^H ^HI ^H «- ■ M I I ' ! ■ j>j ■ ^H SYSTEM ov PRACTICAL MEDICINE COMPRISED IN A SERIES OF ORIGINAL DISSERTATIONS. ARRANGED AND EDITED BY ALEXANDER TWEEDIE, M.D. F.R.S., •«i FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL AND TO THE FOUNDLING HOSPITAL, ETC. WITH NOTES AND ADDITIONS, W. W. GERHARD, M. U., LECTURER ON CLINICAL MEDICINE TO THE DNIVERSITY OP PENNSYLVANIA, PHYSICIAN TO THE PHILADELPHIA HOSPITAL, BLOCKLEY, ETC. THE SECOND AMERICAN EDITION. IN THREE VOLUMES. ^''j.3^'SS^> ?13 VOL. II. PHILADELPHIA : LEA & BLANCHARD. 1842. Entered according to Act of Congress., in the year 1842, by LEA &. BLANCHARD, in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. WB Tills GRIGGS & CO., PRINTERS. J NERVOUS DISEASES, (CONTINUED.) ORGANS OF RESPIRATION, CIRCULATION, AND ARTERIES. CONTENTS OF VOLUME SECOND- NERVOUS DISEASES— Continued. SPINAL IRRITATION. {Dr. Bennet.) Explanation of the term spinal irritation.—Various anomalous symptoms.—Predisposing causes.—Exciting causes.—Nature.—Diagnosis.—Prognosis.—Duration.—Treatment. Page 17 SPINAL MENINGITIS. {Dr. Bennet.) Definition.—Symptoms—of the acute Form—of the chronic Form.^-Causes.—Anatomical Characters.—Nature.—Diagnosis.—Prognosis.—Treatment, ... 22 MYELITIS, OR INFLAMMATION OF THE SPINAL CORD. {Dr. Bennet.) Definition.—Symptoms of acute Myelitis—of chronic Myelitis.—Causes.—Anatomical Cha- racters.—Nature.—Diagnosis.—Prognosis.—Treatment, 26 HYDRORACHIS, (Dr. Bennet.) Definition.—Congenital Hydrorachis.—Hydrorachis developed after Birth.—Causes.—Ana- tomical Characters.—Nature.—Diagnosis.—Prognosis.—Treatment, 21 SPINAL APOPLEXY. {Dr. Bennet.) Symptoms.— Causes.—Anatomical Characters.— Nature.— Diagnosis.— Prognosis.—Treat- ment, ..-..-----37 CHOREA. {Dr. Theophilus Thomson.) Characteristic Symptoms. — Analogous Affections.— Anatomical Characters. — Nature.— Causes.—Diagnosis.—-Prognosis.—Treatment, ..... 39 HYSTERIA. {Dr. Theophilus Thomson.) General Observations.—Division into three Forms—regular—irregular—complicated.—Diag- nosis.—Prognosis.—Causes.—Nature.—Curative Treatment.—Moral Management and pre- ventive Treatment, ..-..--• 51 Vol. II .—2 VI TETANUS. . (Dr. Bennett.) Explanation of the term Tetanus and its Varieties.—Trismus.—Opisthotonos.—Emprostho- tonos.—Pleurosthotonos.—Trismus Nascentium.—General and local.—Acute and chronic— Idiopathic and symptomatic—Continued and periodic—Premonitory Symptoms of Te- tanus.—Symptoms of the Paroxysm of Trismus—of Opisthotonos—of Emprosthotonos—of Pleurosthotonos.—Chronic Forms of Tetanus.—Predisposing Causes.—Exciting Causes.— Anatomical Characters.—Nature.—Diagnosis.—Prognosis.—Treatment, - - 67 HYDROPHOBIA. {Dr. Bennet.) Definition.—Premonitory Symptoms.—Symptoms of the Attack.—Various Modifications observed in the Symptoms in the Human Subject.—Symptoms of Rabies in the Dog.— Predisposing Causes.—Exciting Causes.—Nature.—Anatomical Characters.—Diagnosis.— Prognosis,—Prophylactic or preventive Treatment.—Curative Treatment, - 83 NEURALGIA. {Dr. TheophUus Thomson.) Definition.—Symptoms.—Varieties.—Diagnosis.—Causes.—Nature.—Treatment, - 99 PARALYSIS. {Dr. Bennett.) Explanation of the term.—Varieties and Distinctions.—Symptoms.—Mode of Accession.— Description of the various Forms and Varieties of Paralysis.—General Paralysis.—Hemi- plegia.—Paraplegia.—Various Forms of local Paralysis.—Paralysis of particular Muscles.— Strabismus.—Ptosis and Lagophthalmia.—Aphonia.—Paralysis of the Face.—Paralysis of a Limb, or particular Muscles of a Limb.—Paralysis of Sensibility.—Amaurosis.—Copho- sis.—Anosmia,—Ageustia^—Antesthesia.—Paralysis of Motion.—Paralysis of the Insane.— Paralysis from metallic Poison.—Mercurial Palsy.—Lead Palsy.—Paralysis Agitans.— Causes of Paralysis.—Anatomical Characters.—Nature.—Crossed Effect from Lesions above the Medulla Oblongata.—Direct Effect from Lesions below.—Diagnosis.—Seat of the Lesion.—Nature of the Lesion.—Prognosis.—Treatment, - - - HI BARBIERS. (Dr. Bennett.) Symptoms.—Causes.—Morbid Anatomy.—Diagnosis.—Treatment, - . - 131 INFLAMMATION OF THE EYE. {Dr. Taylor.) General remarks on ophthalmic inflammations and their classification.—I. Inflammation of the conjunctiva.—(a) Catarrhal ophthalmia—symptoms—causes__diagnosis__treatment.__ (b) Purulent ophthalmia of infants—symptoms—causes—treatment.—Of adults__symp- toms—causes—treatment.—(c) Gonorrhceal ophthalmia—symptoms—causes__treatment__ (d) Strumous ophthalmia—characteristic symptoms—causes—treatment.__(e) Variolous ophthalmia—symptoms and treatment.—(f) Morbillous and scarlatinous ophthalmia__symp- loms and treatment.— (g) Erysipelatous ophthalmia.—II. Inflammation of the sclerotica__ symptoms and treatment.—(a) Catarrho-rhcumatic ophthalmia—symptoms, causes and treatment.—III. Inflammation of the cornea—symptoms, causes, and treatment.__IV In flammation of the iris.—(a) Acute idiopathic iritis—symptoms—causes—diagnosis__treat- ment—varieties.—(b) Syphilitic iritis—symptoms, diagnosis, and treatment.__(c) Rheu matic iritis—diagnostic symptoms and treatment.—(d) Arthritic iritis—symptoms, causes and treatment.—(e) Strumous iritis—characters and treatment.—V. Inflammation of the retina—symptoms of the acute—of the chronic—causes—diagnosis—treatment.__VI Tn flammation of the choroid—characteristic symptoms, causes, and treatment,—VII. Inflam motion of the lining membrune of (he aqueous chamber, and of the lens and its caD eule'..........133 CONTENTS. VII AMAUROSIS. (Dr. Taylor.) Definition.—Idiopathic and symptomatic—Symptoms.—Causes.—Diagnosis.—Prognosis.— Treatment, 170 INFLAMMATION OF THE EAR, OR OTTITIS. (Dr. Bennet.) Definition of otitis and otorrhoea.—Acute and chronic otitis.—Symptoms of acute external otitis—of acute internal otitis—of chronic otitis or otorrhoea.—Causes.—Anatomical cha- racters—Diagnosis.—Prognosis.—Treatment of acute external otitis—of acute internal otitis—of chronic otitis, - - . ..... 178 DISEASES OF THE ORGANS OF RESPIRATION. ON THE DIAGNOSIS OF DISEASES OF THE LUNGS. (Dr. Williams.) General observations.—I. Examination of the chest through its physical properties—by sight and touch—by mensuration—by its sounds—by percussion.—Sounds of the respiration.— Rhonchi.—Sounds of the voice.—Mode of employing auscultation,—Comparative advan- tages of immediate and mediate auscultation.—Principles and construction of the stetho- scope.—II. Examination of the chest through the vital properties or functions of its organs. —Analysis of the general symptoms.—Dyspnoea.—Cough.—Expectoration.—Pain.—Symp. toms connected with the circulation.—Analysis of the pulse.—Symptoms from the venous and capillary circulation.—Of the symptomatic fever.—Respective value of the physical signs, and general symptoms, ------- 195 LARYNGITIS. {Dr. Williams.) General observations.—Two forms of laryngitis—the Acute and the Chronic.—Symptoms of the acute.— Anatomical characters.— Diagnosi?. — Causes. — Prognosis. — Treatment. — Chronic Laryngitis—its symptoms.—Anatomical characters.—Diagnosis.—Causes.—Prog- nosis.—Treatment, .-------- 235 TRACHEITIS, OR CROUP. (Dr. Williams.) Symptoms of its various forms.—Anatomical characters.—Nature.—Diagnosis.—Causes.— Prognosis.—Treatment, ........ 247 LARYNGISMUS STRIDULUS. {Dr. Williams.) History and causes.—Nature.—Diagnosis.—Prognosis.—Treatment, - - 256 NERVOUS AFFECTIONS OF THE LARYNX, IN THE ADULT, p. 259. {Dr. Williams.) ACUTE CATARRH. {Dr. WiUiams.) General observations on catarrhal inflammations.—Symptoms of Acute Catarrh.—Coryza.— Mild Bronchitis.—Physical signs.—Causes.—Treatment, - • - - 26] VM C0NTENT9. BRONCHITIS. {Dr. Williams.) Acute bronchitis.—Sthenic and asthenic forms.—Symptoms.—Physical signs.—Infantile bronchitis.—Causes.— Symptomatic bronchitis.— Anatomical characters.— Diagnosis.— Prognosis.—Treatment of the sthenic and asthenic forms—of infantile bronchitis—of the various forms of symptomatic bronchitis.—Chronic bronchitis.—General observations on chronic inflammation.of the air-passages.-r-Characteristic symptoms.of chronic bronchitis.— Causes.—Anatomical characters.—Prognosis,—Treatment of chronic bronchitis.—Diet and 267 regimen, .---?--- BRONCHORRHCSA. (Dr. Williams.) Symptoms, general and physical.—Causes.—Hay.asthma.—Anatomical characters.—Prog- nosis.—Treatment, ------.-* "79 BRONCHIAL CONGESTION. (Z?r. Williams.) Its symptoms and physical signs.—Causes.—Anatomical character.—Prognosis.—Treat- ment, ----- ..... 282 SPASMODIC ASTHMA. {Dr. Williams.) Character and history.—Causes.—Diagnosis.—Prognosis.—Treatment.—Atonic or paralytic dyspnoea and its treatment, ....... 284 HOOPING COUGH. {Dr. Williams.) Symptoms—Division into three stages.—Varieties and complications.—;Causes.—Anatomical characters.—Nature—Diagnosis.—Prognosis.—Treatment, - . . 289 STRUCTURAL LESIONS OF THE AIR-TUBES. (Dr. Williame.) Hypertrophy and induration.—Dilatation, Contraction, and Obliteration.—Ulceration.—Tu- mours, ........... 297 PLEURISY. (Dr. miliums.) Definition.—Pathological history, symptoms, and signs of acute pleurisy.—Symptoms and signs of the decline of acute pleurisy.—Chronic Pleurisy.—General symptoms,__Patho- logy.—Signs of absorption of the effusion.—Empyema—its symptoms, signs, and modes of termination.—Causes of pleurisy.—Diagnosis.—Prognosis.—Treatment of acute and chronic pleurisy, and of empyema, •----. 3Q3 PNEUMOTHORAX. (Dr. Williams.) Motles i" whic'n it may arise. Physical sijns.—Prognosis.— Treatment, - . nqc PLEURODYNIA. {Dr. Williams.) Nature and characteristic symptoms of the various kinds of pain in the chest, and their treat mcnf...........330 CONTENT.-. IX PNEUMONIA. {Dr. Williams.) General symptoms of acute pneumonia.—Anatomical characters.—Sanguineous congestion.— Red hepatisation.—Suppuration, or yellow hepatisation.—Gangrene.—Physical signs.—In- dications by physical signs of the situation, extent, and stage of pneumonia.—Varieties and complications.—Typhoid pneumonia.—Complication with bronchitis—with pleurisy, con- stituting pleuro-pneumonia—with phthisis—with the various forms of fever.—Pneumonia and purulent deposites in the lungs after injuries and surgical operations.—Diagnosis.—Prog. nosis,—Causes.—Treatment of the first stage—of the second stage—of the third stage.— Application of the treatment to particular cases.—Of chronic pneumonia—its anatomical characters, symptoms, and treatment, ...... 332 PNEUMONIA OF CHILDREN, p. 352. {American Editor.) GANGRENE OF THE LUNGS, p. 353. (American Editor.) PULMONARY CEDEMA. (Dr. WiUiams.) Anatomical characters.—Causes.—Symptoms and physical signs.—Treatment, - 355 DILATATION OF THE AIR-CELLS, OR PULMONARY EMPHYSEMA. {Dr. Williams.) Anatomical characters.—Causes and nature.— Symptoms.— Physical signs.—Prognosis.— Treatment.—Interlobular emphysema.—Nature and supposed physical signs, - 356 TUBERCULOUS DISEASE OF THE LUNG, OR PULMONARY CONSUMPTION. {Dr. Williams.) General characters.—Anatomical characters.—Pathology of pulmonary tubercles___Symptoms of the first—second—and third stage.—Physical signs—of the first—second—and third stage.—Complications.—Varieties.—Acute—Chronic— Origin and causes.—Diagnosis.— Prognosis.—Treatment.—Prevention of tubercular disease, - - - 361 MALIGNANT GROWTHS IN THE LUNGS. {Dr. Williams.) Encephaloid disease of the lung.—Scirrhus.—Melanosis and spurious Melanosis, - 398 DISEASES OF THE BRONCHIAL GLANDS, p. 400. (Dr. miliums.) INFLUENZA. {Dr. Theophilus Thomson.) Nomenclature.—Description.—History of the principal visitations.—Diagnosis.—Nature of the disrase.—Source of the epidemic.—Treatment, ----- 401 ASPHYXIA. {Dr. Carpenter.) Preliminary observations.—Causes.—Phenomena.—Anatomical characters.—Nature.—Treat- ment.—Strangulation.—Anatomical characters.—Treatment.—Submersion.—Anatomical characters.—Treatment, -.....-. 414 DISEASES OF THE ORGANS OF CIRCULATION. DISEASES OF THE HEART. {Dr. Joy.) Preliminary observations.—Anatomy of the heart—its site.—Relation of the lungs to the heart.— Structure.— Weight and measurement. — Motions.—Natural sounds.— Morbid sounds.—Disordered motions.—Arterial and venous pulse.—General observations on dis. cases of the heart.—Importance of accurate discrimination.—Means of diagnosis by local or physical signs and by general symptoms.—Causes.—Prognosis.—General view of their treatment, .------... 451 NERVOUS PALPITATION. {Dr. Joy.) Idiopathic and Sympathetic.—Causes.—Diagnosis.—Treatment, - - . 489 SYNCOPE. {Dr. Joy.) Symptoms.—Causes.—Effects of the injection of air into the veins.—Diagnosis.—Treatment of syncope founded on its various causes, --...- 495 ANGINA PECTORIS. (Dr. Joy.) Symptoms.—Seat and nature.—Complications.—Diagnosis.—Treatment, - - 503 NEURALGIA OF THE HEART. (Dr. Joy.) Symptoms.—Nature.—Treatment, -----.. 51Q PERICARDITIS, (Dr. Joy.) OR INFLAMMATION OF THE EXTERNAL MEMBRANE OP THE HEART. Anatomical characters.—Symptoms.—Physical signs.—Frequency.—Chronic Pericarditis.__ Duration.—Complications.—Prognosis.—Diagnosis.—Causes.—Treatment, - 511 ENDOCARDITIS, {Dr. Joy) OR INFLAMMATION OF THE INTERNAL MEMBRANE OF THE HEART. Anatomical characters—in the acute stage—in the chronic, including diseases of the valves and orifices.—Symptoms and physical signs of acute endocarditis—of chronic endocar- ditis, and disease of the valves and orifices.—Causes.—Complications.__Duration.__Proe- nosis.—Endocarditis of children.—Treatment, ..... ^oq CARDITIS, (7M Joy) OR INFLAMMATION OF THE MUSCULAR SUBSTANCE OF THE HEART. Infrequency of the disease.—Authenticated cases.—Anatomical characters—Symptoms__ Causes and treatment, -----.., e.. HYPERTROPHY OF THE HEART. {Dr. Joy.) Nature and Causes.—Forms.—Anatomical characters.—Physical signs.—General symptoms__ Complications and secondary affections.—Supposed causes of each form of Hypertrophy.— Duration and prognosis.—Treatment, ...... g.g DILATATION OF THE HEART. (Dr. Joy.) Nature and mode of production.—Anatomical characters.—Physical signs.—General symp- toms.—Diagnosis.—Treatment, ....... 561 PARTIAL DILATATION, OR REAL ANEURISM OF THE HEART, {Dr. Joy.) Aneurism peculiar to the left side of the heart.—Aneurism of the left ventricle, its causes, symptoms, physical diagnosis, prognosis, and treatment.—Aneurism of the left auricle.— Aneurism of the valves, ........ 566 ATROPHY OF THE HEART, p. 569. {Dr. Joy.) CHANGES IN THE CONSISTENCE AND COLOUR OF THE HEART, MORBID EFFUSIONS INTO ITS SUBSTANCE, AND NEW FORMA- TIONS. {Dr. Joy.) Induration. Softening.—OZdema.—Hsemorrhagic effusion.—Purulent deposites.—Ossification of its vessels.—Surcharge of fat.—Tubercle, fungus hsematodes, or cncephaloid cancer.— Scirrhus.—Tumours.—Serous cysts.—Hydatids.—Cartaliginous and bony deposites, 570 RUPTURE OF THE HEART. {Dr. Joy.) Causes.—Frequency in respect of the different cavities of the heart.—Seats of this lesion.— Symptoms and treatment.—Rupture of the valves of the heart.—Wounds of the heart, and their treatment, ......... 576 POLYPOUS CONCRETIONS OF THE HEART. (Dr. Joy.) Origin and mode of formation.—Anatomical characters.—Symptoms.—Prognosis.—Prophy- lactic treatment, ......... 579 HYDROPERICARDIUM. {Dr. Joy.) Causes.—Symptoms.—Treatment, .--.--. 582 SECONDARY EFFUSIONS INTO THE PERICARDIUM, p. 584. {Dr. Joy.) PNEUMOPERICARDIUM' AND HYDROPNEUMO-PERICARDIUM, p. 585. DISPLACEMENT OF THE HEART, p. 585. HERNIA OF THE HEART, p. 587. MALFORMATIONS OF THE HEART. CONGENITAL MALFORMATIONS. Transposition of the heart.—Acardia.—Bicardia, {Dr. Joy-) (Dr. Joy.) {Dr. Joy.) {Dr. Joy.) 588 PRETERNATURAL COMMUNICATION BETWEEN THE TWO SIDES OF THE HEART. (Dr. Joy.) Forms of preternatural communication between the two sides of the heart.—Cyanosis. Symptoms of this lesion.—Progress.—Treatment, . 588 DISEASES OF ARTERIES. FUNCTIONAL DISEASES OF ARTERH3S. (Dr. Joy.) Functional disorder of the aorta and arteries arising from it.—Neuralgia.—Inordinate pulsa- tion.—Treatment, -.---.--- 593 ARTERITIS, OR INFLAMMATION OF ARTERIES. (Dr. Joy.) Anatomical characters and effects of arteritis.—Predisposing" causes.—Exciting causes.— Symptoms.—Treatment of arteritis and its consequences, ... - 596 ANEURISM OF THE AORTA. {Dr. Joy.) Varieties—true—false—mixed—hernial.—Comparative frequency in the sexes.—Predisposing causes.—Symptoms of aneurism of the aorta and effects on contiguous structures.—Spon- taneous cure.—Aneurism of the thoracic aorta.—Aneurism of the pulmonary artery.— Aneurism of the abdominal aorta.—Treatment of aortic aneurism, - - 602 DISEASES OF VEINS. (Dr. Joy.) General observations on diseases of the veins and their functional derangement, - 617 PHLEBITIS, OR INFLAMMATION OF VEINS. (Dr. Joy.) Anatomical characters.—Secondary purulent deposites in organs.—Secondary organic inflam- mations and symptomatic fever.—Causes.—Phlegmasia alba dolens.—Treatment of phle- bitis and phlegmasia dolens, - - - - - - -61S VARICOSE VEINS. {Dr. Joy.) Causes, effects, and treatment, - ----.. 624 MISCELLANEOUS AFFECTIONS OF THE VEINS. (Dr. Joy.) Spontaneous perforation and laceration of the veins and of their valves.__Obliteration of their cavity.—Calcareous deposites.—Phlebolites.—Fatty tumours.—Gaseous effusions, 626 ( 17 ) SPINAL IRRITATION. Explanation of the term spinal irritation.— Various anomalous symptoms.—Predisposing causes.—Exciting causes.—Nature.—Diagnosis.—Prognosis.—Duration.—Treatment. This term has been used to designate an affection usually characterized by pain in the back, either induced or increased by pressure of the spinous processes of the vertebrae, accompanied by neuralgic and hysteric symptoms of a nature so variable as to simulate almost every form of disease to which the body is liable. Spinal irritation ought to be considered rather as an effect of disease, than as a malady sui generis, but as the subject is of the highest practical importance, it is proper to direct attention to it by giving a detail of its phenomena in this place. Various forms of this affection have been described in cases of neuralgia, and termed thoracic, epigastric, or intestinal, according to the locality of the pain,-,, practical writers, especially Nicod {Nouv. Journ. de M>,/. Chir. et Pharm. torn. iii. p. 247., 1818,) Teale {On Neuralgic Diseases,) and Brown {Glas. Med. Journ., 1828.) They have been described in connexion with hysteria by Tate {Treatise on Hysteria.) The disorder has been called spinal irritation by Par- rish {Amer. Journ. of the Med. Sciences, 1832,) Darwell (Midland Med. and Surg. Rep. 1829,) Griffin {On Functional Affections of the Spinal Cord, S,-c.,) Entz {Rust's Magazin fiir die Gesammelte Heilkunde, 1836,) and Ollivier {Sur la Moelle' EpinUre, 3d edit.) The term spinal irritation, although objec- tionable in many points of view, has been generally received, and is therefore re- tained in this place. Symptoms.—When it is remembered that the spinal cord furnishes directly or indirectly nerves to every organ in the body, the numerous symptoms which may be produced by the increased, diminished, or perverted functions of one or more of these may be readily imagined. Hence the phenomena this affection presents differ according to the extent, seat, and intensity of this irritation, and are so greatly diversified as to prevent the possibility of giving a description which would be applicable even to the majority of cases. The only means we can think of for conveying a general idea of this disorder, is by referring to the dif- ferent forms of hysteria, neuralgia, and chronic rheumatism. A combination of the symptoms occasionally presented by all three, constitutes spinal irritation. The only constant symptom is more or less pain on pressing the spinous pro- cesses of the vertebrae. It may be confined to one spot, or be more or less dif- fused over the spinal column, pointing out the extent of the spinal irritation. In many cases the patient is unconscious of any thing wrong in the back, often denies the existence of pain in that situation, and refers all the uneasiness to the ultimate distribution of the nerves arising from the part. Sometimes there is a dull constant pain, which is overlooked, and thought to be wholly unconnected with the local complaint. When pressure, however, is made on the affected part, the pain in the back is increased, and not unfrequently the patient starts as if an electric shock had been received, or falls into tt state of syncope. The seat of pain generally corresponds with the origin of the nerves ramifying on the organs, or portion of the surface complained of, although in some instances, as stated by Vol. IT.