acute disease is attended by much febrile excitement, and by the general characters of an inflammatory affection. Indeed, it is either connected with an ordinary inflammation, or the secre- tion of the tuberculous substance itself is but little different from that process by which the common products of inflammation are formed. In the chronic disorder the alteration is not of an inflammatory, or even of an active secretory kind, — it is a slow change in the condition of the capillary vessels of the body. Both the acute and chronic varieties may be attended with a local inflammatory action in the lungs, or may be almost entirely free from it. In the latter case the lungs are merely involved as a part of the general disorder which shows itself in these organs, from their structure being favourable to the tuber- culous deposit. When the disease is complicated with local 15* 174 PULMONARY PHTHISIS. inflammation, this may precede, accompany, or follow the tuber- culous secretion. In the acute variety, the inflammation gene- rally attacks the serous membranes, and in the chronic the mu- cous, although this is not always the case, for the inflammation of any tissue of the lung may be closely connected with the abnormal formation. There has been much confusion of ideas on this subject from the great variety in the connexion which often exists between inflammation and tubercle ; this is very similar to the connexion between the local disease and the general diathesis. Indeed, the complicating local disease is almost invariably of an inflammatory character, so that the question is at last almost narrowed down to this — is inflamma- tion the cause of tubercles in the lungs, and we may also add of the body in the other organs, though this is not immediately con- nected with our subject ? If we seek a reply to the naked question, we will be compelled to answer negatively,—but, if we modify it so as to apply it to those varying conditions which are continu- ally occurring in the human body it may be answTered that it is one of the causes. That is, it will develope the disease very frequently in persons who present a strong tuberculous diathesis, and occasionally in those who do not. In the latter case espe- cially, and to a certain extent in the former, it acts in two ways, — it is a direct disturber of the lungs, and a depressing agent upon the whole system. When inflammation occurs in this way before tubercles are positively developed, it may act as a pre- disposing cause during its continuance, and the tuberculous affection then coincides with the inflammatory action, or it then may occur after the latter has terminated. It then acts chiefly as a disordering agent upon the general system, with a slight local determination of disease to the part. In the former case, the local action of the cause is the predominant one. The inflammation of different tissues does not, as I have stated, exert an equal agency upon the development of tubercle. To understand this, we must analyse them separately. 1. First of the serous membranes. Pleurisy is perhaps the most active of all these inflammations. Like the others, it attacks individuals in good health, or labouring simply under a scrofulous diathesis, and tubercles are developed during its course, or. soon afterwards, or it coincides with the rapid for- mation of tubercles, which are then usually formed at the same time in the pleura, the false membranes, and the lungs proper; or it may occur as a mere secondary inflammation after the tubercles are formed, or are even tolerably advanced; in the latter case the pleurisy is a healthy, or at least a preservative inflammation, designed to prevent perforation of the pleura. PULMONARY PHTHISIS. 175 All these varieties may be properly classed under the head of tuberculous pleurisy. The first variety is the most difficult to distinguish, because the disease does not at first differ from ordinary pleurisy, and the important complication may be overlooked. The signs of the pleurisy are either gradually mingled with those of the tuberculous disease, or at least they.disappear when the symp- toms of phthisis show themselves. In this case the pleuritic effusion is often extremely large, and the disease is then some- times ascribed to the absorption of the empyema. The pus has undoubtedly an influence upon the formation of tubercles, but in most cases it acts merely as other causes of the disease,— that is, by producing an irritating action upon the part, and a general depressing influence on the whole body. The second variety is that in which tubercles are formed at the same time, and apparently by the same morbid action as the ordinary pro- ducts of inflammation. The pleurisy is readily recognised ; but the tuberculous complication can only be distinguished by careful attention to its symptoms, and even then the diagnosis is but a probable one. In the last variety there is, of course, no difficulty in ascertaining the nature of the pleurisy. 2. Bronchitis and pneumonia occasionally occur amongst the earliest lesions in the acute forms of phthisis. The bronchitis is then of the common mucous kind, and very rarely passes into tuberculous phthisis, except in those cases in which it is con- nected with a strong developed scrofulous diathesis. But the bronchial inflammation is extremely frequent as an early com- plication, coinciding with the first formation of tubercles, or following them. In the latter case it is most marked in the tubes which run through the clusters of tubercles, and it is then nothing but the ordinary secondary bronchitis, which gradually increases as the disease advances, and is most intense when softening has taken place, and the mucous membrane is irri- tated by the continual passage of the softened tubercles. Pneu- monia is the least frequent of those local inflammations which act as determining causes of acute tubercles ; it is rarely of the frank sthenic kind, but generally occurs in scattered lobules, bearing a close analogy to the lobular pneumonia of young children, or the variety of inflammation which attends the for- mation of metastatic abscess ; it is, of course, difficult in these cases to decide, if the pneumonia is really antecedent. to the tubercles, or occurs under the relation of a mere attendant, or even a secondary result. In chronic cases of phthisis the preceding inflammation is usually of the bronchial variety, a common chronic mucous 176 PULMONARY PHTHISIS. catarrh passing by insensible shades into pulmonary phthisis, — that is, a time arrives wThen the secretion of tuberculous matter takes place, and the bronchitis is no longer simple. This is not, however, the only inflammation which proves a determining cause of the more chronic forms of phthisis ; pleurisy not un- frequently produces a like result, especially in those cases where the effusion has been large. Pneumonia rarely produces the same result; indeed, this inflammation is, on the w-hole, re- markably independent of tubercle. Phthisis without local inflammation at the commencement. — There is no doubt that many cases of phthisis, probably the larger number, originate without being preceded, or even at first accompanied by local inflammation ; when this occurs, it is strictly secondary. These cases of the disease are sufficiently described in the commencement of this chapter, and in fact they do not differ from those of general or constitutional tuberculous disease, except in the predominance of the disorder of the lungs. They may therefore be latent for a considerable time, and only attract attention to the lungs when the disease is sufficiently ad- vanced to produce some secondary inflammation. The prin- cipal symptoms of the disease are therefore those of the general tuberculous disorder, with or without the addition of the signs caused by the local mischief; these are not always developed sufficiently to attract much notice until the disease is quite de- cided. The mechanism of the pulmonary disorder, if such an expression can be used, merely consists in a direct secretion of tuberculous matter from the vessels, and it is sometimes con- nected with a diminished, instead of an increased vascular ac- tion in the part, although this is not invariably the case even at first, and is very seldom so after the disease is developed. Symptoms.—Phthisis is, or soon becomes so complicated to disorder, that a constant analysis is necessary in the study of the symptoms. If these are regarded in a crude, general way, they are often extremely indistinct; hence, many writers upon the subject content themselves with the signs of the disease as fully established when diagnosis is no longer a matter of doubt, or they add to this the general characters which are usually des- cribed as designating the scrofulous temperament. But as the discoveries of Laennec prepared the way for a full understand- ing of the pathological characters of the advanced disease by a knowledge of the physical signs which attend them during life, physicians have not rested satisfied with this view of the subject, but have ascended, as it were, to the source of the affection, and have laboured to point out the initial steps, or at least the symptoms which occur very early in the disorder. Still you PULMONARY PHTHISIS. 177 will find in many works on the subject, even of the most recent date, that the physical signs which occur sometimes quite late in the disease, are brought forward as indicative of the earliest stage of the disorder, which in most cases they certainly are not. We are obliged, therefore, to divide the symptoms into several different classes, which will lead us naturally to the study of the connected or dependent diseases. 