—3 18 spinal irritation, {Symptoms.) Griffin, the morbid changes in the cord appear somewhat more extensive than the external tenderness. The local pain is often produced or increased by lifting heavy weights, or twisting the body, and has often been excited by jerks or slight concussions when walking.* In conjunction with the spinal tenderness there may be neuralgic pains, more or less diffuse, over different parts of the surface, diminished sensibility, convul- sions or paralysis; and as the functions of the different viscera and organs of the body are often impaired, various diseases are simulated. Thus women suffer neuralgic pains sometimes in the right, but more commonly on the left side, beneath the mamma; sometimes, again, the breast itself is more especially af- fected, constituting the irritable mamma of Sir A. Cooper. In other cases there is a feeling of numbness, as pointed out by Dr. Brown of Glasgow, or of con- striction round the thorax, as if a walnut or other hard substance were pressed within a tight belt. Occasionally the affection commences with pain in the occi- put, and rheumatic sensations in the neck and shoulders, several cases of which are given by Mr. Teale of Leeds. At other times, instead of neuralgic pains, there is a sense of numbness in the hands or feet, extending more or less over the extremities. We have seen a case where the only symptom was excessive cold- ness in the hands and fingers, that often amounted to actual pain, and prevented the individual from sewing, and carrying on her usual employments. If the spinal irritation be more severe, the internal organs participate, and the symptoms produced vary according to the portion of the cord that is affected. When the spinal tenderness is confined to the cervical portion, there may be headach; loss of voice; neuralgic pains in the face and gums; trismus: various disorders of vision, as ocular spectra, muscae volantes, night blindness, &c; more or less deafness, or confused sounds in the ears; diminished or perverted sensation of taste and smell; dysphagia; paralysis of the tongue; sickness; vomiting; loss of appetite, inordinate hunger or thirst; pain at the stomach; pyrosis; diffi- cult breathing, cough, irregularity of the pulse; palpitations; disposition to syncope; paralysis of one or both arms, sometimes confined to the fingers, hands, arms, or shoulders; increased sensibility or numbness in those situations; pricking, formication, &c. Although these symptoms may have coincided at different times with cervical tenderness, it is evident that many of them, more particularly such as affect the special senses, arise from irritation of the cranial portion of the cord. When vertigo or delirium is present in such cases, it is probable that the brain itself is more or less affected. When the irritation is in the dorsal region, the palpitations of the heart and dyspnoea are more marked; there is sometimes dry cough; pleurodynia; pain under the clavicles, in the shoulders and superior extremities; sense of constriction in the thorax, often like a tight band; neuralgic pains in the side; diminished sensibility in the breast and epigastrium; more or less derangement in the digestive organs, 5 \ Treatment. The treatment of myelitis, both in its acute and chronic forms, » exactly the same as that recommended for spinal meningitis; and we have nothing to add to what has been there stated. With regard to the value of certain renJ dies which have been recommended for the cure of paralysis, in the chronic form of the disease, such aa strychnine, galvanism, electricity.- A:,-., this suEs di™ cussed in the observations on the treatment of Paralysis J ( 31 ) HYDRORACHIS. Definition.—Congenital hydrorachis.—Hydrorachis developed after birth.—Causes.—Anatomi- cal characters.—Nature.—Diagnosis.—Prognosis..—Treatment. This term (from v$ap, aqua, and Sot-xis, spina) is applied to abnormal collec- tions of fluid within the spinal column, whether congenital or occurring- after birth. Magendie has pointed out, that in the healthy state there is always a cer- tain quantity of fluid in the sub-arachnoid cavity of the spinal canal, which is ab- sorbed soon after death. Whenever, therefore, a considerable quantity of this fluid is discovered twenty-four hours after death, we may consider it morbid, and resulting from previous disease of the brain or spinal marrow. On account of the free communication between the arachnoid and sub-arachnoid cavities of the spinal cord and the brain, it is often difficult to determine whether hydrorachis occurs primarily from the membranes of the one or the other, but if the seat of effusion be between the dura mater and osseous coverings there can be no doubt (as observed by Abercrombie) that it is spinal only. Congenital hydrorachis in the foetus Or new-born infant is always associated either with hydrocephalus or spina bifida. When connected with the former, all the symptoms of water in the head are present; when hydrorachis is complicated with spina bifida, there are certain local and general symptoms which indicate the affection. These we proceed to enumerate. On examining the spine, one or more tumors containing fluid are found, situa- ted immediately over the deficiency in the vertebra, most commonly the lumbar, this affection being seldom met with in the dorsal and sacral, and still more rarely in the cervical region. When the disease occurs in the latter situation, there is generally separation also of the cranial bones. There may be one or more dis- tinct tumors in the cervical, dorsal, or lumbar regions, or, if the whole spine is bifid, one tumor may occupy all three regions, being proportionate in length to the number of malformed vertebrae. Feiliz gives a case in which all the spinous processes were deficient, and the tumour occupied the whole length of the spine. (Richter, Chir. Bibl., band 9, p. 185.) In magnitude it varies from the size of a hazel nut to that of an adult head, and is usually of a globular or ovoid shape, but sometimes pyriform, semilunar, or flat, with either a large base or a narrow neck. In a case by Brewerton, it was bi-lobed. (Edin. Med. and Surg. Journ., July, 1820.) To the touch it is either tense or flaccid, according to the position of the infant; for as there is always a free communication between the cavity of the tumor and that of the spine, and generally with the cranium; it is more dis- tended when the infant is in such a position as will allow the fluid to gravitate towards it. By gradual pressure, also, its bulk may be diminished, and if small, all the contents may be thus forced into the spinal or cranial cavity, stupor being often produced from the pressure on the brain. In some cases, as noticed by Cruveilhier, the tumor expands during expiration, and sinks during inspiration, but he was unable to observe movements synchronous with those of the pulse. {Anat. Descrip., torn, iv, p. 564.) The coverings of the tumor may present va- rious appearances, which have been divided by Billard into three varieties. In 32 hydrorachis, {Symptoms.) the first, the integuments covering the tumor are in a healthy and uninflamed state; in the second, the skin is thin and discoloured, sometimes with exudations of a sero-sanguineous fluid, indicating the approaching rupture of the panetes of tumor; in the third variety, the tumor has burst, the effused fluid escaping through a fine ulcerated perforation, surrounded by a red, rugous, and unequal elevation of the skin. Of these, the first is the most uncommon and the least dangerous. In seven cases observed by Billard, two were born with the skin covering the tumor in the healthy state. Spina bifida sometimes coexists with other malfor- mations, as of the urinary or genital organs; with imperforate anus; malformation in the digestive canal, &c. The constitutional symptoms of this affection present no remarkable difference from those of other spinal diseases. Infants after birth are generally emaciated and feeble. There is more or less paralysis of the lower extremities, sometimes connected with oedema, occasional convulsions, inability to take the breast, resolution of the sphinc- ters, difficulty of breathing, which, as the disease approaches its fatal termination, becomes stertorous. The infant becomes gradually more and more exhausted, its cries weaker, the extremities cold, the pulse excessively quick and feeble; and convul- sions or coma, more frequently the former, precede death. These symptoms bear a re- lation to the state of the tumour, being less urgent if it is small, and if there be no opening. In the latter case, if the aperture be minute, no distressing symptoms may appear for sometime, though a certain quantity of fluid is continually dis- charging, or may be pressed out. In this way, several pints have been removed. Very often, however, the nature of the fluid becomes altered, and from being colourless and limpid gets turbid, more or less purulent, and sometimes foetid. The exhaustion of the little patient is proportionate to the quantity and purulent cha- racter of the discharge. These effects are the result of inflammation of the meninges, which sooner or later comes on and destroys the infant Of the seven cases observed by Billard, he found traces of spinal meningitis in five. If the tumour be large, and burst suddenly, and a large aperture afterwards form, death occurs more quickly, generally preceded by convulsions. This event has taken place in utero without having been immediately fatal. Duges has given a case where there was a large scar in the sacro-lumbar region, covering a membranous substance, by wm. n the vertebral canal was not very firmly closed. The child perished six weeks after birth. Hydrorachis developed after birth. Cases have been recorded by Frank and Reydellet, where tumours with an aperture in the spinal canal have occurred after birth. Such cases, however, are very rare, and when the bones of the column are perfectly formed, no tumour is produced except in the sacral region, which is naturally open. Morgagni gives a case from Genga (epist 12, sect 9,) of hydro- cephalus following a blow on the head, in which a tumour appeared at the coccyx. This was opened, and the head diminished in size as the fluid was evacuated What farther proved the communication between the fluid in the head and that within the tumour, was, that on pressing the cranium it escaped with impetuosity Tumours may also be produced by acephalocysts, and the escape of fluid between the vertebral lamina?; cases of which are given by Ollivier. Hydrorachis developed after birth is generally symptomatic of spinal congestion or meningitis, and may be associated with, or depend upon hydrocephalus It is characterized by pain in the back, extending a greater or less distance- uaralvsis of the lower extremities with humbness or complete loss of sensibility; sometimes cedema of the legs and feet, or gangrene of the toes; paroxysms of convulsions or tremors have been occasionally observed (Bonnet. Sepulchrelum torn in ™«i 307;) and resolution of all the limbs, involuntary stools and urine, laborious it± tion becoming stertorous before death. ^Urt If hydrocephalus as is generally the case accompany the spinal disease, all the symptoms of the former affection are combined. Itard gives a case of hvdro^ cephalus, m which, on ice being applied to the head, the cerebral symptoinfZ appealed, and complete paraplegia followed, apparently from the changed posit^ hydrorachis, {Anatomical Characters.) 33 of the effused fluid. Dr. Graves speaks of a case in which, when the patient was lying down, the lower extremities could be moved with a certain degree of force, but when the individual stood erect, he could not place one leg before the other. Ollivier attributes this to the presence of serous effusion, which, when the patient was in the latter position, pressed with greater force on the lumbar portion of the cord. When the seat of effusion is between the dura mater, and the bony walls of the vertebral column, as in cases given by Bergamaschi, Ollivier, Aber- crombie, and Lallemand, the same general symptoms are present. Causes. The causes of congenital hydrorachis have been supposed to depend remotely on constitutional disorder in the mother, as syphilis, scrofula, scurvy, or rickets; violent mental emotions, excessive venereal indulgences during preg- nancy; concussions or other injuries affecting the mother, and imagined to act upon the foetus in utero, &c. There is no proof, however, that any of these circumstances bear any relation to the presence of hydrorachis in the foetus. The immediate causes are organic changes in the placenta or umbilical cord, producing more or less interrupted circulation and subsequent serous effusion into the spinal cord; inflammation of the membranes of the cord, or of the brain, &c. Hoffman imagined that pressure on the head during parturition sometimes squeezed the fluid into the spinal canal. {Miscel. Nat. Cur., obs. 208.) In the majority of cases, however, the occurrence of hydrorachis cannot be traced to any cause. The numerous theories brought forward to' explain spina bifida, it is unnecessary to discuss. The causes of hydrorachis, when developed after birth, are of course the same as those which produce the disease with which it is complicated, or on which it depends, as hydrocephalus, spinal meningitis, &c. Anatomical characters. The characteristic appearance found after death in hydrorachis is the abnormal collection of serous fluid, the presence of which is generally associated with morbid alteration of the neighbouring tissues, such as detailed in the description of spinal meningitis and myelitis. It may, however, be the only morbid appearance present. Duges gives the case of a man who died with paraplegia, in whom no other morbid lesion could be found except an effusion of serosity in the sacro-lumbar region, that gave the dura mater the appearance of an intestine filled with water. {Diet, de Med. el Chir. Prat., art. Hydrorachis.) The fluid is sometimes limpid, often turbid, flocculent, or mixed with pus. In the latter case it is the result of meningitis or ulceration of the tumour. Its colour may be of a light yellow, green, or black tint, and often more or less sanguineous. The amount of the effusion differs considerably from a slight accumulation of serosity, to such a quantity as fully distends the mem- branes, occupying the whole of the spinal canal pressing on the brain, or com- municating with a fluid in the cavity of the cranium. M. Montault found 14 ounces in the first situation alone. {Journ. Hebdom., August, 1833.) It may exist in three" situations:—1. between the pia mater and the arachnoid mem- brane, the seat of the cephalo-spinal fluid of Magendie; 2. in the arachnoid cavity; and, 3. between the dura mater and bony walls of the vertebral column. When the fluid collects in the first two situations, it generally, but not always, communicates freely with the ventricles, and the arachnoid cavity within the cranium. In two instances Billard observed that the effusion into the cranium, and that into the vertebral canal, was different in colour, showing that they were perfectly distinct, and in one of these the fluid in the fourth ventricle was re- tained by a firm reddish membrane, which formed a cul-de-sac below its inferior angle, interrupting all communication with the sub-arachnoid cavity. {Billard, 3d edit. obs. 69.) Two other cases have been reported by M. Lediberder. {Arch. Gen. de Med., torn. v. 2d series, p. 39.) Cruveilhier has seen a similar membrane to that described by Billard in a case of hydrocephalus, where the fluid was prevented from entering the spinal canal. {Anat. Pathol., liv. xv.) In the third situation it is impossible any communication can exist with the brain, on account of the adhesion of the dura mater to the margin of the foramen Vol. II.—5 34 hydrorachis, {Prognosis.) magnum. It must not be forgotten that a serous fluid may be effused into the substance of the cord. In a case given by Portal there was a cavity in the cord extending to the fourth dorsal vertebra, large enough to admit a common quill, distended with serous fluid, and communicating with the ventricles. The serous cysts which are occasionally developed in the cord or membranes, if small, can- not be said to constitute hydrorachis, any more than similar cysts in the brain or its membranes constitute hydrocephalus. In congenital hydrorachis combined with spina bifida there are deficiencies in the vertebra, which Fleischmann has divided into three classes:—the first com- prehends division of the whole vertebra, body as well as processes; the second, imperfect development of the lateral arches only; and the third, development without union of the lateral arches. (De Vitiis Congenilis, circa Thoracem et Abdomen. Erlangae.) The first and third of these are rarely met with. The anatomical character of the tumour also varies, its walls being sometimes natural, composed of skin, dura mater, and one layer of the arachnoid or both, according as the fluid is situated in the arachnoid or sub-arachnoid cavity; in other cases its parietes are more or less diseased, being inflamed, thickened, ulcerated, gan- grenous, covered with fungous growths or tufts of hair. In these cases, also, the spinal cord may be more or less affected, its substance being, according to Meckel, either softened, reduced to a pulp, diminished in size, divided into two parts, or expanded into a membrane; according to the observations of Ollivier, however, these alterations are not common. The cord is often preternatu- rally long, owing, as Ollivier thinks, to the adhesion between it and the water of the lumbar tumour fixing it permanently at a point of the spinal canal where it ought only to have remained temporarily. More rarely the substance of the cord is entirely wanting; the membranes, according to Otto, having fallen toge- ther, and being usually slit at one or more places, or they are more or less degenerated, and adherent to each other, forming sometimes a closed sac filled with lymph. Morgagni cites cases from Tulpius, Lechel, and Alpinus, who saw the nerves floating in the aqueous tumour. (De Sed. et Cans., epist. 13.) This has also been seen by Ollivier and Cruveilhier. Mr. Stafford has described the nerves as distributed on the inside of the tumour in which they terminated, and where occasionally they formed a nervous net-work. {Injuries and Diseases of the Spine, p. 21, et seq.) Nature.—The pathology of hydrorachis will always be found in perfect ac- cordance with that of other spinal diseases, and with the facts stated in the gene- ral observations. As the palsy which accompanies hydrorachis is explained under Paralysis, it is unnecessary to discuss the subject here. Diagnosis.—In the congenital form, when combined with spina bifida, the situation of the tumor, and the effects of pressure, will readily detect the nature of the disease. When at birth or at a later period it is complicated with hydro- cephalus, it is distinguished by the peculiar symptoms of that disease. In the^e cases, however, in addition to the cerebral symptoms, those denoting lesion of the spinal cord, as convulsions, paralysis of the extremities, rectum, and bladder are more marked. When it is the result of spinal meningitis, myelitis or me- ningo-myelitis, the peculiar symptoms of those maladies are observed We are not aware of any symptom which may be considered as diagnostic of hydrora- chis in an idiopathic form, unless the circumstance noticed by Dr Gr ' f merly alluded to, may be so considered. We have seen two cases of incomplete paraplegia, in which the patients could move the inferior extremities much more readily in bed than when supported in the erect position. As these individual- are still living, it is impossible to say whether this depends upon the gravitation of fluid in the spinal canal; very little attention has hitherto been paid to Si's Prognosis.