1. First we have a series of symptoms dependent upon the tubercular disease, considered as a general disorder. 2. Symptoms connected necessarily with the development of tubercles in the lungs, including, of course, the physical signs of the disorder, properly so called. 3. Symp- toms dependent upon the accessary disease of the lungs and air- passages, including the larynx and trachea, which are present to a greater or less degree, in nearly every case of the disease. 4. Symptoms of disorder of the organs, some of wThich depend upon a deposit of tubercle in the tissue, but for the most part they are connected either with a positive inflammation or a mere functional disorder; to a greater or less extent these take place in most instances of phthisis. You do not, of course, expect to meet these symptoms in every case of the disease; many of them may be obscure, and some absent entirely ; but we do in reality scarcely ever meet with a case in which they are all badly defined; that is, with a case of true latent phthisis. Cases in which the disease is so obscure as to be nearly latent, are quite common. 1. General symptoms common to phthisis and other tuberculous diseases. These differ in the acute and chronic varieties, in degree and to a certain extent, in nature. In the acute variety a rapid deposit of tuberculous matter takes place, generally throughout a number of organs at the same time; this approaches very nearly to an inflammatory secretion, and it is attended with a general disturbance of the body, which differs little from inflammatory fever, especially the fever which attends a sub- acute inflammation of the pleura or other serous membranes. The pulse is extremely frequent, generally from one hundred to one hundred and thirty in the minute, quick and jerking ; these characters are often difficult to define, but are at the same time very well marked. The febrile excitement is continued, and does not cease during the twenty-four hours, diminishing a little in the morning, and becoming more intense towards the mid- dle of the day ; at night there is almost always sweating, which at times is extremely profuse, and as a general rule, is abun- dant. There are rarely chills, generally a mere sensation of chilliness at irregular times and differing therefore from the chills of well-defined hectic, which occur in the latter stages of 178 PULMONARY PHTHISIS. phthisis. The accessory symptoms, or those connected with the alimentary canal, are strictly such as would be supposed to exist in cases of high fever, such as thirst, anorexia, and con- stipation ; but they are less severe than in most instances of febrile excitement, because the stomach and bowels do not at all participate in the earlier disturbance of the system. The general appearance and countenance of the patient change when the fever is developed. The expression is restless, — the lips and countenance pale and flushed at irregular times, — the flush is often circumscribed when the fever is most considerable, but the tint is of a much lighter and at the same time a brighter red than in pneumonia. The flush is not peculiar to any one form of tuberculous fever, but occurs without reference to the part affected. Thus it occurs in tubercular, meningitis, pleurisy and peritonitis, in these cases it is, however, generally less marked than in tuberculous disease of the lungs. The countenance is often indicative of much dyspnoea, with dilatation of the nos- trils, if there be a very large and rapid secretion of tubercles. The emaciation is rapid, partly as a direct effect of the tuber- culous disorder, and partly from the profuse sweats which rapidly enfeeble the patient. These signs, in themselves, although not positively pathogno- monic of acute tuberculous disease, can scarcely occur in a high degree from any other cause. Although all cases of acute tuberculisation are not necessarily attended with them in their highest degree, we will find that they exist to a greater or less extent in nearly every case of the disorder, and that their value is much increased by the very slight development or en- tire absence of other lesions sufficient to account for the fever, especially if conjoined with one other character, — that is their persistence, —for this fever does not rapidly decline ; on the contrary, it usually lasts for a considerable period, and then re- sists all treatment. Pleurisy of a sub-acute character approaches very nearly to the febrile symptoms of acute phthisis, whether the pleurisy be complicated or not with tubercles; in fact, I have little doubt that the pathological condition of the economy which attends the formation of the lymph, and that of acute tuberculous disease, differ but very slightly from one another. This, however, is not sustained by a course of demonstrative reasoning, and therefore is of little interest until it is better developed. Reasoning by way of exclusion we may attach great importance to the tuberculous form, especially when it cannot be accounted for by the existence of any other disease capable of producing it. In the more chronic cases of phthisis the general signs of the PULMONARY PHTHISIS. 179 disorder are more difficult to distinguish, because their develop- ment is slow and the fever in the early stages is comparatively unimportant. The signs which are most decided are those indicative of a deterioration of the constitution and of the nu- trition. The skin of the patient is generally of a dull tint;" or if his complexion be naturally very clear, and the capillary cir- culation extremely active, the cheeks are from time to time flushed with a circumscribed redness, not very unlike that of, acute phthisis, but less decided. At the same period, those peculiarities which are supposed to indicate a scrofulous or tuberculous constitution are often more developed,— that is, the blueness of the conjunctiva, and the rounded fusiform appear- ance of the ends of the fingers, which, although not peculiar to this condition of things, is certainly more common then, than under any other circumstances. The moderately chronic cases are also accompanied with fever, which is often slight, and sometimes limited to a mere sensation of heat or burning at the palms of ^the hands and feet: the sensibility to cold is at the same time often much increased ; but there is very rarely a dis- tinct chill, except from inflammatory complication. In short, the ordinary cases of phthisis offer as symptoms; emaciation and slight fever, with an increase of the peculiarities designating either a constitutional diathesis or a tendency to the disease from an original feebleness of constitution. The very chronic cases are more and more obscure as regards the general symptoms in proportion as the disease is slower in development. The addition of local signs of irritation confirms the value of the more chronic constitutional symptoms, as well as of the acute, provided these local symptoms do not disappear very readily. Hectic Fever is a very frequent consequence of tubercles after they have attained a certain stage of development, — not that the fever is peculiar to tubercles, but, on the contrary, it is com- mon to all diseases attended with suppurating cavities commu- nicating with the exterior. It scarcely occurs under other circumstances. — that is, the true hectic ; the fever of irritation, on the contrary, is very frequent, when no suppuration exists, and is then very analogous to the initiatory fever of ordinary tuberculous disease. The true hectic occurs in the advanced stages of phthisis, when softening of tuberculous matter has taken place, and a pus-secreting cavity is formed. It is charac- terised, as is well known, by a strong tendency to a regular paroxysmal type, which sometimes approaches closely to inter- mittent, by abundant sweats generally coming at night, and by 180 PULMONARY PHTHISIS. a pulse, which is at least as frequent, but generally more com- pressible than that of an early irritative fever. We may add to the general symptoms of phthisis the extreme exhaustion and tendency to cedema which occur in the latter stages of the disease. These, of course, are not peculiar to it. 2. Symptoms directly dependent upon the development of tuber- cles in the lungs. The bronchial or other inflammations which occur very early in phthisis, are not properly dependent upon this disorder if they precede it, but true secondary inflamma- tion of the lungs is a necessary consequence of the tuberculous deposit, and is strictly consecutive to it. The signs of the in- flammation are of course scarcely different from those of ordi- nary bronchitis, and have been sufficiently noticed already, — that is, if we restrict the term bronchitis to those cases in which the inflammation extends over a large surface, and is in itself tolerably severe ; but if the slighter cases of bronchial irritation, in which a cough occurs very early in connection with tuber- cles, are to be regarded as instances of bronchitis, the symptoms are very different from those of ordinary catarrh. It is not pos- sible to discriminate between the influence of the slight bron- chial inflammation and of tubercles in the production of the cough. We therefore class both these causes together, and regard the cough which occurs at the commencement of phthisis as the result of either; this is at first very insignificant, and sometimes, though rarely, quite absent. At first it is much more frequent early in the morning than at any other period of the day, although you will find a great irregularity in this raspect; it gradually increases in severity, and in the frequency of its return, until at last it becomes severe and more or less pa- roxysmal. This occurs when cavities of some size have formed, and the liquid contained in them tends gradually to accumulate until it gives rise to a violent paroxysm of cough. In the latter stages of the disease the patient is often disturbed in the night, but especially towards morning by the intensity of coughing, he thus relieves himself of accumulations of liquid sputa which oppress his respiration, sometimes to a very great de- gree. After he has expectorated, he again breathes writh com- parative ease, for a time. In the last stages of the disease the cough becomes feeble and hollow, or cavernous in its character ; a circumstance which is familiar to every one who has seen many cases of consumption. The expectoration is of course nearly connected with the cough ; at first it is, like the cough, very slight, and often insig- nificant ; but, after a time, it becomes more and more abun- PULMONARY PHTHISIS. 