—The prognosis in hydrorachis must always be very unf M In the congenital form, when connected with spina bifida, it is not aV°" .,e; fatal, many cases having been recorded that existed several years and^^Sn ? rydrorachis, (Treatment.) 35 death was apparently unconnected with this affection. Individuals have been found in whom this disease was complicated with spina bifida—by Bonn at 10 years; by Martini at 11 years; Paletta and Acrel at 17 years; by Henderson at 18 years; by Copland at 19 years; by Warner, Hochstetter, and S. Cooper at 21 years; by Camper at 28 years; by Cowper at 30 years; and Ollivier cites a case by Swagermann, who saw it in an individual 50 years old. (Ollivier, vol. i. p. 227, 3d edit.) Generally speaking, however, the larger the size of the tumor, and the greater the destruction of the cord or brain, the greater is the dan- ger, and this is increased when there is sloughing or gangrene. When the tumor bursts, the patient generally dies quickly in convulsions. Ollivier says, that once only in such a case a cure has followed. The death takes place more rapidly if the laceration in the tumor be large, or inflammation attacks its walls. When other malformations are combined with the disease, it is unnecessary to say the case is more hopeless. Treatment.—The treatment of congenital hydrorachis with spina bifida may be considered as radical or palliative. The radical treatment is very hazardous, and in the majority of cases has has- tened the fatal result. Sir A. Cooper has cured two cases by repeated small punctures. Probart another (Lancet, No. 186,) and Rosette and MM. Robert one each. (Arch. Gen. de Med., torn. xvii. p. 280, and torn, xviii. p. 102.) In the last two cases the inferior extremities were completely paralyzed, proving that this circumstance does not contra-indicate the performance of the operation. Experience has shown that the sudden bursting of the tumor almost always pro- duces death, by occasioning spinal meningitis; and consequently whenever it presents an inflamed appearance at any point, and is apparently about to break, a puncture should be made with a small cataract knife, at the most depending part of the tumor, and the fluid gently squeezed out. Before the pressure is re- moved, the orifice should be covered with a piece of adhesive plaster, in order to favour union by the first intention, and a bandage applied so as to occasion gentle pressure, and support the walls of the tumor. After a time this may be repeated if necessary, and the treatment conducted nearly on the principles recommended by Mr. Abernethy for psoas abscess. All other radical methods of cure, such as the ligature, setons, &c, are incompatible and dangerous. Except under the circumstances we have alluded to, the palliative treatment should always be employed. Compression was proposed by Mr. Abernethy, with a view of supplying the deficiency in the spinal canal, and giving support to the part. Sir A. Cooper applied a plaster of Paris mould to the tumor, to effect this. In whatever manner pressure is applied, care must always be taken that it is gradual, for if it be sudden, or carried too far, convulsions or paralysis will be the consequence. Although this practice is undoubtedly useful, it may be questioned whether the local application be the principal means of cure. Most probably the improvement in the general health, by strengthening the system, increasing the activity of the circulation, and thus preventing local congestion, which tends to keep up or increase the amount of serous effusion, must be < the chief indication of treatment in this disease. While, therefore, gentle pressure on the tumor, either by bandages, plaster of Paris, or a discutient plaster, is em- ployed, great pains should be taken to increase the general tone of the system, and apply such remedies as will induce absorption of the fluid, and prevent its tendency to increase. With this view, change of air to a dry situation in the country ought to be recommended, and a healthy wet nurse employed. Small doses of the Hydrarg. c. Creta, or one or two grains of calomel, according to the age of the child, should be given every other morning for two or three weeks. The preparations of iodine may also be administered with a view of procuring absorption, or the nurse may undergo a course of this medicine. Small blisters applied above the tumor, in the course of the spine, so as to cause a rubefacient effect only, may be employed frequently. Extreme caution, however, is neces- sary, that vesication is not produced, as in infants, particularly those of a weak 36 hydrorachis, (Treatment.) constitution, sloughing and farther exhaustion may be occasioned. Great atten- tion must be paid to the regularity of the alvine discharges, and gentle aperienls given to insure this if necessary. The child should be warmly clothed, and car- ried out frequently in the open air when the weather is fine. When hydrorachis is associated with hydrocephalus, or with congestion, or inflammation of the spinal cord or its membranes, the treatment recommended for those affections should be employed. The same measures are to be employed when the disease is developed after birth, the remedies having reference to the age of the patient and the stage of the disease. There is a form of spinal disease which follows intermittent fever, that seems to be of the nature of that described in the text, as the hydrorachis of adults. I have not had an oppor- tunity of examining cases of this disease, at least not in its early stages, but the sudden appear- ance of this disorder, the moderate degree of pain, and the comparatively rapid development and extension of the paralysis from the lower to the upper extremities, seem to prove that a liquid must be rapidly secreted in the spinal sheath. The acuteness of the symptoms and their rapid increase, if much motion be allowed, indicate that the disease is of an inflamma- tory nature. This sub-acute inflammation is a more frequent attendant upon intermittents in some years than in others, but it arises from causes which are totally unknown. The best means of treating the disease are, rest, frequent cupping to the spine, and repeated blistering: purgatives are also most useful aids, but are less essential than the other remedies which I have just mentioned. These cases, if carefully managed will, in general, terminate favourably, though the disorder is sometimes quite intractable, and may prove rapidly fatal. 6. ( 37 ) SPINAL APOPLEXY. Symptoms.—Causes.—Anatomical characters.—Nature.—Diagnosis.—Prognosis.—Treat- ment. Although there are some doubts as to the propriety of applying the word apo- plexy to haemorrhage into any tissue, its general use has induced us to adopt it to express the spontaneous extravasation of blood into the spinal canal, either between the membranes or into the substance of the cord. Symptoms. We have noticed, when speaking of cerebral apoplexy, the symp- toms denoting haemorrhage into the cranial portion of the cord. But spontaneous effusion of blood into the cervical, dorsal, or lumbar portions is an occurrence of extreme rarity, and its history isAconsequently very defective. We have every reason to suppose, however, that haemorrhage will give rise to the same effects as destruction of these parts by accident or disease, and that they will be more sud- den and well-marked, according to the violence and the extent of the effusion. The cases recorded by Abercrombie, Chevalier, Stroud, Cruveilhier, Monod, Gri- solle, Gaultier de Chaubry, and others, show that the attack is always characterized by acute and sudden pain in the back, corresponding with the seat of effusion. Sometimes there are precursory symptoms of shivering, and slight dorsal pains, which have been mistaken for rheumatism. In some instances, there is sudden paralysis in one or more of the extremities below the seat of pain; in others, the paralysis comes on gradually, and is preceded by pain in the portion of the spine corresponding with the supposed seat of the haemorrhage. The other symptoms which have been observed are similar to those we have noticed when treating of myelitis affecting the cervical, dorsal, or lumbar portion of the cord. Eschars are often formed on the sacrum before death; the sphincters are paralyzed, and the respiration becomes gradually more and more laborious; in [the case of M. Cri- solle, there was nausea with sense of suffocation, and in that of M. Cruveilhier vomiting of black blood before the fatal termination. In the case of M. Monod, pus and blood were mingled with the urine, and in that of Abercrombie there was tetanic rigidity and convulsion. In this last case, however, the spinal marrow was not changed in structure, the haemorrhage having occurred between the dura mater and bones. There is in general no fever, the pulse is not affected, and the intelligence remains perfect to the last. Causes. Effusion of blood into the spinal canal may result from blows, falls, contusions, fractures, and other kinds of direct violence. Spontaneous apoplexy of the cord has been observed to follow when the individual has remained some time in the sitting posture, from lifting a heavy weight, and as a consequence of rheumatism, cerebral apoplexy, and myelitis. Anatomical Characters. The haemorrhage in spinal apoplexy appears to be occasioned by the same causes that produce it in the brain. It may form circum- scribed extravasations in the substance of the cord, as in cases recorded by Hutin, Cruveilhier, and Stroud. In such circumstances a cyst forms, and the blood ef- fused undergoes exactly the same changes we have described in cerebral apoplexy. 'n some instances it is combined with softening (Gaultier and Grisolle,)when the 38 spinal apoplexy, (Treatment.) nervous substance is more or less broken up and mixed with theuextra^^ The gray matter appears most liable to this alteration. Haemorrhage may also occur in the sub-arachnoid or arachnoid cavity, or between the .durarr?f ^,2?° bony walls of the canal, as in the case given by Dr. Abercrombie The ettuson may be referred to haemorrhage occurring in the brain, which is forced into the spinal canal, or to rupture of some blood-vessel in the adjacent structures, to which only, in the latter case, it can be attributed. Nature The pathology is perfectly consistent with the known functions ol the spinal cord. The amount and seat of the paralysis is attributable to the degree of pressure or disorganization occasioned, and the portion more immediately affected. The study of the recorded cases also shows that the changes after the attack are pro- portionate to the alterations occurring in the extravasation. The occurrence of convulsions in Dr. Abercrombie's case, in which the effusion was exterior to the dura mater, thus occasioning partial pressure, illustrates well the influence of this cause in producing excited action. This symptom has not been observed, when the extravasation has affected the substance of the cord directly. In Dr. Stroud's case, circumscribed effusion of blood took place on the left side of the cord, pro- ducing first hemiplegia of the same side of the body, and afterwards paraplegia. (Brighfs Reports, vol. ii. p. 339.) Diagnosis. The diagnosis of this disease is very obscure, as our observation of it is as yet insufficient to enable us to indicate its peculiarities; the premonitory symptoms, however, have been confounded with rheumatism, from whicn it can only be distinguished by the progress of the case. In general, the sudden and acute pain distinguishes it from other spinal affections, and when the spinal mar- row is the seat of the haemorrhage, there is no convulsion or tetanus. Prognosis. The case of Cruveilhier, in which the patient lived five years after the first attack, proves that this disease is not always speedily fatal. In the majo- rity of cases, however, the greatest danger is to be apprehended Treatment. In the treatment of spinal apoplexy, absolute rest, in order to pre- vent any recurrence of the extravasation, and to favour the absorption of effused blood, is the chief element. Bleeding should be employed if there be no signs of prostration, but not to any great extent, as the symptoms do not indicate active vas- cular excitement. The diet should be low, and great attention paid to the alvine evacuations, which are to be regulated by injections, active purgatives being as much as possible avoided. The state of the urinary bladder should be inquired into daily, and, if necessary, the urine drawn off by the catheter. Counter-irritants are obviously useless. Care should be taken to prevent the eschars, which are likely to form on the sacrum and back, by placing the patient on the hydrostatic bed, or by adjusting cushions and air-pillows so as to prevent long-continued pres- sure on any part. ( 39 ) C H or R E A. Characteristic symptoms.—Analogous affections.—Anatomical characters,—Nature.—Causes. —Diagnosis.—Prognosis.'—Treatment. The disease to which the name of Chorea is most commonly applied, and to which it was first restricted by Chaussieur is characterized by incomplete sub- serviency of the muscles of voluntary motion to. the will, rendering their actions irregular, tremulous, and often ludicrous. It occurs most frequently in the female sex, and in general between the ages of eight and fifteen. The designations, " St. Vitus's dance and dance of St. Guy," became popular in consequence of the practice which formerly prevailed among the subjects of similar affections, to repair annually to a chapel at Ulm, in Swabia, dedicated to the saint, called by the Ger- mans St. Weit, and by the French St. Guy; who, having suffered from the com- plaint in his lifetime, was supposed to be rewarded with the power of curing it after his death. It is probable that, from the influence of sympathy, a temporary aggravation of the complaint was produced in so large an assemblage of subjects, but it is said that they afterwards remained for a year free from the malady. In chorea the muscular disorder may either be general, affecting the extremi- ties, trunk, and face, or partial and confined to the face or neck, or to one extre- mity. It occurs for the most part in persons of a weak constitution, either na- tural or acquired, and is commonly preceded by derangement of the organic functions, indicated by variable appetite, tumid abdomen, constipated bowels, and impaired vivacity. The convulsive motions are preceded by slight irregular twitchings of the muscles of the face, which may easily be mistaken for voluntary grimices. In the progress of the complaint the irregular action becomes more in- tense, and implicates a greater number of muscles; those of the extremities, of the lower jaw, or of the head and trunk, being at different times affected. The patient does not walk steadily, but moves irregularly from side to side, or proceeds by jumps or starts; one foot is rather dragged than lifted, and the movements of the arms resemble fhe gesticulations of players. As the complaint increases, the patient seems as if palsied, and becomes unable to walk or to perform the neces- sary movements of the arms. In extreme cases deglutition is difficult, and arti- culation interrupted, so as to produce stuttering; the mouth is distorted, and saliva drivels from it. Different muscles may be successively convulsed, but those first affected usually continue involved throughout the whole course of the disorder^^.^ In severe cases the irregular actions are never suspended excepting during ) sleep, and may even continue irrespective of this condition. They may be conti- nuous, intermittent, or remittent; and are increased by observation, contradiction, ! or any irritating cause, and especiallytby any attempt forcibly to restrain them. The eye loses its lustre and intelligence. The liability to causeless emotions, and the disposition to concealment characteristic of hysteria, are often present; the mind becomes capricious and irritable, and there is a tendency to take alarm or to weep at the slightest cause. The disease when long protracted may induce fatuity, epilepsy, or hemiplegia, or may terminate in marasmus. Chorea in the female is frequently associated with deranged uterine function, 40 chorea, (Symptoms—Varieties.) sometimes with chlorosis, but perhaps more frequently with amenorrhcea. Hyste- rical symptoms are in general superadded when the disease occurs about the tune ' of puberty. At this period chorea may be superseded ^n^^^^ later period may in turn give place to neuralgia, the siisceptibihty to these diseases seeming to depend on a similar condition of the nervous system, modified.bychf- ferent periods of life. Serous effusions, especially into the aiadinoid and penia^ dium, Sometimes attend protracted cases. The complication with rheumatic affections of the muscles, pericardium and spine, has been well elucidated by Dr. Copland, as well as by Drs. Prichard, Roeser and Bnght. Various cutaneous eruptions, of which urticaria and roseola, are the most fre- quent, may be associated with chorea; but since the irregular movements may either precede, attend or follow the eruption, we must consider the phenomena, not as in the relation of cause and effect, but rather as results of the same state of the nervous centre. It is, however, probable that the eruptive condition tends to moderate the spasmodic disorder. In the disorder to which we now limit the name of chorea, the will is properly exerted, but is only partially efficient. The analogous affections to which the term has been occasionally applied, consist chiefly in energetic and often measured actions of the muscles, under the influence of a morbidly excited will. Such ap- pears to be the nature of the original chorea of the Germans, of Tarantism, and of Leaping ague. Sometimes, however, the muscular disturbance seems inde- pendent of the will, and unassociated with consciousness, and differs from con- vulsion only in the orderly nature of the motions. Cases of rotation of the whole or part of the body, of malleation, and of irresistible propulsion forwards or back- wards, belong to this class. The phenomena which have occasionally occurred under the excitment of religious enthusiasm, although in the first instance result- ing from mental impressions, often become involuntary in their progress, I. In the first class of analogous affections we may specify the following ex- amples :— 1. The original chorea consisting of inordinate and almost supernatural mus- cular exertions, depending on a mental impulse and excited" by imitation or by music, the measure of which seemed to regulate the movement Felix Platerus mentions a woman of Basil who danced for a month; and it appears from the accounts of Horstius and others, that the complaint was apt to recur annually, and that those affected would continue dancing when under the influence of music, for an incredibly long period, until at length exhausted by their exertions. (De Mentis Alien,, vol. i. p. 15.) Later writers have referred to the affection under the names of Epilepsia saltatoria and Morbus saltatorius. The first distinctly recorded manifestation of such a malady occurred, a. d. 10*27, near Bernberg, on St. John's Day; a festival during wh;ch it was customary, perhaps in imitation of Bacchalian rites, to kindle the nodfyr, and to dance around or through it with various frantic gestures. There is reason to believe that these performances sometimes gave origin to the disorder in question. For several centuries after this period the af- fection was occasionally witnessed. The excitement produced by destructive epi- demics and other calamities, and the superstitious ceremonies of Popery probably contributed to its prevalence. In St. John's dance, as well as in that of St. Vitus, and in the affection next to be described, a tympanic state of abdomen was a fre- quent symptom. 2. Tarantism (sometimes designated Tarantulinmus, Chorea Sancti Valen- tini, Choreomania, Dmmonomania, Meldhcholia saltans, fyc.) in every important particular resembhng the affection last described. A few hours after beine bitten by the poisonous spider called Tarantula, the patients fell down senseless and mo- tionless, with difficult respiration and heavy sighing. As these symptoms subsided they appeared desponding and melancholy, frequented church-yards and solitary places, evinced a capricious fancy for particular colours, and sometimes anne ed to have an irresistible propensity to roll themselves in the dirt. At the so Hi f chorea, (Symptoma— Varieties.) 