181 dant, and of the usual bronchitic character, for there is either no purulent matter, or this is so small in quantity as not to attract notice. After the tubercles have begun to soften, pus is necessarily found in the sputa, and those are of a yellowish colour, differing often in appearance from ordinary muco-puru- lent sputa, for the softened tuberculous matter of which they are in great part composed, is extremely viscid and different in appearance from pure pus. If the softening is very rapid, the quantity of the thick pasty substance often amounts to ten or twelve ounces in twenty-four hours. In general, it is com* bined with more or less thin mucus, which is intermixed with the thick yellow matter. As soon as cavities form, the thicker, more purulent part of the sputa, which is retained in them is moulded into a rounded, irregular form, often with loose, cottony edges ; these portions are suspended, if they contain air, or if not, they fall to the bottom of the transparent mucus. This constitutes the nummular sputa, which are not characteristic of phthisis in general, but only of one stage of it. If the walls of the cavities become hard, and cease entirely, or in great part to secrete purulent matter, the expectoration consists merely of a thin mucus, as the lining membrane does not in that case materially differ from that of the bronchial tubes. In the advanced stages of phthisis, and occasionally at a rather earlier period when the strength of the patient is much enfee- bled, the walls of the cavity may soften down rapidly, and fall into a foetid, thick, grayish liquid ; this is nothing else than gangrene of a tissue partly filled with tuberculous matter. The gradual obstruction of the lung with tuberculous matter, and its removal by softening, renders so large a portion of the vesicles unfitted for purposes of respiration, that the dyspnoea is always considerable in the advanced stages of phthisis. In the earlier period, however, this will often occur to a greater or less extent, so that dyspnoea is very far from being a mere mechanical result of the obstruction, but is in part caused by the vital action going on in the lungs. It is most severe in acute phthisis, and sometimes is one of its most prominent symptoms. There is almost no pain from tubercles, properly so called; the uneasiness felt from time to time in the chest seems to de- pend entirely upon the accompanying inflammation. The local signs purely belonging to phthisis, with the exception of the cough and expectoration, are slight; but those belonging to the secondary inflammations are very numerous ; even the cough and expectoration may be nearly absent, owing to causes which, in many cases, are not understood. We know, however, that 16 182 PULMONARY PHTHISIS. the same causes which render Other pectoral diseases latent, act here, — that is, the feebleness of the patient, and the diseased condition of the brain. Hence in lunatics we find that phthisis is always obscure, and sometimes scarcely betrayed by any local symptoms. They gradually emaciate, seem unwilling to stir about, and have very little pain, but the cough is very slight, and even apparently absent altogether. So that in them, one of the most frequent signs of phthisis is the diarrhoea, which is less deve- loped than in chronic dysentery, but is still quite severe and together with the other symptoms will make the case evident. Physical signs. — These are amongst the most decided in advanced cases, but very obscure in the early periods of the disorder. We do not now refer to the signs of the concomi- tant inflammations, but to those of phthisis, properly so called. At first these occur at the summit of the lungs almost always, and are limited to the signs of mere obstruction; the vesicular inspiration is feeble or harsh, and slightly puerile, while the expiration is becoming louder and louder. The character of the respiratory sound, therefore gradually becomes rude, and at last approaches the bronchial respiration, in which it terminates as soon as the vesicular structure is completely replaced by the tuberculous matter. The bronchial respiration is more or less local, and is present chiefly at the summit of the lungs, both an- teriorly and posteriorly, according to the quantity of tubercle, and the more or less obstruction of the larger bronchi them- selves. If these remain uncompressed, the air of course passes freely through them, and the bronchial respiration may be tolerably loud; if, on the other hand, they are soon closed, the respiratory sounds are all feeble. Then the bronchial respiration may sometimes be not heard with any distinctness. As soon as softening begins, a slight rhonchus is heard, approaching more nearly to the sub-crepitant than any other, this gradually passes into decided crackling, and finally into gurgling, as the liquid becomes more abundant, and the cavity increases in size. The crackling is not always constant however, neither is the gurgling. Both these sounds may disappear when the liquids in the cavity are removed by expectoration. If the patient remains however, quiet for a time, without much cough, these signs may again be heard. The cavernous respiration is gene- rally developed with the gurgling, and sometimes replaces or alternates with it. The signs of percussion are of course limited in phthisis to those of induration of the parenchyma ; they give us no in- formation as to the progress or approach of softening. As the tubercles are generally most developed at the summit of the lungs, the dulness is early perceptible there; hence it may PULMONARY PHTHISIS. 183 often be first detected by percussing above the clavicle, or upon, or immediately beneath it; and however slight the dul- ness may be, there is little difficulty in distinguishing it, if at- tention be paid to the natural degree of resonance, and the two sides be carefully compared together. The intercurrent inflam- mation may, of course, give rise to varying degrees of dulness, which may rapidly increase or diminish. We should also carefully auscult the voice in cases of sus- pected phthisis. If the resonance of the voice be extremely slight and limited to the summit of the right lung, it is a sign of very little importance unless conjoined with other indications of the disease. But if it exist in the left side, or if it be con-i nected with bronchial respiration and dulness of percussion, it is a valuable indication of phthisis. When the tubercles exist to a greater degree, the resonance of the voice becomes more evident and passes into bronchophony. In cases in which the cavities are formed the resonance of the voice is gradually con- verted into pectoriloquy. The latter sign usually remains as a permanent symptom, but in some cases it becomes confused and less distinct, the change occurs when the resonance of the voice becomes amphoric, as it sometimes does in very old cases of consumption. The signs of percussion and auscultation are the most im- portant, but in the course of the disease, attention should be paid to the conformation of the thorax. The parietes of course contract when pleuritic adhesions have taken place ; even if there are no adhesions, the consolidation of the lung produces a partial contraction of the tissue, which causes a slight sinking of the ribs ; the most sensible, however, is caused by the ad- hesions. These are most perceptible near the clavicles and behind them. The same causes render the ribs comparatively motionless in this situation, as the air enters imperfectly into the tissue which is thus hardened. It naturally occurs to every one that these signs are rather applicable to the advanced than to the early stages of the dis- order ; but there are generally some characters which afford a tolerably good indication of commencing phthisis, as soon as a slight deposit has formed, or a partial infiltration of the tissue has taken place. These are not so much signs which are refer- able to any of the regular classes which I described at the early period of this course, as mere trivial alterations of the natural respiratory sounds, which become important from their position and the coincidence with them of the general symptoms of common phthisis ; without these, the signs are of some value, though a very limited one. Thus the commencement of rude 184 PULMONARY PHTHISIS. respiration, which is denoted by a trifling increase of expiratory sound, especially if it is heard in the left side, and a