41 suitable music they began to move first the fingers, then the hands, feet, and suc- cessively other parts of the body, and then sighing and dancing threw themselves into every variety of violent and fantastic gesture. Sauvages says, " Those who are stung die in a little time without the present assistance of music, all other remedies giving no relief." Those affected were capricious as to tune, and re- quired the notes to be run over with the greatest quickness. This quickness of sound, called terantella, afforded a test for the detection of those who feigned the disease, a practice, according to Baglivi, common among the women of Apulia, when they wished to be indulged in music and dancing. If they were satisfied with slow musical movements the deception was at once discovered. An instance of convulsive disorder resembling tarantism, produced by the bite of a spider, and cured by music, is related in the New York Medical Repository. 3. The Leaping ague of the Scotch writers, characterized by increased effi- ciency, but depraved direction of the will, producing an irresistible propensity to dance, tumble and run about in a fantastic manner, often with far more than the natural vigour, activity and precision. The subjects of the malady, after some pain of the head and lower part of the back, become affected with bodily distor- tion. They leap in a remarkable manner, climbing or springing from the floors to the rafters of cottages, and swinging by or whirling around them. This state is often accompanied with a disposition to secrete any thing within their reach. In the Edinburgh Medical and Surgical Journal there is an account of a girl affected with this complaint, who also exhibited a remarkable inclination to com- mence sentences with the last word, and often put the last letter of a word fore- most. In writing she would proceed right to left, placing the last word and the last letter first; often with great rapidity, and apparently without consideration. In the treatment of this case, purgatives proved useless; opiates sometimes pre- vented a paroxysm, but did not permanently relieve. Locked jaw of eight days' duration followed the use of a shower bath, and the symptoms did not return. Some cases of periodical jumping and shrieking, related by Armstrong, following pertussis, and considered epileptic, probably belonged to the same class of affec- tions. At the close of the seventeenth century, a case in some respects resembling those above described occurred at Edinburgh, and an account of it was published with the title, A True Narrative of the Sufferings of a Young Girl, who was strangely molested by Evil Spirits and their Instruments. A commission from the long was appointed to inquire into it, and seven persons were in consequence committed to the flames for witchcraft. (Edin. Med. Com. vol. ix.) n. The second class includes those analogous affections in which the movements are systematic, but involuntary; viz. malleation, rotation, and propulsion in various directions. 1. The affection to which the term Malleatio has been applied, examples of which have been described by Morgagni, Dr. Crawford, and other writers, con- sists in an apparently irresistible disposition to beat the knees with the hands as with a hammer. The action is regular but involuntary, and occurs in parox- ysms. 2. Instances have occasionally occurred of involuntary rotatory motion of the whole or part of the body. For example, rotation of the head has been observed by Drs. Conolly and Crawford, and Mr. Hunter has related a case in which rotation of the head and trunk occurred, and was relieved by the application of tartar emetic ointment to the scalp and spine. Under the name of chorea, Dr. Watt has related the case of a girl ten years of age, who, after suffering from vomiting and excruciating headach, evinced a singular propensity to turn round on her feet like a spinning-top. , On the subsidence of the affection (in about a month) the head was aggravated, and the muscles of the neck were partially para- lyzed. After this, paroxysms occurred daily, in which she placed herself across the bed, and rolled rapidly on her side, from one end to the other. About sixty Vol. II.—6 42 chorea, (Symptoms— Varieties.) rotations were accomplished in a minute. They were not checked by the affu- sion of cold water; indeed, when placed in the shallow bed of a river, the girl kept up the motion, although at the risk of being drowned. In about five weeks a different movement was substituted, namely, that of approximating the head and heels, raising the trunk, and then falling forcibly on the back. These mo- tions continued to characterize the affection for five weeks, when they were suc- ceeded by a propensity to stand on the head, to raise the feet perpendicularly, and then fall as if dead; these evolutions were performed more than twelve times a minute for fifteen hours daily. The malady did not yield to blisters, setons, local depletion, emetics and cathartics, which were successively employed, but disappeared after a spontaneous diarrhoea. 3. Propulsion, either forwards, backwards, or in zigzags, has occasionally oc- curred. M. Piedagnel has given an instance of a man who sometimes went out and walked forwards till he was exhausted and obliged to be carried home in a litter {Magendie's Physiology, by Milligan, p. 189;) and Dr. Laurent of Ver- sailles, has related a counter part to this case, in a girl irresistibly propelled back- wards with such violence, as to sustain considerable injur}'. Drs. Dufour and Rennis (Arch. Gen.; Lond. Med. and Surg. Journ., June, 1832) have related examples of zigzag movements occurring in persons addicted to intoxication, who had previously suffered from bronchitis. The phenomena were at first mistaken for those of drunkenness, but yielded to the use of opium. Mr. Kinder Wood has recorded a most interesting example, in which the phe- nomena of the original chorea were associated with malleation, rotation, propul- sion, and leaping ague. It occurred in a woman whose nervous susceptibility was probably increased by prolonging lactation for fourteen months, the catanie- nia having appeared during the latter three months. At first she suffered from pains of the face, which were relieved by a liniment of opium and ammonia; twinkling of the eye, motions of the legs, and rotation of the arms, succeeded. The palms of the hands were beat upon the thighs, and the feet upon the ground, the backs of the wrists were struck frequently against each other; at other times the middle fingers being extended inwards, struck the palm of the opposite hand, and so alternately with almost inconceivable quickness. The affection of the eyelids was usually succeeded by headach of short duration, with sickness and vomiting. On some occasions she would move up and down, or from side to side on her chair, and then springing on her feet, leap and jump, or be propelled forwards. Sometimes she would go into every corner of the room, striking the furniture. She would frequendy dance on one leg, holding the other in the hand. In the course of the complaint it was observed, that the blows on the furniture were in musical time, and the involuntary actions, as they were considered, changed to a measured step. Although ordinarily an inexpert dancer, she would on these occasions move about elegantly in a minuet. It was ascertained that there was always a tune in her mind, impelling her to the movements. When this tune was performed on the drum, she ran up to the instrument and danced with great activity and apparent delight, but the movements were always stopped by rolling the drum. Although yielding, as it seemed, unavoidably to the desire of dancing, she always wished for the rolling of the drum, that the muscular excite- ment might be checked; for, till a new impression was made by a change of measure, the morbid desire prevailed over the rational will. As occurs in tarant- ism, the motions always commenced in the fingers and then extended to other parts of the body, and became more frequent as their duration lessened On thP day the motion ceased, diffused patches of a bright red eruption came' out near the elbows, and continued for three days. The catamenia afterward o A and health seemed established. In five weeks, however, the nuiscular m recurred, and the eruption appeared on the arms. This attack lasted *he™ days. Five weeks afterwards the affection returned for the third time but *!! a more spasmodic character: when laid down the patient turned involum^ her back, and the muscles of the neck were so affected as to force back th h °3 chorea, (Anatomical Characters.) 43 and occasion dyspnoea. On this occasion no relief was obtained from music, but a cure was effected by bleeding. The previous attacks had been treated with aperients, tonics, and anodynes; and it is worthy of notice, that in each instance the most decided improvement succeeded the use of calomel and jalap. The catamenial function was suspended at the time of the malady, but had been pre- viously regular. III. The convulsive disorder which has sometimes occurred in religious as- semblies, and has occasionally prevailed as an epidemic, is usually accompanied with shouting, singing, dancing, laughing, and coughing, with irregular exacer- bations and remissions. During a remission, shaking hands with, or even look- ing at a person affected with the complaint, will excite a paroxysm. The seizure is at first violent and convulsive, and continues even on lying down, but after a time becomes chronic, and more closely resembles chorea. The phenomena have been well described by Dr. Robertson, as they occurred among a sect of enthusiasts in Tennessee and Kentucky, in the year 1800. (Inaug. Essay on Chorea St. Viti, 1805.) A similar affection occurred in a congregation at Cambuslang, in the year 1742. The movements, which were at first voluntary, became spasmodic, the muscles of the neck and upper extremities were convulsed, and the sufferers were thrown down and agitated with motions like those of a live fish upon land. Anatomical characters. The opinions of authors regarding the morbid ana- tomy of chorea are extremely various, and the descriptions of occasional appear- ances serve chiefly to prove that there is not necessarily any structural change. Dr. Clutterbuck considers the disease dependent on inflammation of the brain; Drs. Coxe and Patterson on turgescence of its vessels with tendency to hydroce- phalus. Roeser and Willan have found serum in the ventricles. Monod refers the malady to hypertrophy and injection of the brain and spinal cord; Hutin to hypertrophy and hardening of the anterior part of the spinal cord. Changes in the membranes of this part, such as the effusion of turbid serum or lymph, or the formation of bony plates, have been described as occasional phenomena by Drs. Copland, Prichard, Aliprandi, and Bright; and ecchymosis of the membranes, with a pulpy state of the medulla spinalis, was detected in a case related by Dr. Keir of Moscow. (Edin. Med. and Surg. Journ., No. cxxii, p. 93.) Dr. Serres having found, in one case, a tumour pressing on the corpora quad- rigemina, in two instances inflammation of these parts, and in another example sanguineous effusion, is disposed to refer the disease to a morbid condition of these organs. Dr. Brown discovered a concretion in the medullary substance of the left hemisphere of the brain. In Dr. Hawkins's case there was increased vascu- larity of the uterus, with concretions in the pancreas, omentum, and mesentery. Duges, Ollivier, Rufz, Gerhard,* Hache, Rostan, Lawrence, and many other patho- logists have, however, searched in vain for any morbid changes which could be regarded as necessarily connected with the disease; and it is evident that many of the appearances above described must be considered simple coincidences; whilst others, as Drs. Patterson and Percival have observed in reference to hydrocepha- lus, must be viewed rather as effects than causes of the complaint. Since the scalpel fails to reveal the seat of the malady, we must have recourse to the light which physiological investigations may throw on the inquiry. There is considera- ble evidence in favour of the opinion, that the stimulus of the will passes from the * The case cited by the author was that nf a young girl of nine or ten years of age, who died purely of the disease, that is, worn out by the excessive and continued movement. No lesion whatever could be detected in the brain or spinal marrow, although I examined those organs with the most scrupulous attention. It is is cited in the memoir of Dr. Rufz. (Ar. chives Generates.) G. u chorea, (Nature.) brain through the spinal cord to the voluntary muscles; and the conclusion which Magendie has deduced from his experiments, namely, that the will passes through the hemispheres of the cerebrum, and that the direct cause of motion is in the medulla spinalis, is at least plausible. The disturbance of harmony between the part which supplies and that which conveys the stimulus of the will to the muscles, must be sufficient to produce the irregular movements of chorea; and this harmony may probably be interrupted by derangement, whether structural or functional, of any part intervening between the cerebral hemispheres and the portion of the spinal cord from which the nerves of the affected muscles proceed. The frequency with which, in extreme cases, change of structure of the cerebro-spinal axis has been observed, is favourable to this view, since long-continued functional derange- ment, although it does not necessarily occasion organic change, will frequently pro- duce that result. There is direct experiment in support of this explanation of the cases of propul- sion forwards and backwards, and of rotation, which have been above described as in some respects analogous to chorea. Magendie found, that when the corpora striata were removed, the animals operated on darted irresistibly forward; and that, when injury was inflicted on the cerebellum or medulla oblongata, they receded. (Op. cif., p. 187, 202.) The experiments of Serres, Flourens, and Rolando, are favourable to the same conclusion. When the peduncles of the cere- bellum were divided, rotation took place towards the side cut; and vertical sections of the cerebellum, or pons varolii, produced ths same effect, which was always most decided in proportion as the injury was near to the peduncle, the movement being to the right or left, according as the incision was right or left of the mesial line. Lesions of the medulla oblongata, where it approaches the external part of the anterior pyramid, occasioned a rotatory movement; but, on cutting through the spinal cord behind the occipital bone, the motions became involuntary and irre- gular. In connexion with these inquiries it may be interesting to mention,»that effusion, into the ventricles, pressing upon the corpora striata, has been constantly found in horses affected with inability to go back. The physiology of the nervous system is not sufficiently advanced to enable us to fix the locality of its individual functions; allowing their full weight to the expe- riments and observations which have been referred to, we are not authorized, with Serres, to limit the seat of chorea to the corpora quadrigemina or striata, or with Bouillaud and Magendie to the cerebellum. Cases of rotation may probably depend on derangement affecting the pons yarolii, medulla oblongata, or the peduncles of the cerebellum; propulsion for- wards on an altered state of the corpora striata, and backwards on morbid condi- tion of the cerebellum: but the correct exercise, yet inefficient power, of will, which characterizes true chorea, seems rather to indicate an affection either of the spinal cord, or of some part closely approximating to it. Tarantism and the chorea of the Germans may probably consist with integrity of functions of these parts. The muscles in those affections accurately obey the stimulus of the will which exists in excess, possibly from excitement of some part of the sensorium more directly connected with the mind, perhaps individual faculties of the mind inasmuch as they are associated with material structure, may possess a power of stimulating to action analogous to will; and which, in contradistinction to the rational will, may be termed instinctive. The morbid excitement of this power rendering it uncontrollable by the judg- ment, may occasion some of the irresistible actions present in affections analogous to chorea, and may also produce some of the phenomena of monomania to which indeed, these maladies seem closely allied. Nature. Galen and Mead considered the disease a modification of nalsv Sydenham regarded it as a convulsive disorder, occasioned by a humour affectl ing the nerves; Baumes and Pinel attributed it to a combination of convulsion and palsy; Sauvages, Cullen, and many others, have referred it to a state of general debility, and consequent mobility of the system; others, among whom chorea, (Causes—Diagnosis.) 45 Drs. Parr and Hamilton may be particularly mentioned, consider that the de- rangement of the muscular actions arises from sympathy with disorder of the digestive functions. Chorea may doubtless occasionally arise from a morbid condition of the cerebro-spinal axis or its membranes, sometimes induced by the excitement of mental impressions or moral emotions; but the peculiar irritation of the nervous system essential to the malady, seems to be generally associated with, and pro-, bably dependent upon, disorder of the organic functions, which, acting on a sus- ceptible nervous system by means of the ganglionic nerves, may sympathetically interrupt the functions of those parts which convey to the muscles the stimulus of the will. Causes. When derangement of the bowels occur in young subjects of sus- ceptible nervous system, almost any powerful impression, either on the mind or the body, may be sufficient to excite the disease. Among mental causes, jea* lousy, envy, anger, disappointment, anxiety, and excited imagination, may be / mentioned, but fright is generally allowed to be the most frequent. A majority of the cases related by Dr. Reeves, Mr. Bedingfield, Dr. Bright, and others, are referrible to this cause; and its influence in producing chorea cannot be denied, notwithstanding the contrary opinion of Guersent, who argues that the liability to be easily alarmed is a characteristic of the morbid condition, rather than the cause, of the malady. The disease is occasionally induced by the irritation accompanying the second dentition. Mechanical injuries (Med. Chir. Rev. vol. ii. p. 569,) especially of the head (Edin. Med. and Surg. Journ., vol. ix. p. 123; and Med. and Pliys. Journ., vol. xv. p. 127,) and through the orbit (Phil. Truns., vol. liii,) suppressed eruptions, the healing of ulcers, extension of rheu- matism to the spinal membranes, worms and intestinal accumulations, and the influence of fever or other previous disease, are among the causes enumerated by authors of repute. Dr. Marshall has detailed a case resembling chorea, appa- rently produced by lightning. The symptoms were much aggravated by pres- sure at certain points of the spine. The example is of peculiar interest in connexion with the evidence adduced in Dr. Marshall's work, of the occasional production of softening of the spinal cord by lightning. It also serves to illus- trate some milder examples of the disease, which were relieved by treatment applied to the spine. All the causes of constitutional debility, whether hereditary or acquired, are favourable to the production of chorea; but premature excitement, either of the intellectual faculties or moral feelings, sedentary employments, innutritious diet, and impure air, may be especially mentioned. Females are much more liable to the affection than males. The proportion in Dr. Reeve's cases was 57 to 27; in Dr. Manson's, 53 to 19; in those of M. Rufz, 138 to 51: from these state- ments, and from the recorded experience of Heberden, Frank, Elliotson, and Copland, the liability of the sexes may be calculated as in the proportion of 3 to 1. The time of life in which the disease is most common is from the period of second dentition to puberty; but instances have occurred as early as the fifth year, and the disease has been known to exist from infancy. No age, however, seems to be absolutely exempt, Dr. Copland having witnessed the disorder in a man above fifty years of age, Dr. Powell, in a woman, aetat. seventy, after epilepsy, and M. Bouteille associated with hemiplegia in a woman, aetat. eighty. The complaint appears to be little influenced by atmospheric changes; but Rufz, Duges, Blache, and Spangenburg, consider it most common in summer. There is reason to believe that it is very rare in the southern hemisphere, M. Rochoux not having witnessed any example in Guadaloupe, Chervin in the Antilles, nor Danste in the course of thirty years' practice in Martinique. Imitation has little influence in the production of the disorder. In the Hopital des Enfans, Blache never witnessed its production by this cause. Diagnosis. The characteristic partial dependence of the irregular muscular motions on the will, is sufficient to distinguish chorea from most other disorders. 46 chorea, (Treatment.) In convulsions, whether epileptic or hysterical, the movements are more violent, and are entirely independent of the will. In paralysis agitans, a disease for the most part of later life, the agitation is more constant, more limited, and is devoid of ludicrous character. The tremor produced by mercury has a greater resem- blance to chorea, but is accompanied with a peculiar quick catching. In cases combining the phenomena of chorea and hysteria, attention to the history and attendant circumstances will enable us to analyze the symptoms as far as is essen- tial for practical purposes. The prognosis is generally favourable, chorea being scarcely ever fatal, and becoming dangerous only when associated with, or merging in, any more formi- dable disease, such as epilepsy, dropsical effusion into the serous cavities, para- lysis, or change of structure of the brain or spinal cord. Dr. Elliotson observes, that when the disorder is confined to the muscles of one arm or of the head, and especially when occurring in the adult, he has never seen it cured. Since the susceptibility of the nervous system is less in the adult than in the child, the pro- bability of the existence of important organic lesion is greater when the disease occurs in advanced life, especially if the limited nature of the malady implies a local seat. Treatment. Cases which are not very severe, frequently yield to almost any plan which, without impairing the strength, produces a decided effect on the sys- tem. Hence it is easy to explain the diversity of remedies recommended by different practitioners; Dr. Bardsley senior, mentions, that in the Manchester In- firmary, notwithstanding the variety of treatment adopted by successive practi- tioners, an incurable case had not presented itself in the course of thirty-three years. Still the duration of the complaint, and the facility with which it is reme- died, will often in a great degree depend on the judicious adaptation of treatment. A case, for example, may be cured in two or three weeks by suitable treatment, which, under less appropriate management, would be protracted for several months. The general abstraction of blood has been adopted by those who considered the disease congestive or inflammatory, and has been sanctioned chiefly by M. Bouteille, Lisfranc, and Dr. Clutterbuck, who repeats the bleeding at intervals of a few days. Serres, considering the disease to depend on congestion or some other morbid state of the corpora quadrigemina, applied leeches and counter-irri- tation to the upper part of the spine. Dr. Watt speaks favourably of bleeding, but Cullen and Armstrong found it frequently injurious. The purgative plan has been adopted chiefly by Whytt, Hamilton, Cheyne, Guersent, and Chapman, and by a large proportion of the most successful practi- tioners. Dr. Hamilton generally cured the disease by these means alone in ten days or a fortnight. The purgatives which have been most employed are aloes. senna, calomel, scammony, and jalap, but probably sufficient discrimination has not always been exercised in the selection of the individual remedy. Of the vegetable tonics employed in the treatment of this complaint may be mentioned cinchona bark, as particularly recommended by Cullen, Mahon,' and Werlhoff; the flowers of the cardamine pratensis by Sir George Baker and Michaelis; the powder infusion or decoction of Seville orange-tree leaves by Haen and Engelhard. "" J Among the metallic tonics may be enumerated, the oxide of zinc, which was considered a specific by Mr. Bedingfield, and is favourably noticed by Dr Craw- ford: many of the German authors commend its powers, but Stoll has not ob- served any advantage from its use. The sulphate of zinc is much employed bv Dr. Bright, and is preferred to the oxide by Dr. Copland. The latter author confirms the statement of Dr. Odier of Geneva, that the addition of two " ■ of ammoniuret of copper to each dose of the oxide of zinc, prevents that m"j from irritating the stomach. The nitrate of silver, which was recomme 'd^v/ Frank, Uwins, and Crampton. Fowler's arsenical solution, in doses % h minims, gradually increased to ten, three times a-day, has been advanta w chorea, (Treatment.) VI employed by Mr. Martin and Dr. Gregory. But the use of arsenic is sometimes productive of injurious effects, an objection which applies also to sulphate of copper and nitrate of silver. Of all tonics iron is perhaps the safest and most efficacious. Dr. Elliotson's experience leads him to confide in the remedy with- out the previous use of purgatives. He prefers the sesqui-oxide in doses of from half a drachm to half an ounce, but sometimes administers from one to four grains of the sulphate. Cold-plunging was the method constantly employed by Dupuytren; his plan was to immerse the patient suddenly five times in twenty minutes: this treatment continued for a fortnight, or at most a month, generally cured. Dr. Hamilton was accustomed to adopt this measure previous to his employment of the purga- tive plan; but attributes bad consequences to its use. It is difficult to suppose that a disease, associated with so much organic derangement, could be removed by the shock of the cold bath without the risk of superinducing some other ma- lady. The use of cold affusion or the shower bath, the patient standing in warm water, is not liable to the same objection. Extract of belladonna in doses of a sixth to a quarter of a grain was adminis- tered by Stoll, who at the same time employed an antispasmodic liniment with j great advantage. Valerian is recommended by Bouteille and Guersent, assafcetida by Bayle and Jadelot, musk by Bardsley, and a combination of camphor and ex- tract of henbane by Dr. Bright. Among internal counter-irritants may be specified spirits of turpentine, first prescribed in this disease by Dr. Copland, a solution of tartar emetic by Ferran, large doses of the same remedy (from four to eight grains) by Breschet, and emetics by Laennec. External counter-irritants, such as blisters, setons, and issues, have been employed by many practitioners, and by others tartar emetic ointments, or plasters to the scalp and spine; and Chrestien advises aromatic em- brocations. Galvanism, recommended by Meyreaux, and electricity, first introduced as a remedy by De Haen, appear to act as counter-irritants. The application of elec- tricity often produces an eruption of the nature of lichen urticatus. This agent seems especially efficacious in cases associated with defective catamenial secre- tion, and has been lately employed by Dr. Addison with considerable success. The above enumeration is not intended to imply, that the authors referred to confided exclusively in the remedies which they particularly sanctioned, since many of them were accustomed to combine and vary resources according to the peculiarities of individual cases. If the opinion be correct, that the disease usually depends on nervous mobility, associated with derangement of the digestive organs, whether we regard these conditions in the relation of cause and effect, or as simultaneous expressions of the same diseased state, it is equally obvious that two indications are presented, viz. the correction of the morbid state of the digestive organs, and the removal of the nervous susceptibility. The relative degrees of these two conditions doubtless vary. Probably the nervous affectibility is less in Scotland than in England; and from this circumstance we may derive an explanation of the fact, that Dr. Hamilton found purgatives adequate for the cure of the cases which fell under his management, whilst the same mode of treatment has often failed in England. Dr. James Johnson tried purgatives alone without success in cases which afterwards yielded to the administration of oxide of zinc with alteratives and antispasmodics. Of twenty cases treated by Dr. Bardsley on the purgative plan only fourteen were cured, and the average duration of the treatment was more than six weeks. Of twenty cases treated by purgatives for a time, and afterwards by antispas- modics, the whole were cured in an average period of less than a month. Dr. Bardsley tried the uncombined antispasmodic treatment, selecting remedies of acknowledged power, such as camphor, opium, valerian, ether, and musk. He gave a fair trial to the tonic method, employing the sulphate and the carbonate of iron, the ammoniurets of copper and of iron, oxide of zinc, nitrate of silver, and 48 chorea, (Treatment.) arsenical solution. He also had recourse to iodine, strychnia, electricity, the shower bath, tartar emetic ointment and blisters to the spine; and he denveU from his experiments the conclusion, that no single plan of treatment was entitled to confidence, and that the combination of purgatives and antispasmodics was the best* The principle of combination was also countenanced by Sydenham. His method was to employ purgatives, tonics, and antispasmodics; and although he perhaps carried depletion to too great an extent, in other respects it is probable that his treatment has not been much improved by subsequent practitioners. Vi e are strongly impressed with the desirableness of commencing the treatment with purgatives. Underwood has indeed objected to the opinions of Parr and Hamil- ton, that if the intestinal irritation which they assume exist, it is dangerous to increase it by the employment of purgatives; but whatever may be said of the theoretical explanation, the advantage of commencing the treatment of chorea with purgatives may be considered established. Dr. Bright, who seems to disparage the purgative plan, employs chiefly calo- mel, scammony, and senna, and Dr. Bardsley aloetics; but Dr. Hamilton rarely omitted occasional doses of calomel with jalap; and we believe that when this combination is not contra-indicated, it is the most efficacious in the treatment of chorea, freely emulging the biliary ducts without producing much irritation. The advantage derived appears to be proportioned not to the quantity of scybahe passed, or to the amount of irritation induced, but rather to the production of free secretion without concomitant irritation. The indications in the management of chorea are, 1. To ascertain the existence of any congestion or irritation of the cerebro-spinal axis, and if such a condition be found to exist, to relieve it by moderate local depletion; 2. To act freely on the bowels by suitable purgatives; and 3. To administer remedies calculated to invigorate the frame, and thus to diminish nervous susceptibility, and increase the energy of the digestive function. 1. In some cases of chorea, although by no means a large proportion, various symptoms, such as pain and heat of head, throbbing of the carotid or temporal arteries, suffusion of the eyes, tenderness at the back of the neck or other parts of the spinal column, and excitement of mind, indicate congestion or inflammation of the cerebro-spinal axis or its membranes. In such instances the abstraction of blood cannot safely be dispensed with, and should be succeeded by counter- irritation, and the application of cooling lotions to the head and of warmth to the extremities. The state of the pulse will materially assist us in determining the extent to which the abstraction of blood may be carried. Unless the pulse pos- sesses some degree of incompressibility, the application even of a few leeches will often be productive of eventual injury; and it is better to deplete less than the urgency of the symptoms may appear to indicate, trusting to the use of pur- gatives, which, if not alone sufficient, prove most important auxiliaries in correct- ing the condition above described. All excitement of the senses must be as much as possible avoided, light and noise being excluded; the mental faculties must be suffered to rest, and moral emotions be restrained. 2. In the simple form of the disease, the judicious employment of purgatives is sufficient materially to moderate the symptoms; we are accustomed to confide chiefly in occasional doses of calomel and jalap, followed in a few hours by castor oil, and repeated at intervals of two or three days. Spirit of turpentine will some- times prove a valuable auxiliary, especially when there is reason to suspect tlie presence of worms in the intestinal canal. The number of doses of calomel and jalap must be regulated partly by the appearance of the intestinal evacuations, partly by the effect produced on the muscular disorder, and on the cenera] health. While the evacuations continue scybalous and fetid, the renetV I t-Ua />alrmn<»l is llSliallv inrlinntorl ■ Knt u'lion tho «u>rafiA»n hpenmo ♦ HIOI1 oil, or a combination o: sometimes the irregulai chorea, (Treatment.) 49 muscular actions disappear in less than a fortnight, under the use of purgatives; at other times the symptoms are temporarily relieved, but after a few days recur or increase. Under such circumstances we have immediate recourse to the tonic plan, which indeed may often be commenced after the first or second dose of pur- gatives. 3. In cases characterized by general debility, tonics may be required almost from the commencement of the treatment; and few cases occur in this country, in which they are not eventually required to render the cure rapid and permanent. The diversity of opinions regarding the most effectual tonic has been already noticed. Dr. Bright prefers sulphate of zinc, especially in cases produced by fright, in doses of from one to ten grains; in patients of weak and irritable habit, nitrate of silver combined with aloes and myrrh may be suitable: but we have rarely met with instances of which the indications were not readily fulfilled either by the ses- quioxide of iron or the sulphate of quinine; each of which medicines has occasionally succeeded after the failure of the other. In cases characterized by general laxity of fibre, or by decided intermissions, quinine has appeared to be most effectual. In the majority of instances, however, especially in those accompanied with de- ficient energy of circulation, or in which undue repletion has been employed, iron has far surpassed all other tonics. Dr. Elliotson finds that it may be continued notwithstanding the presence of headach and paralysis, and there seems to be scarcely any limit to the quantity which may be administered. Mr. Maclure has detailed the case of a little girl who took more than thirty pounds in a few months with advantage. In many instances ten or fifteen grains in treacle or sirup of orange-peel, given three times a-day, will accomplish the object; sometimes it is necessary to increase the dose to several drachms. Valerian and calumba may occasionally be given with advantage combined with iron and an aromatic. By some practitioners antispasmodics have been considered essential, and they must not be despised as auxiliaries; but we consider them rather as palliatives than remedies, and repose more confidence in the permanency of cures accomplished chiefly by the agency of purgatives and tonics. Dr. Bardsley recommends musk and camphor, in doses of four grains each every four hours, and every evening an enema containing twenty or thirty drops of laudanum in four ounces of assafcetida mixture. The tendency of laudanum to produce constipation and cerebral congestion is an ob- jection to its frequent use, and the object may probably be as effectually obtained by a combination of camphor and extract of henbane. The sulphur bath is very generally used at Paris in these complaints: Baudelocque has found it almost invariably efficacious. The power of the remedy in improving the condition of the capillary circulation, regulating the bowels, and augmenting the general vigour, render it well deserving of greater attention than it has yet received from the Pro- fession in England. Treatment of complicated states. Chorea in the female is so frequently asso- ciated with amenorrhcea, that it has been referred by Bouteille to a puberty diffi- cult to establish. In such instances a combination of Pil. Galbani Co. with Pil. Aloes et Myrrhae forms a suitable medicine. If proofs of congestion be present, leeches may be applied to the upper part of the thighs or to the back; if there be deficient tone, or a state of anaemia, the Tinct. Ferri Muriatis, or some other preparation of iron is indicated. In cases accompanied with chlorosis, a combi- nation of iodine with iron is singularly efficacious. A draught containing from five' to ten grains of carbonate of iron, and from five to ten drops of tincture of iodine, may be given twice or thrice a-day; or if the bowels be too irritable to bear inter- nal stimulants, the transmission of electrical shocks through the pelvis will some- times accomplish the object. Complications with disease of the heart and pericardium, or of the spinal cord and its membranes, require careful treatment: if of an inflammatory nature, well-regulated depletion and counter-irritation must be employed; if there be' rheumatism, without inflammation, ammoniated tincture of guaiacum, with ser- Vol. II.—7 50 chorea, (Treatment.) pentaria and camphor, will be appropriate. Cod liver oil may be given to patients who can tolerate the remedy. In cases combined with paralysis, or with stuttering, especially when occurring in adults, and exciting suspicions of effusion under the arachnoid, the use of iodine has sometimes produced gratifying results. The iodide of potassium when pure, in doses of from three to five grains judiciously administered, is a safe and power- ful remedy. In some cases a course of mercury may be required. It is obvious that in the treatment of the disorder, as well as in the management of convalescence, the general habits of mind and body, and the regulation of diet, demand especial care. The shower bath, and subsequently sea bathing, are useful tonics, especially when followed by friction of the skin. Mineral waters adapted to the peculiarities of the individual case may be employed with advantage—Pyrmont, Spa, Ton- bridge, and other chalybeates, being well adapted to the pallid and leucophleg- matic; Ems to cases characterized chiefly by irritation; and Carlsbad perhaps more especially to instances of the disease associated with the strumous habit Free exer- cise in country air is very desirable, and the use of the skipping rope, horse exer- cise, or other sports accustoming the muscles to prompt and accurate subserviency to the will, should not be neglected* * The use of warm sulphur baths, made by dissolving the su'phuret of potassa, was intro. duccd by Dr. Baudrlocque at the children's hospital of Paris, and the practice was found to be very successful. No other remedy was used. In private practice, these baths are incon- venient, but they will sometimes be useful as an adjuvant to other modes of treatment. G. C 51 ) HYSTERIA. General observations.— Division into three forms—regular—irregular—complicated.