harsh, rough, inspiratory murmur, which differs from the natural vesi- cular sound, are both of some value, that is, if they are combined with a slight dulness on an extremely careful percussion; always however with the proviso, that the general symptoms should be in some degree developed, for I cannot repeat too often that the general signs are at the commencement of the disease the most important. If the physical signs are to be heard in addition to them, a probable opinion may be converted into a certain one, which affords a good measure of the degree of the disorder; but if they are absent, the importance of the general signs is diminished, but not destroyed. The physical signs of deposit and softening of tubercle ex- tend gradually over the lungs, in proportion to the progress of the disorder, until a considerable portion may be involved. But the parts last affected do not offer as well marked charac- ters as those first attacked ; hence the respiration in the parts which remain comparatively healthy, becomes in a great degree supplementary and puerile ; and, even when tubercles have invaded them, the vesicles still dilate, and their peculiar murmur is loud and harsh, notwithstanding a certain number of them may have become impervious to the air. 3. Symptoms dependant upon the accessary disease of the lungs and air passages, including larynx and trachea. — To a great extent the remarks relative to these affections have been already anticipated, from their necessary connexion with the subjects previously treated of. Thus the secondary inflammation of the bronchi produces few symptoms differing from those of the tuberculous disease of the lungs : the bronchitis, however, may occasionally become acute, and thus the rapid increase of the cough and dyspnoea, and the formation of the characteristic rhonchi, establish the nature of the intercurrent affection. The sputa are often also increased in quantity, and become more transparent, like those of the earlier stages of ordinary bron- chitis. Pneumonia too gives rise to increased dyspnoea, and to more or less crepitus and roughness of respiration, with fre- quently a viscid transparent expectoration ; but the bronchial respiration is much less loud than in ordinary pneumonia and the increase of dyspnoea is much less considerable than we might a priori suppose it to be. In other words the chronic disease modifies the symptoms of the acute affection. The secondary pleurisy is almost always of the dry kind. Effusion sometimes, however, takes place during more advanced stages of tuberculous disease, but this is rather an exception than a PULMONARY PHTHISIS. 185 rule : the ordinary symptoms of the pleurisy are pains which vary from a mere stitch to a severe, sharp, lancinating pain, preventing the patient from lying on the affected side. The flying or wandering pains which are at times felt in the thorax during the course of phthisis, are probably dependent upon the the same pleuritic complication, although this is not perfectly certain. The inflammation of the larynx and trachea has a much more important connexion with phthisis. Chronic laryngitis is often called laryngeal phthisis, which is a sufficient proof that a close connexion or a great similiarity was supposed to exist between these diseases. When the affection of the larynx occurs late in phthisis, it is absolutely secondary, and results, in part at least, from the irritation of the sputa passing from the lungs over the larynx and trachea, and thus giving rise to inflammation and ulceration. The form of chronic laryngitis which attracts most attention, however, is that in which the lesion of the larynx pre- cedes the disease of the lungs, and for a long time appears totally independent of it. But after a time which is very variable as to length, the signs of consolidation of the lungs are apt to super- vene, and the case may then terminate in decided phthisis. From our knowledge of this frequent connexion, we must be cautious of the prognosis of such cases. It is true that if the laryngitis can be arrested at a tolerably early stage, the patient will probably not become consumptive; but should it resist our efforts to cure, the disease almost always terminates in a tuberculous affection ; this is the case both with the common and syphilitic varieties of acute laryngitis. Of course the ex- istence of a highly developed tuberculous diathesis greatly enhances the danger of the case, and, under these circumstances, the laryngitis is sometimes little else than the commencement of the morbid phenomena. The same remarks apply to chronic trachitis, except that it is a more obscure affection, not connected with a special function like the larynx. The symptoms are generally merely cough, wTith an obscure sensation of tickling or soreness above and immediately below the upper margin of the sternum ; while those of the laryngitis, in addition to the sensation of irritation, are hoarseness, gradually passing into aphonia. The trachitis is less important in itself than the laryngitis, unless there be some evidence of general tuberculous disorder, when it is quite as grave. Like the laryngitis, it should be removed as soon as possible. The disease known by the name of chronic pharyngitis, or sometimes " clergyman's sore throat," is occasionally connected 16* 186 PULMONARY PHTHISIS. with phthisis. But the connection is rather an accidental than a fixed one, for the disorder consists essentially in an inflam- mation of the fauces, including the uvula and tonsils. It is cer- tainly rather more apt to occur in individuals who offer the char- acters of the scrofulous diathesis, than in others; and it has apparently some agency in favouring the development of phthisis in these individuals. It is often complicated with a chronic inflammation of the larger bronchial tubes. 4. Symptoms of other organs than those of respiration. — The symptoms of the diseases of other organs than those imme- diately connected with the lungs, are very numerous in the dif- ferent periods of pulmonary consumption. Indeed, every dis- ease which produces so deep an impression on the whole economy must of necessity give rise to many functional disor- ders in the different stages of its progress ; and, on the other hand, those local affections will often determine the develop- ment of phthisis by the operation of the general laws which we have already laid down as to the connection of tuberculous disease with the enfeebled condition of the body, which is readily brought about by the action of a local affection. When these local symptoms precede phthisis, they are not in most cases dependent upon the development of tubercle ; when they occur during the course' of the disease, they are more frequently the direct symptoms of the growth and progress of this morbid body, but in the majority of instances this is not the case. The proper way of stating the subject is this: — 1. In some cases of tuberculous disease the morbid product is de- veloped in different organs of the body to a sufficient degree to cause its proper symptoms, while the proportion of the tuber- culous matter in the lungs is still so much greater than in other viscera, that the specific designation, pulmonary consumption, is retained ; in most of these cases the tubercles in the differ- ent viscera, are developed at a later period than those of the lungs ; in a few, the former precede the latter. 2. The ac- companying disorders and symptoms of other organs than the lungs, may have no immediate connection with the growth of tubercles. These symptoms are extremely numerous, and occur either previously to phthisis, or in its various stages. The symptoms of tuberculous disorder of the organs of the body, other than the lungs, cannot be distinguished from those of ordinary chronic inflammation ; indeed, the two affections are often united, -and occur together. This is particularly the case in the serous membranes ; that is, the pia mater, pleurae, and peritoneum. The inflammation is in these cases of a slow sub-acute variety, and we recognise the tuberculous complica- PULMONARY PHTHISIS. 187 tion chiefly from its persistence and slow progress. In the in- testines the tuberculous disease of the follicles is essentially intermittent at first, and the symptoms vary incessantly, diar- rhoea often occurring for several days, and then being followed by constipation ; after a certain time the diarrhoea may entirely cease, and the follicles, which are the seat of the tuberculous de- position, will cicatrise. There are no other cases of tuberculous deposit in mucous membranes, in which we can recognise its symptoms. In the serous membranes, it is essentially connected with inflammation ; and the symptoms are therefore inflammatory, but of the sub-acute kind. All the varieties of these disorders are closely allied together, and constitute the tuberculous dis- ease of serous membranes which may occur before any tuber- cles are formed in the lungs, but in the majority of cases they occur in adults during the progress of pulrrionary phthisis. In other cases of tuberculous deposit than those just mentioned, the lesion is attended with symptoms of functional disorder of the organs attacked, in proportion as it produces a positive destruc- tion of the tissue, or as it is accompanied with inflammatory action. We see, therefore, that the tuberculous deposit gives rise to few symptoms, except it is so situated as to disturb the function of an organ. The other lesions, and the attending symptoms which occur in phthisis, or before tubercles are actually formed, are ex- tremely