—Diag. nosis.—Prognosis.—Causes.—Nature.—Curative treatment.—Moral management and pre- ventive treatment. The term Hysteria, although established by long usage, seems to have been generally employed with more than ordinary vagueness too often characteristic of attempts to designate disease. It is also liable to the objection of suggesting a theory of the complaint, which is extremely questionable; yet as attempts to sub- stitute other titles have not been more successful, we might readily submit to the etymological inaccuracy of the appellation, if it answered the useful purpose of conveying to the minds of medical men the idea of a certain and definite series of phenomena. Unfortunately, however, the idea attached to the name by various practitioners is almost as varied as the phenomena themselves; and the word Hysteria owes perhaps much of its popularity to the convenience with which it may be employed to cover our ignorance, and to furnish a receptacle for those cases which, in the present state of our knowledge, cannot easily be referred to any distinct place in the nosological arrangement. It must be allowed that the pro- gress of pathology has not materially tended to curtail these cases, but it is on that account the more important to endeavour to fix their limit, and to assist the stu- dent in their recognition. The peculiarities of individual constitution occasion varieties in the phenomena of most complaints, which render it extremely difficult to frame definitions accurately representing their essential characteristics. It can- not, therefore, be deemed surprising that a disease, pre-eminent in the irregularity and variety of its symptoms, should defy all attempts at rigid definition, although a description of its principal phenomena may be given sufficiently specific for practi- cal purposes. The phenomena of the hysterical paroxysm are well known; but those who are prone to such attacks are often subject to other affections, naturally referred to the same predisposition. A similar condition not unfrequently exists in some who rarely or never present the more prominent phenomena; and we therefore find it necessary to treat of the disease, not merely as an assemblage of certain characteristic symptoms, but also as a general condition disposing to the production of various analogous disorders,. < when suitable exciting causes are presented. We may, therefore, describe hyste- V\ ria as a peculiar nervous susceptibility, leading to the production of symptoms remarkable for the capriciousness of their character, the changeableness of their seat, and the suddenness of their accession and subsidence, the function of nutri- tion being seldom interfered with, notwithstanding their severity and long conti- nuance. The mental condition of hysterical females is generally modified, and often distinguished by sensitive feelings, sudden impulses, and fickle temper. Suf- ficiently well-marked cases of the disorder have occurred in men, under the in- fluence of sexual restraint or of depressing passions; but it more especially apper- tains to women, whose originally susceptible nervous system has been rendered 52 hysteria, (Regular—Irregular.) more than naturally mobile by an injudicious system of education: and it is from the age of puberty to the cessation of the catamenial function that the greatest lia- bility to the malady is observable. The difficulty of conveying an idea of the varied phenomena of hysteria will perhaps be diminished by describing the disease under three forms: the regular, the irregular, and the complicated. This division will best enable us to exhibit the characteristic features of the malady, although when we come to the subject of treatment, it will be necessary to modify the arrangement. 1. Regular Hysteria. The regular form may be distinguished by its strikingly paroxysmal character. The patient does not necessarily present any symptoms of habitual disorder, but is liable, under the influence of slight exciting causes, physical or mental, and sometimes without any appreciable cause, to sudden attacks of a spasmodic nature. After feelings of general uneasiness, and perhaps headach, cramp, or stiffness about the throat, and a vacant stare, or irre- gular movement of the eyeball, a sensation as of a ball is felt in the left iliac region, which, rising upward to the throat, produces the feeling called globus hystericus, sometimes followed by a violent fit of laughter, alternating with weeping, and in milder cases the patient quickly returns to her usual state. In more severe seizures there is great mental and bodily agitation, oppression of chest, dyspnoea, palpitation, and incapability of utterance. The sufferer falls down, and beats her breast or the pit of her stomach, in which situation there is often violent pain. The breathing is slow and laborious; the abdomen extremely distended and flatulent. Sometimes the patient strikes her head, tears her hair, and attempts to bite her arms, or even the person who may be near her. The limbs are either motionless or convulsed; and the body is perhaps supported on the heels and back of the head. The violence of the contortions may occasion- ally intermit, and be again renewed, but after considerable eructation, vehement expiration, and perhaps sobbing or laughing, the patient comes to herself, often retaining, but not generally acknowledging, a recollection of much that has passed during the paroxysm, but complaining of fatigue, and sometimes suffering from temporary paralysis of the bladder, arms, or other muscles either of volun- tary or involuntary motion. Frequently there is a copious excretion of limpid urine. In some instances the fit lasts for several hours, and, instead of the usual favourable termination, passes into a state of coma, or of syncope, rather peculiar in its character, and sometimes so closely resembling death as to have led to serious mistakes. Those who are liable to attacks of regular hysteria, usually possess a suscepti- bility, which renders them prone to hurried breathing, or to sighing, sobbing, or laughing, under the influence of ordinary emotion, and they are, for the most part, apt to pursue objects with ardour, and to exaggerate grievances. The more severe paroxysms chiefly occur when the catamenia are suspended, the bowels torpid, or the digestion deranged. Those who have been long subject to these attacks frequently have tenderness at the sides of some of the vertebra?, which, however, is seldom suspected by the patient, and only discovered by a close examination. When the complaint has continued for manv years unchecked, the nervous system becomes more "seriously affected, and paraplegia, weakened memory, or even mania, may ensue. 2. Irregular Hysteria. The irregular form of hysteria may exist without the occurrence of decided paroxysms. The phenomena which it presenls are in- describably various. There is scarcely any part the function of which it mav not disturb, so as to excite the suspicion of organic disease: but the rapidity with which the morbid condition is transferred from one part of the system to a ther and the marked disproportion between the symptoms, are generally suffi ' tn indicate the real nature of the malady, although there is probably no °\ ( cases in which errors of diagnosis are so frequent. The most constant symptom is pain under the left mamma, confined to 11 hysteria, {Irregular.) 53 space, and not necessarily increased by a deep inspiration. Sleep is generally disturbed; there is great susceptibility to impressions, whether bodily or mental, and generally a liability to palpitation, spasmodic cough, flatulent colic, tender- ness of skin, or to neuralgia of a peculiar character. A few of the more marked phenomena require particular notice. Hysterical headach is sometimes fixed to one spot, particularly of the forehead, over one eye, producing the sensation as of a nail driven into the part; hence called claims hystericus; at other times it may affect the whole head, and be attended with tenderness of the scalp, intole- rance of light or sound, and other symptoms of phrenitis. This state is often associated with an irritable condition of the uterus; it is not removed by the remedies of indigestion, but is generally relieved by nervine medicines. ^ The subjects of irregular hysteria generally evince much capriciousness, incon- stancy, and irritabihty, and are sometimes liable to temporary delirium, present- ing a very peculiar character, intermediate between somnambulism and mania. One patient will hide her head under the bed-clothes and shun observation; ano- ther will employ outrageous language, and endeavour to injure those who approach her, to destroy children, or to commit suicide: a third will sing, or repeat words in some language with which she is not ordinarily familiar, but of which, under this particular state, she seems to possess a vivid recollection. The hysterical condition sometimes produces dysphagia. It is not necessarily spasmodic, but may depend on defective action of the voluntary muscles. The difficulty of swallowing is sometimes so great as to excite suspicions of hydropho- bia. The opposite condition of remarkable avidity for swallowing has been ob- served. In the Dublin Medical Journal, vol. iii. an interesting example is related by Dr. Graves, in which any attempt to interrupt the process of swallowing was followed by hysterical convulsions. The oesophagus is sometimes so remarkably sensitive, that the introduction of a probang is sufficient to produce a decided hys- terical paroxysm. (Bright's Medical Reports, vol. ii. p. 257.) Sydenham observes that hysterical patients often spit a thin saliva for many weeks, as if produced by Mercury: the same phenomenon has been noticed by Mauriceau, Stoll, Rowley, and Darwin. Dr. Graves thinks it is secreted from the fauces. In some hysteri- cal subjects we have observed the tongue covered with a profuse thick secretion resembling cretaceous mixture. The laryngeal muscles may be either in a state of irritation, or of deficient power. The former state not unfrequently occurs in young hysterical females, producing in some instances spasmodic closure of the glottis; in others fits of loud convulsive cough, often followed by stridulous inspiration and threatened suffoca- tion. The attack generally comes on in the evening; it may last two or three hours, and close with a common hysterical fit, or with syncope or convulsions, but is never fatal. The intervals of healthy respiration, the absence of fever, of pain on swallowing, or of tenderness on pressure, distinguish this affection, when simple, from chronic laryngitis; but in some instances the two disorders exist to- gether. Hysterical cough may be hard, loud, and solitary, producing hurried breathing, palpitation, and perspiration, and is sometimes followed by a long sonorous expira- tion, not unlike the howling of a dog. At other times the paroxysm consists of short, rapid, tearing coughings, producing great distress and exhaustion. Mental emotion is a frequent cause of these affections; and it is worthy of notice that, of three cases of this character mentioned by Dr. William Stokes, one on dissection exhibited proofs of meningitis; and the phenomena of the other two furnished strong grounds for suspecting a similar condition. (Treatise on the Diseases of the Chest, p. 266.) Loss of voice may occur at the catamenial period from mental emotion, or from slight intestinal irritation. It comes on and ceases very suddenly, often without evident cause. Any great excitement sometimes restores the power of articulation for a time, but on its cessation the voice is again reduced to a whisper. 54 hysteria, (Irregular.) Hiccough is occasionally among the phenomena of irregular hysteria, or an ex- clamation resembling the latter half of hiccough, which we have known to continue without intermission for many days and nights. Palpitation of the heart, characterized by extreme violence, and by the slight nature of the causes which induce it, is no uncommon occurrence. Bellows' sound, in the region of the aorta, is sometimes produced in such patients by mental emo- tion; but its irregularity and want of persistency soon betray its nervous origin. The stomach is, in some instances, peculiarly irritable, rejecting a large portion of every thing taken into it. The vomiting is not much influenced by the nature of the diet, and is often accomplished with very little effort. It generally occurs soon after taking food, but may sometimes be controlled by a powerful effort of the will, and it is remarkable how long it may continue, without materially impair- ing nutrition. Spasm of the abdominal muscles producing a hard and knotted surface is occa- sionally observed. Tympanitic distention of the abdomen may proceed to such a degree, as to cause the patient, if immersed, to float on water; and, through neglect of the simple expedient of percussion, has been mistaken for ascites. This state probably de- pends sometimes on partial paralysis of the intestinal muscles; sometimes on secre- tion of gas. The gas thus produced, in a case of hysteria, was analyzed by Dr. Osborne, and found to consist of carbonic acid gas with a slight proportion of nitro- gen, hydrogen, and carburetted hydrogen. Hysterical ischuria is more frequent than is generally supposed, being often over- looked by the practitioner, or concealed by the patient. It sometimes depends on deficient secretion, at other times on defective action of the will In the former case the affection is not relieved by the catheter, and in the latter is rendered more obstinate by its use. There is a form of neuralgia which may justly be considered hysterical. It comes on suddenly, is generally attended with puffiness and tenderness of the skin, and often with alternate heat and chilliness of the part affected, and is peculiarly apt to migrate from one place to another. The pain under the left breast, which may almost be considered pathognomonic, more particularly of irregular hysteria, is probably of a neuralgic character. The joints enjoy no immunity from the all-pervading influence of the disorder, but are liable to be affected with morbid sensibility or severe pain. The hip and knee joints are the most frequent seats of the complaint; and in the latter the inner side, and apparently the branches, of the anterior tibial nerve. Serious local disease is too often suspected, and sound limbs have sometimes been sacri- ficed to this mistake. With a view to diagnosis, it may be observed, that pinch- ing the skin gives as much pain as pressure on the joint; that examination gives less pain, if attention is directed to other objects; and that there is no wasting of the limb, or painful starting in sleep. To enforce the importance of such mscrimina- tion it will be sufficient to quote the remarkable statement of Sir Benjamin Brodie r" «Sl n°VTT* ,° C'that am°ng the hiSher classes of ^^ty at least four-fifths of the female patients who are commonly supposed to labour under dis- eases of the pints, labour under hysteria and nothing else" The voluntary muscles may be affected in different decrees of violence or extent One or more muscles is sometimes attacked with paralysis, as comnleto whUe it lasts, as that which arises from softening or compression of the s3 cord t wSS^ZS 7, Peimanent ^r^ °f the Hmbs' of a condition wnicn nas Deen denominated "leaping ague," characterized by a remark-ahl* nrn. pensity to skip, swing, dance, and jump, in a degree to which trJZ,arKaDle P °" patient, in the natural state, would be unequal. the P°wers of the Various perverted sensations, such as inordinate hunger anrl thw . L L be noticed, but the catalogue of symptoms is already sufficientlv vnhw g «f have known the majority of those above described to occur succe* mous> We same individual, but a very few, if well defined, will be sufficient tn!»I?7 m ** . lu "Utnorize our hysteria, (Complicated—Diagnosis.) 55 referring them to that remarkable disorder which has defied " all systems of no- sology, all doctrines of pathology, and all kinds of remedy except time." 3. Complicated Hysteria. When the other diseases attack persons of hyste- rical constitution, the symptoms of the two complaints may be so blended, that the more important malady may be modified or even masked. Such a complica- tion may increase the formidable aspect of the principal disease, without neces- sarily augmenting the danger, although it may eventually augment existing disorder by promoting inflammatory action at the extremities of irritated nerves. Common continued fever is often ushered in by hysterical phenomena, which may also indeed occur during its course, especially in the form of croupy breathing, spasmodic action of the abdominal and respiratory muscles, fits of laughing and crying, &c. During convalescence from fever, such phenomena may appear in males as well as in females, and are probably in part dependent on debility. When hysterical complications attend the latter period of phthisis, or of other chronic diseases, the pain of head, throbbing of the carotids, and excitement of the imagination, by which they are often characterized, may induce an apprehension of phrenitis; but free depletion rather aggravates than relieves the symptoms. To attempt a description of all the various complications of hysteria would, however, be a vain and useless task. Diagnosis. There are few disorders which hysteria does not occasionally simu- late ; but the variety, changeableness, and incongruity of the symptoms; the irregu- larity of their course, and the rapid alternations of violent derangement, and of a nearly natural state with which they are attended, generally disclose to the ob- servant practitioner the true nature of the malady. When accompanied with spasmodic phenomena the disease may be mistaken for epilepsy, and in its chronic form for hypochondriasis. The genuine epileptic paroxysm is generally sudden, making its onset with a i shrill cry; the eyeballs are distorted; the pupils dilated; the teeth ground against ] one another, or closed upon the tongue, which is protruded from the mouth; the I face is swollen, discoloured, or ghastly, and the larynx spasmodically closed, occa- | sioning ineffectual efforts at expiration. The fit is followed by heavy sleep, and^A on waking the patient does not recollect what has happened. The countenance of those who have suffered long from the complaint, becomes dull and inexpressive. The hysterical paroxysm seldom occurs in the streets, and is characterized by laughing, crying, and the sensation of globus; the muscles of the face and the pupils of the eyes remain nearly in their natural state; the respiration is heaving ' and sighing. After the fit the patient has more or less recollection of what has passed; and although disposed for quiet, seldom falls into profound sleep. There is in general no evidence of organic disease, and the habitual physiognomy is rest- less or lively. A combination of the two conditions may, however, occur. In > epileptic hysteria the patient laughs on one side, and the eyeballs are distorted. In hysterical epilepsy the fits are more frequent than in pure epilepsy, and are more apt to be produced by mental emotion. Hypochondriasis and hysteria have been regarded as identical by various au- thors, particularly by Lepois, Highmore, Sylvius, Sydenham, Boerh'iave, Van Swieten, and Whytt; but the more ancient opinion of their diversity, supported by Hippocrates, Celsus, Galen, and Aretams, has been in later times sufficiently esta- blished by numerous writers, among whom Willis, Hoffmann, Sauvages, Cullen, Pujol, Louyer-Villermay, Georget, and Brachet, hold a conspicuous place. The last mentioned author regards hysteria as a spasmodic affection of the cerebral, nerves, and hypochondriasis as a morbid condition of the ganglionic nerves, but it is very questionable, whether the present state of physiological knowledge au- thorizes such theoretical refinement. It may be sufficient to mention, that hypo- chondriasis is characterized by a false direction of the moral energy, and is gene- rally associated with inactivity, a concentration of interest upon self, and a dispo- sition to have recourse to a great variety of medical practitioners. Hysteria is accompanied with vicious innervation, fitful activity, and often with a lively interest 56 hysteria, (Causes—Nature.) in the welfare of others, and with confidence in the usual medical attendant. Th. former disorder is marked by sullen countenance, gloomy ideas, and dejecte< spirits; the latter by a restless animated expression, convulsive paroxysms, an< fickle temper. We must, however, remember, that the two diseases are not in compatible, and that hysterical hypochondriacism does occasionally occur. The circumstances 'which may assist in distinguishing various isolated aflec tions incidental to irregular hysteria from organic diseases of the same parts hav< been already noticed; it must be here noticed, that the coma of hysteria may tx distinguished from apoplexy by the variableness of the pulse, and the occasion* intervention of symptoms inconsistent with compression of the brain. The ten- derness of abdomen present in some hysterical cases may be distinguished from peritonitis by its superficial character, and by the absence of the sinking or yield- ing physiognomy which serious disease of that part usually produces. The con- currence of regular pulse with violent pain, or of irregular pulse with slight symp- toms, and the presence of other and well known hysterical phenomena, rarely fail to elucidate the real nature of the disorder, however alarming it may at first sight appear. Laycock mentions the plumpness of the form, large mammae, and dark areola?, as characteristic of the hysterical diathesis, and when these circum- stances are present they certainly merit attention. Causes. Dubois has advanced the opinion, that hysteria is an exaggeration of the sanguineo-nervous temperament. (Hist. Philos. deV Hypochondrie et del Hysteric) Persons possessing that constitution are doubtless particularly prone to'the disease; but a certain mobility or affectibility of the nervous system seems also necessary. Parents who are gouty, epileptic, or in any way sickly, are most apt to engender this condition in their offspring; but the conduct of early life may also remarkably conduce to its development. The various emotions resulting from social life, rendered more frequent and intense by civilization, and the exercise of the sensations rather than of the active powers incidental to the same state, appear to increase the general susceptibility of the nervous system. From the influence of luxury, indolence, and sentimental reading, the hysterical habit is becoming a common characteristic of the female inhabitants of towns, and gaining increased prevalence among our country population. In like manner fe- males who have been long inured to an active hardy life, when removed to the mansions of the opulent, often acquire the hysterical susceptibility. The causes of plethora sometimes induce a liability to hysteria in nervous habits, and particu- larly to the convulsive form of the complaint; but the disposition is more fre- quently produced by the causes of debility, such as a sedentary life, attacks of fever, excessive evacuations, or the long-continued use of sedative, depletory, or irritating remedies. Nature. The question regarding the intimate nature of hysteria is one of peculiar difficulty, rather increased than diminished by a reference to its literary history. Hippocrates adopting the opinion of Pythagoras and Plato that the uterus was an animal, referred the phenomena of hysteria to the wanderings of this animal to the head, throat, liver, and limbs. Aretaeus embraced the same absurd doctrine. Galen refuted the notion of the movements of the organ, but agreed in making it the seat of the disease, and .Etius illustrated the view of Galen. 1 he theory of Hippocrates was afterwards revived by Holler and Duret, to be again confuted by Baillou, who substituted, for the movements of the uterus, a chilling malignant humour arising from the same source. The principal views which have since been entertained by authors mav he ar ranged as follows:—1. Hysteria has been referred to a morbid condition of the uterine nerves by Cullen, Pinel, Lieutaud, Louver-Villermav and FmX Ac and to chronic inflammation of the uterus by Pujol. 2. A" morbid enHV f the stomach with imperfect digestion, producing, according to c? on °! Parry, acid humours, and, in the opinion of Pitcairne, imperfectly concoct ^"ki a affecting the brain through the arteries, and to gastro-enteric inflam . , ' Broussais. 3. Congestion of the lungs and heart by Highmore, and ma^0n * hysteria, (Nature.) 57 portae by Stahl. 4. A morbid condition of the nervous system generally by Dumoulin, Loob, Pomme, Lorry, Whytt, Tissot, Boerhaave, Hoffmann, Sau- vages, Andral, and numerous other writers. 5. A morbid condition of the brain or cerebral nerves by Lepois, Willis, Barbeyrac, Georget, arid Brachet. A mor- bid condition of the spinal cord by several recent authors, and of the ganglionic system by Van Swieten, Lobstein, and Willis. Amard ascribes hysteria to dis- order of the lower portion of the spinal cord. Frank, M. Colson, Drs. Bradley, Brown, Darwall, Griffin, and Marshall, refer it to a more or less general irrita- tion of the same organ; and Tate, to spinal irritation connected with irregular or defective catamenia. The information afforded by morbid anatomy respecting hysteria being almost entirely of a negative character, affords us but little assistance in the attempt to determine its essential nature. Villermay has quoted cases from Diemerbroeck, Vesalius, and Morgagni, to prove the frequent coexistence of disease of the ovaries. Georget has endeavoured to connect the phenomena with changes in the brain, and Broussais with morbid appearances in the intestinal canal; but no sufficient evidence has yet been adduced to prove the dependence of hysteria on any struc- tural change, and we are therefore left to form our opinion chiefly from analogy. Extensive disordered action may be considered as a change of vital properties; and since life is not monopolized by any one of the organs or structures, but dif- fused through them all, we must avoid the error of hastily limiting disease to single organs, which may perhaps be affected only as parts of the whole. At the same time the evidence adduced by Geoffroy St. Hilaire and Serres, to show that the development of the body has a remarkable reference to the nervous system, and the instances continually presenting themselves in which various functional disturbances are produced by causes acting directly on the nervous centre, authorize the suspicion that a disorder, characterized by peculiar nervous susceptibility, depends on a morbid condition of this particular system; and although physiology does not at present enable us to fix precisely the functions of individual parts of the nervous system, yet a remarkable analogy may be traced between the effects produced by indisputable changes in the cerebro-spinal axis and the phenomena of the disease under review. We believe with Dr. Marshall Hall, that the spinal cord is "the axis of a system of excito-motory nerves, which is the peculiar seat of action of certain diseases, and of certain causes and reme- dies of disease;" and although the nature of such actions may be inappreciable, there are various considerations which give force to the opinion that they consti- tute the essential source of hysterical disorder. Injuries and diseases of the spinal cord often produce effects resembling the phenomena of hysteria. Krimer found the urine become limpid when the cord was divided in the dorsal or lumbar region; Chausset observed loss of voice pro- duced in dogs by division of the cord in the neck; and Nasse noticed the same result from its division in cats and rabbits. Inflammation or disorganization of the cervical portion of the cord often pro- duces vomiting, impaired deglutition, sensitiveness of the oesophagus, or inter- rupted respiration; and a similar condition of the cervical or dorsal region may occasion convulsions or palsy of the muscles of the trunk; and it is a natural con- clusion that phenomena similar in kind, though less permanent and less severe, may result from functional disturbance of the same parts. This opinion derives strong confirmation from the ease recorded by Dr. Billing, of a man aged twenty- eight, who having strained his spine by falling with a heavy load, suffered after- wards from globus hystericus and palpitation. (Lancet, vol. iv. p. 426.) Various hysterical symptoms are often associated with puffiness of the integu- ments, and a peculiar sensitiveness of the cutaneous nerves of some part of the spine, and may often be increased by pressure at the sides of the vertebrae. We have observed this condition in connexion with painful affections of various parts, difficult deglutition, cough, eructation, colic, and fainting. Such symptoms are frequently relieved by local treatment directed to particular parts of the spine. Vol. II.—8 ' r f y 58 hysteria, (Nature.) It is true that some phenomena illustrative of hysteria may be produced by irritation of the sympathetic ganglia: for example, contraction of the intestines from irritation of the splanchnic ganglia or coeliac plexus, as proved by Volkmann and others; but this fact is not inconsistent with the explanation proposed, since there is reason to believe that the brain and spinal cord are the chief sources of power to the organic nerves, and the reflex action of the sympathetic is most readilv excited by irritation of the cerebro-spinal. It is highly probable that interference with that part of the nervous axis more directly connected with the eighth pair is the condition most essential to the pro- duction of the characteristic phenomena of hysteria, the parts supplied by this pair being so remarkably influenced by the disorder, and its lesion, from what- ever cause, being productive of analogous changes of function. Brachet found the sensation of hunger, which is apt to be morbidly felt in hysteria, suspended by the division of the par vagum; and Gendrin has related an interesting case of cough of a decidedly hysterical character produced by exposure of this nerve to the atmosphere, in consequence of opening a neighbouring abscess, which sub- sided as soon as a cicatrix perfectly closed the wound. In order to appreciate the important relations of this nerve, we must remember its communication with the corpora restiformia, the corpora olivaria, and with those fibres of the corpora pyramidalia, which pass into the cerebellum: we may thus trace its influence on sensation and respiration; and if the views of Gall and Spurzheim be true, we may even derive an explanation of its relation to sexual conditions through the cerebellum. If the opinions of Bellingeri be correct, we can readily understand how increased, perverted, or impaired sensations or motions of various parts may be produced, according as different portions of the gray or white matter are most affected; and we may refer interference with the state of the rectum or bladder to a similar disturbance of the lateral strands of the medulla spinalis. The close connexion of the different parts of the cerebro-spinal axis, and the ready trans- ference of congestion or irritation from one part to another, will readily explain the mutability of hysterical symptoms; and we thus reduce to a simple and connected arrangement the " disorderly heap of phenomena," of which the dis- ease has been defined to consist. Dr. Conolly is of opinion that causes productive of irritation in various viscera may occasion the nervous disturbance producing hysteria; but Dr. Copland thinks it essential, that the nervous or vascular condition of the sexual organs should first be affected. It seems difficult, however, to reconcile the doctrine, that the uterine system is necessarily concerned in the production of hysteria, with the fact, that the disorder may coexist with every appreciable variety in the condition of this system, with menorrhagia or amenorrhoea, with inflammation in various degrees, or without any disturbance at all. The existence of a special irritation seems scarcely consistent with such a variety; and when the function of an organ is unaltered, there is no ground for supposing it disordered. The occurrence of all the characteristic phenomena in men is fatal to the uterine hypothesis. Napoleon in his boyhood is said to have had a fit of hysteria from wounded pride. Dr. Ferrear {Medical Histories and Reflections) relates the case of a young man affected with globus hystericus and apparent insensibility, yet retaining consciousness, and who was treated successfully with an emetic anti- spasmodics, and afterwards tonics. In the Edin. Med. and Sur* Journ vol. xi., there is an account of a strong, healthy man who had alternate laughing and crying, and inability to speak, from a feeling of something in the throat If addi- tional evidence be required of the occasional occurrence of hysteria hi men we might refer to the statements of Lepois, Willis, Whytt, Sydenham Hoffman Trotter Cullen, Watson, Georget, Conolly, Billing, aid 'even oTvmema2 although some of the cases described by these writers mav seem referriole to sexual conditions, there are many which are not capable of such an ex 1 tinn Several have fallen under the observation of the author in children ofP , and in adults under circumstaiues of debility or mental depression wh" h* ^t hysteria, (Treatment.) 59 be referred to such causes; and it cannot be denied that treatment applied to other parts will often effect a cure without changing the condition of the sexual organs. At the same time it is readily allowed that, owing to its great nervous .endowment, the uterus must be fully as competent as other organs to produce sympathetic dis- turbance of the nervous centre; and it is equally natural to conclude, that an organ possessing such intimate associations with that centre must be peculiarly liable to be affected by its derangements: and hence it will often be a problem in such cases, whether the uterus is primarily or secondarily concerned. In his very instructive work on local nervous affections, Sir Benjamin Brodie has attributed the susceptibility to their occurrence to imperfect development of the nervous system; but since of all parts of the body the nervous system is per- haps that which least frequently exhibits marks of insufficient development; since it often contributes by its derangements to the disorganization of other parts, and yet survives the ruins it has caused; and since in maladies of a nervous cha- racter its actions are rather perverted than enfeebled, and more frequently exalted than deficient, whilst the susceptibility to them is greatest in youth, and dimi- nished by the progress of age, this opinion, notwithstanding the deserved eminence of its author, seems to be questionable. When the condition of the nervous system above described exists, a very slight excitement will be sufficient to induce hysterical symptoms. Among these, emo- tions of mind of whatever kind, as of grief, joy, unrequited affection, jealousy, disappointment, or surprise, are conspicuous. The force of imitation is also very remarkable. Dr. Mead supported the popular opinion, that the fits were pecu- liarly liable to occur about the time of new and full moon. Fanciful as such an opinion may be, we are not perhaps authorized entirely to repudiate statements regarding lunar influence on the animal frame. The opinion that electrical agency may affect nervous subjects is gaining ground, and has the decided support of Rostan. The principal exciting cause, however, is irritation in some important organ; and since the association of hysteria with such conditions is the most im- portant circumstance in reference to treatment, it will be found desirable to adopt a corresponding division of the malady as the basis of a more simple and available arrangement of practical remarks. Treatment. During a paroxysm of hysteria it is important to adopt such mea- sures as may be necessary to prevent the patierit from sustaining injury during the violence of the struggles. Any tight clothing about the neck or waist should be loosened. Cold water may be' sprinkled on the face, and stimulating scents applied to the nostrils. If the patient can swallow, a dose of ether, foetid spirit of ammonia, or tincture of valerian, may be administered, or an enema of assa- fcetida, turpentine, or of iced water, which is recommended by Professor Chiappa as peculiarly effectual in arresting the fit. Some modifications of treatment are required even during the paroxysm, by peculiarities of the individual case; and in the intervals they are more especially requisite according to the varieties of aspect which this Protean malady assumes; but it is hoped that an arrangement may be introduced, by means of which the principles of treatment may be simply ex- pounded and readily applied. If the view which has now been offered be correct, namely, that the essence of hysteria consists in a peculiar disorder of some portion of the nervous centre which may produce the symptoms, either spontaneously under ordinary influences, or by irritation communicated from other organs, we obtain a division of the disorder into the idiopathic and the sympathetic. It is ' probable that the brain cannot produce the symptoms except through the medium of the spinal cord, yet, as these parts are so closely connected, we shall combine: them in our view of the idiopathic form of hysteria, and consider it a cerebro- spinal disease. Sympathetic hysteria may probably be produced by disorder of any organ, since even a wound of the finger may occasion it; but as its principal sources are the intestines and the uterus, we shall embody our remarks on the treatment of the disorder under the divisions of intestinal and uterine. 60 hysteria, (Treatment.) Idiopathic Hysteria. In this form there is no evidence of disorder of any organ except the cerebro-spinal axis, but the conditions of this part may vary in different cases, so as to require a corresponding modification of treatment. The principal diversity regards the state of the circulation; and it is therefore convenient to sub- divide this form into, 1. the congestive, either with general plethora or local deter- mination of blood, and 2. the atonic. 