numerous, and very various in character. They are sometimes prominent enough to attract attention almost exclu- sively to them, and they obscure the characters of the most important affection. Of this nature is dyspepsia, which is a very frequent, though extremely irregular symptom. In some cases it occurs very early in the disorder, and may appear be- fore there is either positive or probable evidence of tuberculous formation ; there are cases of dyspeptic phthisis, in which the disorder of the stomach appears often to be quite independent of either general or local tuberculous disease; but in other cases the gastric disturbance is evident before the local disor- der, and is clearly connected with the loss of appetite ; it may give rise to phthisis in one of two ways,— either by the febrile excitement which it produces when the disease assumes an acute form, or by the alteration of the fluids which produces a peculiar action of the mucous membrane, and causes a slow softening and destruction of it. The complication of dyspepsia and phthisis constitutes one of the worst forms of consumption ; as long as the digestive functions are unimpaired, the disease is slow in its progress, and attended with little suffering to the 188 PULMONARY PHTHISIS. patient; but if the nutrition fails, it becomes much more acute. The intestinal canal is subject to many derangements; the natural effort of the disorder, like most febrile affections, is to produce constipation ; but diarrhoea may occur not only from the formation of tubercles, which has been already mentioned, but from the usual causes of inflammation. In most cases, the symptoms do not differ from those of the same diseases when they occur in a less complicated form ; but those of the pul- monary affection are singularly modified, the cough frequently subsides, and the disease is apparently much better. The in- flammation of the bowels then acts like any other revulsive action. The cough is again increased as soon as the diarrhoea subsides. Fistula in ano is another affection closely connected with the alimentary canal. Dr. Louis came to the conclusion that this was a rare complication in phthisis, but his conclusions are based upon peculiar data: on examining all the phthisical patients who entered the wards of an hospital, he found that fistula in ano was extremely rare. If he had examined, on the other hand, all cases of fistula in ano admitted into a surgical ward, he would have found that a large portion of them end in phthisis, either during the continuance of the fistula, or after it has been healed by a surgical operation. As a general rule, cases of consumption complicated with fistula are quite slow in their course, and they are most frequent in men who are advanced to the middle period of life. The affections of the liver are frequent in phthisis, especially in women, particularly the young. The most frequent of them is the fatty degeneration of the liver, which is rare, except in phthisis of women and in drunkards. Why these two condi- tions should both give rise to the same, or nearly the same alteration, is extremely difficult to explain. The functions of the liver are but moderately impaired, notwithstanding a large portion of its tissue should be converted into fat. There is another disease of the liver which occasionally occurs in phthisis, or rather just before the tubercles are developed, which is more important than the fatty state. That is, cyrrhosis : this disor- der is most frequent when phthisis occurs in countries where intermittents are endemic, and therefore it is often difficult to distinguish the precise time when tubercles are formed. The only mode is to attend carefully to the local indications of disease of the lungs, especially to the physical signs. I am compelled to group together the secondary lesions of phthisis, and their symptoms, otherwise this subject would be extended to too great a length. Condensed as this view is, PULMONARY PHTHISIS. 189 however, some of these secondary alterations must be omitted, for the very sufficient reason, that a disease of great duration, pervading the whole economy, and causing much febrile ex- citement, necessarily gives rise to nervous and irregular secon- dary lesions. Hence we often find that the phthisical patient complains of severe pains in the bones, or muscles, which ap- pear to have no necessary connection writh the disease, but be- long to the class of unexplained sympathies. Diagnosis. — The diagnosis of phthisis is not attended with any difficulty in advanced, or even in early cases, provided they are regular, and the symptoms follow their usual order. But in cases in which the local signs are not well developed, or the symptoms connected with other organs predominate -over those of the lungs, the subject is much more difficult; and we are then obliged to resort to two modes of diagnosis. One is to group together carefully the symptoms we observe, and then to compare with these groups, different diseases which might possibly give rise to similar symptoms. Thus, any two or three of those symptoms which I have just described as belonging to the lungs, with the addition of emaciation and the febrile move- ment so frequent in commencing tubercles, would render it pro- bable that the case was one of commencing phthisis. It is true that a complete diagnosis cannot always be made until the disease has advanced far enough to betray some of its essen- tial physical characters, but this is not the case in the majority of patients. There are certain other signs which are of great value in the diagnosis of early phthisis. These are either individual symp- toms, or peculiar groups of collective signs, which would singly be of little value. The most important of them is, perhaps, hemoptysis. This symptom receives different degrees of atten- tion ; some writers consider it almost pathognomonic of phthisis, while others attach comparatively little importance to it. There is, however, little difficulty in reconciling these conflicting opinions ; and if we examine the facts relative to it under several points of view, but little real difference of opinion re- mains. Hemoptysis, however, is not necessarily connected with tuberculous disease of the lungs. It may arise as a consequence of disease of the heart, in which the lungs become engorged with blood, and relieve themselves by hemorrhage, or it may arise in women as an effect of suppressed menstruation. Besides these cases, it sometimes, though rarely, happens that a flow of blood takes place from the lungs without any such obvious cause, and without an apparent connection with tubercles. The latter cases it must be supposed are quite rare, so that hemop- 190 PULMONARY PHTHISIS. tysis is still, in the large proportion of patients, a symptom of formed or commencing consumption. We may state in general terms, that at least two-thirds of all who have hemoptysis, are actually affected with consumption, or are on the point of be- coming so. But even when consumption follows an attack of hemoptysis, it is not the most fatal form of the disorder; a num- ber of such cases occur in daily practice. Amongst them I would cite the case of a physician of Philadelphia,"^\vho had frequently repeated attacks of hemoptysis, with other symp- toms of phthisis, at the same time, he however recovered, and now enjoys good health, and is able to attend to the fatigues of an extensive practice. Hemoptysis occurs in three different relations to phthisis: 1st, before tubercles are developed ; 2d, when they are still crude, and perhaps few in number ; 3d, when cavities are formed. In the first two cases, the blood is evidently secreted from the mucous membrane of the smaller tubes, and probably from the vesicular structure ; in the third, it comes in most cases from vessels which pass through the bands running across cavi- ties: these may finally give way to ulceration before their calibre is completely obliterated, and a large, and even fatal, hemorrhage may suddenly occur. Hemoptysis is of little value as a diagnostic character, unless abundant, — that is, exceeding a wine-glassful in twenty-four hours ; a discharge of blood from the lungs in less quantities will, to a certain extent, indicate a tendency to tuberculous disease of these organs, but is not in itself of much importance. If the hemorrhage be more abundant, and occur without any obvious cause, it must always be regarded as a sign of com- mencing phthisis, or of a peculiar condition of the lung itself, or of its capillaries, which often ends in tuberculous formation. The evidence in favour of this conclusion is extremely strong, and is not refuted by the fact that a number of patients affected with hemorrhage recover ; for the first stages of phthisis are by no means incurable; and the varieties in which hemoptysis occurs are amongst the most favourable. These cases of ex- emption from phthisis after abundant hemoptysis are not ex- tremely numerous, as any one may ascertain for himself by simply interrogating individuals who have arrived at the mid- dle periods of life, and enjoy good health : of these a very small proportion have ever had hemoptysis ; and this is true not only with reference to healthy individuals, but as compared with the whole number of phthisical patients ; amongst the latter the proportion of cases of hemorrhage is very large. The occurrence of tuberculous, or even the long continuance PULMONARY PHTHISIS. 191 or frequent repetition of simple pleurisy is another indication of phthisis which will strengthen the more direct symptoms of the disorder. But we must not imagine that any single symp- tom is ever sufficient for the diagnosis of a disorder, which, at its commencement, is necessarily complex. Nothing, but the grouping together of a number of signs, together with the in- direct evidence afforded by exclusion, will afford the basis of a positive diagnosis. In abnormal cases tolerably developed, however, there is no difficulty in arriving at a positive diagnosis. The general signs of the disease become more developed, and on examining the chest we will always find dulness at the summit of one or both lungs, and various alterations of the voice and respiration at the same place ; such as bronchial or cavernous respiration, crackling, and finally, resonance of the voice. Prognosis. — The prognosis of phthisis is unfortunately quite clear in the large majority of cases; and when the disease is established, it is regarded as almost necessarily fatal. This prognosis must, however, be taken with some reservation, as the disease is in its nature essentially different in different stages, and cannot be said to be unavoidably fatal except when the disorganisation of the lungs is much advanced, and the tuberculous degeneration of the whole economy is carried to a very high degree. In the earlier stages the disorder may ter- minate in recovery ; and there is no doubt that it not unfre- quently gets well, even when the local sign of the disorder, the deposit of tubercles themselves, is actually formed. But these are not the most frequent cases ; for before any actual deposit of tubercle can take place, a very extensive alteration of the whole fluids has in all probability occurred, and the deteriora- tion will be found to have reached that point which renders recovery rare, but not impracticable. Although in many cases of phthisis the possibility of recovery is now generally admitted, this result is by no means probable, except when a number of favourable circumstances concur; for, as the causes of phthisis are for the most part very slow, but at the same time very powerful in their action, the disease cannot in many instances be materially influenced by remedies. It is therefore unfortunately true, that even when we foresee that the disease is approaching, or distinguish the first steps of the tuberculous formation, it cannot always be arrested,—but there are other cases in which the result is happily much more favour- able. In order to distinguish these cases, we must bear in mind the circumstances already mentioned as complicating the progress of phthisis, or influencing its development. Of these 192 PULMONARY PHTHISIS. the most important are a strong predisposition to phthisis, whether hereditary or acquired, and an exposure to circum- stances known to favour the development of the disease. In- dividuals who present this constitutional tendency are those who offer the well-known signs of the scrofulous constitution denoted by the peculiar colour of the skin, and have generally the very dark or the light rosy complexion; when the disease is hereditary, the dark complexion is perhaps more frequent than the light, and the skin has then a dusky, earthy tint, or a dirty aspect, which is often almost peculiar to this disease. It is not always the case that those persons are thin and feeble,— some of them are stout and muscular, but feebleness of body increases the tendency to the tuberculous developement, and we may make the same remark with still greater force of the fat, pale, tallowlike complexion of some individuals, especially wo- men, who possess an hereditary tendency to phthisis ; the lat- ter class of patients generally offer an enlarged, fatty state of the liver, and the prognosis in this case becomes very unfa- vourable. If exposure to the causes favouring tuberculous development cannot be prevented, the influence of them must be obvious enough, and will greatly increase the probability of an unfa- vourable issue. In all cases, therefore, in which any direct evidence of tuberculous deposit is conjoined with hereditary tendency, or other strongly disposing causes, the disease is most intractable ; this accounts in a great measure for the more frequently fatal termination of phthisis in the crowded and im- pure wards of an hospital. If there be no local signs whatever, but merely that constitutional deterioration which, unless ar- rested, is sure to end in phthisis, our prognosis is different; these indeed are scarcely to be considered as true cases of con- sumption ; they are so only in embryo, and may be often arrested by change of residence, or other means. The mode of development, and the early symptoms of phthisis, have also a considerable influence upon its termina- tion. Some cases are unfavourable from the beginning, not merely from the strongly marked general symptoms, but be- cause the local signs are known by experience to coincide with intractable forms of the disorder. The signs which may be regarded as impressing a favourable character upon the disease, are haemoptysis, if occurring from time to time after exertion, and very moderate, and local inflammation of the lungs before tuberculous matter is deposited in any large quantity. Haemop- tysis, if extremely abundant, is not favourable, unless the pa- tient should get perfectly well without irritative fever or further PULMONARY PHTHISIS. 193 symptoms of tubercles; it then seems to relieve the lungs, and the disease is in general milder, and not unfrequently abates at an early period. But there is another form of haemoptysis which often occurs long before the disease seems to be concen- trated upon the lungs, and is perhaps rather referrible to a pe- culiar condition of the whole capillary system, than to any local mischief: this renders the prognosis much less favourable ; it is the spitting of blood, which often continues for years, a mouth- ful or two at a time after coughing or very slight efforts, and is hardly noticed by the patient. It is most frequent in young women, and in those wTho offer a strong constitutional tendency to phthisis. The local inflammation of the serous membranes, or of the serous tissue of the lungs, is a favourable sign, because the ac- tion which gives rise to the disease is here a positive, tangible one ; and if we succeed in changing it, or modifying its pro- gress before tubercles are formed, the disorder may be arrested much more easily than in the more constitutional cases. If the tuberculous matter be actually formed, but limited to small por- tions of the lung, the prognosis may still remain favourable to a certain extent, — that is, the disease will be slow, and in a few cases will terminate happily, notwithstanding a cavity is formed. The least favourable local signs are those observed when the disease begins in a slow insidious manner, by the trachea or larynx, which does not always call attention to the lungs, and the tuberculous degeneration proceeds in an unsuspected form. Not that chronic laryngitis is of itself necessarily fatal, but it certainly promotes the formation of tubercles ; and when this point is once reached, the disease generally assumes a severe and unmanageable character. In these cases, too, the tubercles are often scattered widely through the lungs, and of course are productive of more mischief than if they are limited to a small space at the summit. The prognosis of phthisis must be taken in a more extended sense than that of its ultimate termination : we have to decide in many cases whether the disease is to terminate speedily or slowly, in death or recovery ; this investigation leads us to the study of the varieties of phthisis in relation to its character. Duration of Phthisis. — Although consumption of the lungs is, in the large majority of cases, a chronic disease, it is from time to time met with in an acute form; that is, it may prove fatal in a period of less than three months. This depends upon the rapid formation of gray granulations, or tuberculous infiltration, in a large portion of the lungs. The disease is then attended 17 6*'2*£lfftTil'•/?'.► -- /<-* * "A■ r/s. , ^r? S:L yfarJ 's/u:\ *✓>:.;> /-,< ^.....**~ '-''■* /"""/,<• '/>->i4*.>nz\ f v * * / 194 ' PULMONARY PHTHISIS. with much fever, and the general tuberculous signs, as already mentioned, are extremely developed. In many instances, death does not take place so much from the pulmonary dis- order, as from the coincident inflammations, or tuberculous de- position in other organs, especially in the serous membranes of the brain. But phthisis may become acute, when it begins in the ordinary chronic form, and the change is then rendered apparent by the rapid increase and severe character of the fever and sweats. Hence, although we know that the usual course of ordinary phthisis is slow, it is always possible that the type may change, and the termination may be hurried much more rapidly than usual. Our prognosis in acute cases is directly dependent upon the diagnosis ; for if we once recognise the disease as of the acute form, we can confidently state that its course will be probably a short and a fatal one. The duration of the ordinary variety of phthisis has been estimated by Dr. Louis to be about eighteeen months; this is, perhaps, sufficiently near the truth, — but a large proportion of cases in hospital practice terminate in less than that period ; in private practice the course of the disease is delayed so much by treatment, that the average duration of all cases, except the acute, is probably two years. The du- ration of consumption is greatly influenced by age ; the disease is often acute in the young— rarely so in those more advanced in life ; in the latter class of patients the disease is much more slow than it is in the young. The female sex has a similar influence with childhood, so that the most frequent cases of acute phthisis are to be met with in young girls, a little after the age of puberty. Treatment.— The treatment of phthisis is by many regarded as never curative, but merely as a means of palliating the most severe or harassing symptoms of the disorder. If we apply the term consumption only to those cases in which the disease is far advanced, and the constitutional deterioration is extreme, it is very plain that no means of cure exist, and that even palli- ation is in many cases difficult; but if we speak of consump- tion as of other diseases which tend to a fatal termination only after having passed through their early and more curable stages, it is strictly curable, and like these disorders must be treated in different ways, according to the mode of its development; for as tubercles are attended with very different symptoms, and originate in various modes, it is very clear that the most oppo- site methods of treatment may prove efficacious in combating the affection in its forming stage. But after the tuberculous deposit has fairly commenced, it obeys its own laws of growth and presents the secondary symptoms, such as hectic fever, PULMONARY PHTHISIS. 195 emaciation, &c, which are peculiar to itself, and then one uniform method of treatment is desirable, or at least seems indicated. Besides, although the modes of development of tuberculous disease are very numerous, there is a form in which the symptoms are regular and uniform ; and even in those varieties in which the modes of origin are most unlike, there is a peculiar character impressed upon the various symptoms, which is dependent upon the scrofulous or tuberculous dia- thesis. This treatment would be specific for the disease, and might be curative if it could cause with certainty the absorption of the secreted product, and favour the cicatrisation of cavities, when the loss of substance was not extremely great. If we possess such a mode of treatment, we might then, with great confidence expect to cure phthisis in nearly every stage. But as no specific exists, we are obliged to content ourselves writh the adminis- tration of alteratives, which have but a limited influence on the growth of tubercles, and of such remedies as act either upon the causes of the disease, or on the accidental disorders which favour the tuberculous deposit in an indirect way. The alteratives used in phthisis are, for the most part, such as exercise a tonic and invigorating influence, at the same time that they produce their proper effect as alteratives. Mercury is always injurious as a direct remedy in phthisis ; it can never be of service except in those cases in which there is decided inflammation, and the tubercles result directly from it; but even in this class of cases, the influence of the remedy is cer- tainly injurious so far as it effects the proper tuberculous disorder, and it must be discontinued as soon as the inflammatory symp- toms are removed. The effect of mercury in phthisis is now so well known that it has almost become an axiom in medicine to avoid it in the treatment of this disease. Iodine is much more used than any other alterative; and if employed with discretion, it scarcely ever does harm. I have found it beneficial at the commencement of cases in which the fever was but moderate, and the local inflammation but slight, especially when a circumscribed chronic bronchitis has preceded for a long time the actual development of tubercles. Hence it is well suited to those cases which are preceded by chronic inflammation of the trachea and larger tubes, and pass slowly into phthisis ; and to the cases which are most closely connected with external scrofula. The patient is then often robust in appearance, and the local disease is slow in forming. Iodine is also useful in the purely constitutional cases, provided it be given cautiously, and the emaciation of the patient has not 196 PULMONARY PHTHISIS. advanced very far ; it should then be combined with vegetable tonics. The preparation to which, from habit, I was at one time accustomed to resort is Lugol's solution, prepared of the strength directed in the United States Pharmacopoeia,—that is, one scruple of iodine, and two of hydriodate of potassa, to seven drachms of water. Of this I give to an adult from three to six drops two or three times daily ; I very seldom exceed six drops three times daily, and often give much less. For the good effects of the medicine may be obtained much more certainly in this way than by giving it in larger but more irritating doses. I have never witnessed any other mischievous effects from the iodine than the disorder of the digestive canal, and a fulness of the head which sometimes results from it; but it is very certain that in some rare cases it acts as other powerful alteratives occa- sionally do, and it may enfeeble or disturb the functions of the whole body, without removing the morbid action. Hence it is advisable to discontinue its use from time to time, and resort to mild purgatives for a few days, or to abstain totally from all medicine until the tone of the stomach is restored ; it then is scarcely possible that an injurious result should follow. As the action of iodine is slow, w-e cannot observe any immediate im- pression produced by it; but when it is acting well, the com- plexion and strength of the patient improve, and the cough at the same time gradually diminishes. The latter effects may be pro- moted by appropriate expectorants, which should be given at the same time with the iodine. The appetite and strength almost always increase; and if these fail, or become less, instead of increasing, it is almost a sure indication that the medicine is not acting well. It is often useful to administer laxatives from time to time, even if the medicine be not suspended. As iodine evi- dently acts merely as an alterative, it is beneficial in that con- dition of the economy which precedes the secretion of tubercles, as well as in their more advanced stages ; and it may be con- joined with other alteratives, such as the compound decoction of sarsaparilla, or with mild tonics. Without attributing to iodine any specific virtue, I am quite convinced that its powers are very great in commencing phthisis, and that it sometimes effectually arrests the progress of the disorder. The remedy seems to me to be least adapted to those cases in which tubercu- lisation is very rapid, or the inflammation of the serous mem- branes very acute. The hydriodate of potass is on the whole preferable to the solution of iodine; that is, it acts with less irritation to the ali- mentary canal, and may be given with safety in many cases of the disease. The dose is five grains three times a day, gradually PULMONARY PHTHISIS. 197 increased to ten grains : the remedy should not, however, be continued long without intermission ; it should be discontinued, and after a week may be resumed. There are some patients, however, who cannot take iodine in any form without great irritation; and at Geneva in Switzerland it was stated to me by several medical gentlemen, that the remedy cannot be given except in very small doses—that is, doses of five grains pro- duced very violent symptoms. This remedy, however, is very far from producing at other places similarly injurious effects: as a rule, it would seem, that from some unknown circumstances, it in that situation loses its remedial power and acquires most mischievous properties. There is no other alterative of a medicinal kind to which I attach much importance. There is none to wThich I could refer as possessing enough certainty of action to make it useful in the majority of cases of phthisis : the mineral alteratives are more or less irritating and depressing in their effects ; and the vegetable, although they are, in some cases, of service, cannot be relied upon with much certainty. They are evidently most beneficial where there is a constitutional deterioration which is going on very slowly, and rather precedes than actually accom- panies the deposit of tubercles, — that is, it is the same disease which has not yet reached its highest point; and although the knowledge we possess of the virtues of this class of medicines is as yet extremely limited, there is great reason to believe that they may possess considerable power in arresting the early stages of constitutional phthisis* Most of the alteratives now used for this purpose are at the same time tonic, such as the preparations of sarsaparilla and the compounds of rhubarb with the bitter tonics, or with soda. In my own practice I resort to these remedies, chiefly to replace the iodine, or to aid its action. When phthisis has fairly commenced, iodine, or any other alterative, is designed to favour the absorption of a product which is actually deposited. But there are many cases in which we know that a tuberculous action is going on; that is, that the process which ends in tuberculous secretion is actually at work, but as yet there are no tubercles. It is then import- ant to arrest the formative action, and iodme is often of benefit in these cases. It is true, that direct proof of this is extremely difficult, because it is not easy to prove that a disease which is slow and obscure in its mode of formation, is really influenced or not by any remedy. The reasoning must be probable, and not demonstrative ; and the truth is approached more or less nearly as the observer possesses the proper abilities for drawing 17* 198 PULMONARY PHTHISIS. conclusions of this kind. In these forming cases of tuberculous disease, iodine seems to act like alteratives of a hygienic cha- racter, and is certainly useful if no directly injurious conse- quences result from it; but it must be given in small doses, and from time to time should be intermitted. If these cases be very acute, the remedy must be omitted ; for as a general rule it is quite unsuited to either the forming or the formed cases of acute phthisis or any other inflammatory form of tuberculous disorder. In these acute cases the inflammatory element predominates, and the action of the remedy is too stimulating, as it is in cases of phthisis which begin by local inflammation. WTith these reservations as to its use, iodine is one of the most efficient re- medies in early and in forming phthisis. How far its useful- ness extends, is not a subject upon which we can speak with entire confidence. In advanced cases of phthisis hectic supervenes; and iodine and all other alteratives are useless, unless they act merely as tonics. Indeed, iodine has generally appeared to me to be of positive injury as soon as softening had taken place. For even if its influence upon those portions of the lungs in which the disease has not advanced very far is good, it acts injuriously upon the surface of cavities and the softened tubercles. In the early stages of tuberculous disease of the lungs, hygienic alteratives have always claimed the first place; indeed, you may readily believe that no medicinal alterative can well be useful if the hygienic measures which are best adapted for the disease be neglected. These are very well understood ; and, besides the choice of proper localities for a residence, and for a journey or sea-voyage, consist mainly in adopting such precautions, and in pursuing such a course of life, as is least fitted to develope the disease. This part of our subject leads us naturally to the examination of some of the causes of phthisis. When we remember the circumstances under which the disorder occurs, we may divide them into two classes — those of a general and those of a local character. The general causes are such as exist originally in the individual, or arise from the circumstances in which he is placed ; the latter are those which may be to a great extent obviated by art, and the action of the former may thus be checked indirectly, or at least not favoured. The local causes of phthisis are either directly inflammatory, or at least belong to morbid conditions which must be removed by medicinal rather than by hygienic measures. If the general causes include an hereditary predisposition to tuberculous disease, it is of course necessary to insist more strongly upon those that are accidental. You PULMONARY PHTHISIS. 199 find these causes enumerated in the work of Dr. Clark, and in most others upon the subject, and it is not necessary to enter much into detail upon this subject; some classification, how- ever, may be adopted, to render the same intelligible. 1. We may place hereditary predisposition in the first in- stance. This is universally admitted, and the strength of it is increased if the parents were actually labouring under the formed disease at, or a short time previously to the birth of the child. It may descend from either parent; but it would seem that the mother exercises the greatest influence in this respect, especi- ally if she nurses the child herself. In other respects the usual laws of hereditary transmission hold good, and the probabilities of their action are increased if the child present the signs of the scrofulous temperament. 2. Depressing causes which debilitate the powers of life, in- crease the tendency to the morbid action. These, of course, are very numerous. Imperfect diet, exclusion from light, and from fresh air, and mental depression, are amongst the most powerful. Inaction, or a diminished activity of body, favours the same result. These causes are very obvious in patients admitted into hospitals with other chronic diseases, and after- wards attacked by phthisis. It is always important to protect the patient from the influence of these causes, and whenever practicable the greatest attention should be paid to them. One of the advantages of a journey certainly arises from its invigorating influence, and the abundant supply of health- ful air which is thus obtained for the patient. The depress- ing causes often arise from the effects of a disease which is cured, but leaves the patient in an, enfeebled state ; this is often the case with typhoid fever ; in other instances it produces a more direct impression, and the phthisis supervenes before the fever entirely ceases. 3. Certain occupations are known by direct observation to favour the development of consumption ; these are such as re- quire a constrained position, and especially sedentary confine- ment in close rooms. Mineral or vegetable dust or powders diffused in the atmosphere contribute to the same result. Hence the propriety of changing the occupation of the patient is often a matter of strict necessity. Irregular exposure to cold and heat has a similar tendency, but it is much more effective as a cause of the accidental inflammations that often precede phthisis. Although these are the chief of the general causes of phthisis, the list might be much extended ; they are, however, more or less analogous in their character, and more or less directly de- pressing upon the individual. The alterative effects of a long journey and of change of resi- 200 PULMONARY PHTHISIS. dence, are well known in phthisis. They both act nearly in the same way: a journey in the pleasant season of the year, or in a climate which renders all seasons agreeable, is often of great benefit in forming phthisis, or in those varieties of the disease in which there is not much febrile excitement or local inflam- mation ; if these exist, the journey is irritating, instead of in- vigorating. If the strength of the patient be good, the journey should be made on horseback, or in an open carriage, and be pursued as long as the strength of the patient continues to im- prove. A sea-voyage is sometimes preferred to a land journey ; as a general rule, however, it is less useful; there are, how- ever, cases in which the strength of the patient is not great, but the disease at the same time is slightly advanced, and the fever moderate, in which a sea-voyage in a mild latitude is of great benefit. It is also of great benefit in those cases in which the phthisis is attended with slight, but frequent hemoptysis during its early stages. A short voyage is of little comparative bene- fit ; it should be long enough to act as a decided alterative ; hence, one to the East Indies, or to the Mediterranean, or South America, answers best. The shorter voyages to Madeira, or the West Indies, are only advisable, because they are neces- sary to a winter's residence in these climates. The question of a change of residence is always of great in- terest to a phthisical patient; in fact, there is no one upon which he is more disposed to consult his medical adviser. The general anxiety felt by patients to resort to this mode of relief, is a conclusive proof that there is something in it, for it still continues although the lapse of years shows that the ad- vantages of such a residence are much overrated. These ad- vantages may be stated very briefly ; by a winter's residence in a warm, but equable climate, the tendency to slight conges- tions or inflammations of various portions of the organs of re- spiration is obviated, and a cause of irritation is then removed. Secondly, the mildness of the climate allows the invalid to en- joy the advantages of fresh air and exercise without much dis- comfort or risk. Lastly, the change of climate and of air is of itself of great benefit as an alterative. These advantages are, however, limited ; they are not specific in the treatment of con- sumption ; hence many cases are not at all relieved, some are even aggravated. If the disease be of the acute form, and especially if it be attended with much fever, the patient is almost always rendered more feverish by the journey, and the affection tends to advance more rapidly ; or if the disorder be so much advanced that the strength of the patient is rapidly declining, no advantage can be expected- It is in the milder and more chronic cases that the change of air does good, espe- PULMONARY PHTHISIS. 201 cially if the patient has found by experience that the winter is of injury to the organs of respiration, and gives rise to much cough or other signs of laryngeal or tracheal irritation. Of this class of patients very few individuals will be found to die abroad ; most of them return with some relief of their symp- toms, especially for the first winter ; if the disease be not ar- rested, however, the benefit of a second winter is very doubt- ful. When the disorder of the digestive organs is a promi- nent symptom, the benefit from the voyage is very considera- ble, but the -u»i WITH LATE DISCOVERIES ON THEIR I STRUCTURE, GROWTH, CONNECTIONS, DISEASES, AND SYMPATHIES. By GEORGE WAITE, A Member of the London Royal College of Physicians. &__---------------------------.------------------- LIST OF WORKS SUPPLIED AS SELECT MEDICAL LIBRARY EXTRAS—BY MAIL. Barrington and Haswell will furnish the following Works as Extras; they are stitched in thick paper covers, with strong elastic backs; and can be sent by mail, charged as Periodicals. 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