1. The congestive variety of idiopathic hysteria often depends on a state of gene- ral plethora. This condition is apt to occur in those who are well nourished, and lead a sedentary life. It generally assumes the form which, in the preceding arrangement, has been described as regular hysteria, and is characterized by vio- lent paroxysms occurring most commonly just before the return of the catamenial period. The convulsions are often severe, the face flushed, the arteries of the neck and head throbbing, the conjunctival vessels distended. In some cases fatal coma has followed these attacks. This, therefore, is the form of hysteria in which deple- tion is generally safe, and sometimes necessary. During the paroxysm, bleeding or cupping between the shoulders will be desirable. Cold should be applied to the head, and if stimulants be administered, the ammoniated tincture of valerian should be given rather than brandy. The purgative plan must be subsequently adopted A dose of calomel with jalap or colycinth should be promptly administered, fol- lowed by a more or less continued use of saline purgatives combined with senna The occasional repetition of the calomel maybe requisite. Late hours, hot rooms, and feather-beds must be avoided, the diet must be light and unstimulating, and exercise on foot must be enforced. As in this form of the disease the paroxysms are generally ushered in with headach, cupping on the first occurrence of that symptom will often avert the attack; but it will be important, by an assiduous attention to diet and medicine, to obviate the necessity of a very large abstraction of blood. Other cases are associated with local congestion rather general ple- thora, and require much care in their investigation and treatment. When the brain is chiefly affected, there may be headach and flushing of the face. One part of the head may be hotter than another: there may be occasional delirium, or some peculiar form of temporary monomania, as a disposition to destroy children or to commit suicide. The sudden occurrence of the symptoms, their temporary and variable character, their dependence in many instances on moral excitement, and their association with other hysterical phenomena, will enable the practitioner to distinguish them from cases of chronic derangement. The patient sometimes lies unconscious of all around her, with torpor of the senses, or even with dilated pupils: but in addition to other modes of distinguishing this from the hydrocephalic or apoplectic states, it may be mentioned that the countenance retains more intel- lectual expression than in those disorders. In these instances leeching, or cupping moderately employed, are often advantageous, or if the strength seems unequal to the abstraction of blood, dry cupping will sometimes answer the purpose. Five or six glasses applied to the nape of the neck, and retained there for ten or fifteen minutes, will often avert the hysterical fit, if employed as soon as headach or other symptoms indicate its approach. Turpentine is a useful remedy. A drachm sus- pended in mucilage, with the addition of a few drops of tincture of capsicum, may be admmistered three times a-day, or several drachms combined with castor oil S2Jwl? f* Man enema- Great attention must be P^ to ^e regulation wv. T ° the Promotion of a free catamenial secretion When local congestion about the spinal cord exists, there will in most instance be found puffiness and tenderness of the part affected. The tenderness DroS depends on a sympathetic condition of the cutaneous nerves, for the snlnal cord 1 too well protected to be directly influenced by external pressure A large proportion of cases of irregular hysteria are associated with this condi- tion, particularly those characterized by spasmodic closure of the "lntt- Jlr cough, dysphagia, palpitation, hiccough, and vomiting The^riw SpaSm faithfully described and instructively illustrated in Griffin's work mTT™ m, Affections of the Spinal Cord.) Dr. Griffin even supposes that there if a f °^j hysteria, (Treatment.) 61 relation between the organs affected and certain parts of the cord: thus, that palpi- tation, vomiting, inordinate hunger and thirst, epigastric pulsation, and cough de- pend on affections of the cervical region; disorders of the stomach and colon, loss of voice, pain in the chest and arms, on those of the dorsal region; whilst irritation of the lumbar portion produces affections of the hip joint, colic, menorrhagia, ischu- ria, constipation, or paralysis of the legs. Such a relation may, no doubt, often be observed; but considering the close connexion of the different parts of the spinal cord, we need not be surprised to find frequent deviations from the rule. Much caution is required in the treatment of these affections, the hysterical susceptibility of the cerebro-spinal system being associated with a peculiar sensitiveness to any disturbance of the balance of circulation, whether on the side of excess or of defi- ciency. When the strength has been good, we have repeatedly witnessed great advantage from the application of a few leeches to the tender part of the spine, and subsequently from counter-irritation by blisters or tartar emetic ointment; and have known a case of vomiting, apparently hysterical, of two years' duration, yield in a few days to this simple treatment. In cases associated with isolated affection of the spinal cord, two blisters, one on each side of the part, are the best counter-irri- tants: when the affection is more extensive and chronic, antimonial ointment is probably more effectual. Palpitation of the heart and teasing cough may often be relieved by the same means. The cough is temporarily relieved by antispasmodics, as ether; more completely by a combination of ammoniacum and prussic acid; but counter-irritation can rarely be omitted, and sometimes a slight course of mercury is essential. In cases of spasmodic closure of the glottis, cold water should be thrown on the face, and ammoniacal salts applied to the nostrils. The fauces and pharynx may be tickled with a feather or with the forefinger, the retching, and consequent expiration thus induced, engage the laryngeal in one combined act with the other respiratory muscles, and the spasm of the glottis is thus overcome. In the epileptic form of hysteria with spasmodic closure of the jaw, we may often succeed in opening the mouth by firmly compressing the muscles attached to the hyoid bone. Mr. Laycock supports mis recommendation by mentioning a case of spasm of the glottis in an adult male, in which inspiration immediately followed pressure of the thyroid cartilage. (Med. Gaz., 1838.) If this method fail, the object may sometimes be accomplished by forcibly overcoming the tetanic flexion of the forearm and fingers. The relief thus obtained may be temporary, but it gives an opportunity for the administration of valerian or assafcetida. Hys- terical hiccough is occasionally relieved by the same measures which prove use- ful in cases of cough and palpitation: one case, however, of a severe character, which had lasted for weeks, and continued during sleep, resisted this method, but was cured by a blister to the epigastrium. In the class of cases under review the author has given a trial to veratria in the form of unguents, but it has not appeared so effectual a counter-irritant as the tartar emetic ointment. When a tympanitic state of abdomen appears to depend on the condition of the spinal cord, turpentine is often useful; and when this remedy has failed, alum in considerable doses has accomplished a cure. Dr. Abercrombie has referred to some interesting cases, probably of this class, in which the application of galvan- ism proved remarkably efficacious. This agent is perhaps peculiarly suitable when the tympanic condition depends on partial paralysis of the muscular coat of the bowels. In all cases of this class it is essential to obviate hepatic conges- tion, and to prevent intestinal accumulation. The long-continued use of a stimu- lating embrocation rubbed freely along the whole course of the spine is a valuable auxiliary; and when the more urgent symptoms are removed, exercise, whether on horseback or on foot, tends to lessen the morbid susceptibility, and probably the disposition to congestion. In most hysterical cases the long-continued use of mercury is greatly to be deprecated, although occasionally necessary, as in the treatment of some cases of obstinate barking cough. 62 hysteria, (Treatment.) To the class of cases depending on spinal congestion may probably be referred many instances of diminished power of volition, some of which also follow me- chanical injuries of the spine. In these cases medical treatment accomplishes little, but some sudden moral excitement seems occasionally adequate to rouse the voluntary power, and to transmit its influences to the muscles. It is chiefly on these cases that alleged miracles, such as those of Prince Hohenlohe, have been wrought. 2. The atonic, variety of idiopathic hysteria is most frequently witnessed in patients who, on account of some severe disease, have undergone free depletion, or taken mercury to excess; as, for example, in the course of treatment required for the rapid ulceration of the cornea; and it is interesting to observe, that the change to the tonic plan is generally as useful to the local complaint, as it is es- sential to the control of the hysterical malady. In some of these instances tenderness occurs in the spine, but it generally exists also in other parts of the body. It is aggravated by leeching, which may even be followed by paralysis. It is not uncommon to witness great cerebral excite- ment, sleeplessness, throbbing of the carotid and temporal arteries, and intole- rance of light and sound. Such cases are sometimes unhappily mistaken for phrenitis; but the sudden changes in the severity of the symptoms—the pulse not being characteristic of alarming local disease—the existence of other hysterical complaints, as tympanic abdomen, urgent pain of various parts, particularly under the left mamma, and the production of the disorder by some mental excite- ment—soon disclose its true nature. The mistake is, however, too often com- mitted, and is of serious consequence, since injudicious depletion aggravates all the symptoms, and may even produce permanent mania, whilst it always retards, and sometimes prevents, ultimate recovery. On the other hand, the application of cold to the head, the use of mild anodynes, such as camphor with extract of henbane, or, if they fail, morphia, with perfect quietness, soon dispose to rest; after which the nitrate of silver, in half-grain doses, exerts a most favourable in- fluence on the morbid sensibility. Should the debility continue long, and the symptoms assume an intermittent character, the sulphate of quinine will be found a valuable auxiliary; or if there be pallor, with neuralgic symptoms, the sesqui- oxide of iron. Some of the chalybeate mineral waters, as the Eger, Pyrmont, or Spa, and exercise in dry country air, will materially promote the recovery of strength. The use of the shower bath is an important auxiliary to the tonic plan, its influence on the cutaneous nerves producing a most favourable effect on the nervous centre. Secondary or sympathetic hysteria is generally associated with derangement of the intestines or the uterus, to which parts it will therefore be neeessary to direct the chief attention. We cannot be surprised that impressions made on the deli- cate extensive plexuses of the intestines should powerfully affect the nervous cen- tre. A striking example of the power of such impressions in producing hysteri- cal symptoms is given by Brachet. On two different occasions, at intervals of nine months, a woman, who had never before exhibited any phenomena of the disease, took food which, without her knowledge, contained cheese, and each time fell into an hysterical paroxysm, which was relieved only by vomiting. The symptoms exhibited, and the treatment required, in hysteria from intestinal de- rangement, vary according to the peculiar nature of that derangement. For practical purposes it will be sufficient to consider it as associated with intestinal irritation, or with intestinal torpor. The first class of cases, those arising from intestinal irritation, often partake of an inflammatory character; the abdomen is distended and rather tender; pain is felt after taking food, especially when of an indigestible kind; the tongue pre- sents large red papillae, and there is much thirst. Eruptions arise on the skin from slight causes; sleep is much disturbed; any indigestible substance detained in the stomach, such as cheese or potatoe, will occasionally produce terrific pal- pitation of the heart. Intense gastrodynia occurring in paroxysms, particularly hysteria, (Treatment.) G3 in the morning, is not uncommon. The hysterical phenomena attending this condition are exceedingly irregular. Perhaps the most usual indications are attacks of violent headach, strong and variable emotions, and a disposition to laughter, or excessive weeping on slight occasions. In these cases if the tender- ness of stomach be considerable, leeches are in the first instance necessary; after- wards great benefit is derived from cooling saline medicines combined with hy- drocyanic acid. If there be much flatulence, and especially if the urine (which is very common) appears muddy, a few drops of Sp. Ether Nitr. may be added to each dose with advantage. The catamenia are apt, in these cases, to be pro- fuse, and accompanied with much pain of back and head. These symptoms are materially relieved by rest, and small doses of Liquor Ammon. Acet. Aloetic and all irritating purgatives must be carefully avoided. Castor oil is almost the only aperient which can be borne. When the paroxysms of palpitation and flatulent colic are urgent, the assafoetida enema will often give relief. Morphia sprinkled on a blistered surface, applied to the praecordial region, will often quiet the heart, and sooth the stomach. Stimulants of every kind should, as far as possible, be avoided, since the temporary relief afforded by them does not com- pensate for the prolonged suffering which the sub-inflammatory state of the diges- tive organs, thereby induced, is calculated to occasion. The diet must be regulated with great care. In the attacks of gastrodynia which occasionally attend or follow the condition just described, we have found great benefit from the use of small doses of sulphate and sesquicarbonate of soda combined with an aromatic. In some instances there is no evidence of general irritation; the tongue is per- haps pale. The symptoms are almost limited to the stomach, which rejects food; and the occasional occurrence of globus is the chief indication of hysteria. The epigastrium may be tender, but the feeling after taking food is one of oppression rather than of pain. In these cases hydrocyanic acid is a remedy of great value, but is better combined with mucilaginous mixture than with salines. A few leeches, followed by counter-irritation, and a strict adherence for a time to farinaceous diet, shortly change the character of the complaint. The sickness attending this state of stomach, when not removed by prussic acid, is sometimes curable by creasote, but the remedy is too stimulating for indiscriminate use, and the nitrate of silver would often be preferable. Globus, palpitation, and the hysterical condition of mind, are occasionally accompanied by haemorrhoids. In these cases hepatic congestion is generally present. The mercurial pill in half-grain doses, continued for some time, is useful; and if paroxysms of flatulent colic occur, a combination of valerian and opium. 2. Hysteria associated with intestinal torpor is generally observed in those who lead a sedentary life, and whose constitution is by no means delicate. A constipated state of bowels is well known to disturb the functions of other parts, to weaken the organic energy, and to predispose to hysteria, which, when com- bined with this state, generally assumes the regular form. Here it is obvious that a judicious purgative plan is strongly indicated; and an emetic of ipeca- cuanha will frequently prevent a threatened paroxysm. This variety is usually complicated with amenorrhoea, and the remarks made under that complication will bear more or less application to the present one. The second leading division of the sympathetic disease is that connected with uterine derangement, and in a practical point of view there are three important conditions with which it may be associated, namely, menorrhagia, defective men- struation, and leucorrhoea. 1. Hysteria accompanied with menorrhagia is particularly apt to occur in those who have had frequent miscarriages. When there is reason to believe that the complaint is passive, and that the hysterical affection is dependent on the debility thus induced, it is necessary to check the discharge by means of sulphuric acid or alum. The acetate of lead may perhaps have a more decided effect, but we 04 hysteria, (Treatment.) have observed a greater tendency to colic from its use in hysterical persons than in others. If there is general or local irritation, sulphate of magnesia dissolved in infusion of roses will be useful; and during the catamenial period, cooling saline medicines, especially the acetate of ammonia, should be employed. Dry air, rest, and freedom from excitement, are essential to the cure. 2. When hysteria is associated with defective menstruation, some of its most decided and prominent features are presented; and this variety of the disease has therefore attracted peculiar notice. Tate has even restricted the term hysteria to this class. The catamenial secretion is scanty, irregular, or unnatural in appearance. The patient does not generally complain of pain in the back, but on examination the spine is almost always found tender, especially near the sixth upper dorsal vertebras, with headach, aching of the loins and legs, and pain under the left breast. The bowels are commonly confined, the tongue is furred, and the pulse variable. Stupor, palpitation of the heart, and suspended respiration, are occa- sional phenomena. Hysteria thus associated usually exhibits a remarkable in- fluence on the motor system of nerves. The paroxysm is decidedly convulsive, and contractions of the limbs may occur, especially at the catamenial period. Cases of hysterical catalepsy, chorea, and paralysis, are generally referrible to this division. In the treatment of this variety the restoration of the catamenial secretion to its natural state is important, but not alone sufficient to effect recovery, since, especially when this depraved catamenial condition has been produced by mental causes, the attendant hysteria will often remain after the uterine function is re- established. Unless the patient is very delicate, cupping or leeching the tender part of the spine will be expedient, and in some cases bleeding is necessary. Subsequently counter-irritation by means of antimonial ointment, and active pur- gatives, with which, if the face be pale and the circulation languid, iron may be combined, constitute the leading points of treatment. When the catamenial period approaches, especially if indicated by pain of the back, headach, and gene- ral uneasiness, a few leeches to the labia or thighs, and the mustard pediluvium, will promote its occurrence. A single dose of calomel, digitalis, and aloes, fol- lowed by an active aperient, as recommended by Dr. A. T. Thomson, and subse- quently the use of pills of aloes and myrrh with galbanum, once or twice daily, powerfully contribute to re-establish the uterine action. The transmission of electrical shocks through the pelvis has considerable efficacy in correcting flatu- lence, promoting alvine evacuation, and exciting the catamenial function. During convalescence, active exercise and the use of the shower bath are requisite, and the general principles of treatment which have been repeatedly proposed must be duly observed. 3. The last variety of sympathetic hysteria, namely, that associated with leu- corrhoea, or depending on chronic uterine irritation, is one of great importance, owing to its frequent occurrence and its liability to be overlooked. The sufferer complains of debility, her movements are languid and her spirits depressed, and she weeps on slight occasions, but makes no specific complaint. The appetite is bad, and the tongue is often fissured, the clefts being filled with a viscid secretion Globus hystericus occurs from time to time, with tenderness of loins and sacrum, pain under the left mamma, neuralgic affections in the region of the stomach, along the margin of the ribs, on the right side, or throughout the abdomen gene- rally, and often a flatulent state of the bowels, especially of the colon. The usual causes are, active exertion during the catamenial period, mental anxiety, or undue excitement, sometimes incidental to matrimony. In these chronic uterine affections the urine generally deposites the triple phosphates, while in the more acute and regular forms it is watery and contains little urea. The treatment which we have found most effectual is a dose of mercurial pill and extract of hemlock, followed by castor oil with tincture of henbane and after- wards saline medicines combined with prussic acid, tincture of henbane' and sDirit of nitric ether. The frequent use of mercury, even in small doses, is to be depre- hysteria, (Treatment.) 65 cated, as it increases the irritability of the system; but an occasional dose relieves congestion and improves the secretions. After a time astringent lotions may be used, such as the Liq. Aluminis Comp. Sexual excitement must be avoided, and every measure employed which is calculated to strengthen without stimulating. The use of tonics must not be rashly or hastily adopted. Chalybeates are gene- rally too exciting, and even quinine cannot always be borne. The sulphate of zinc is occasionally useful; and in some instances, especially when there is a cata- menial deficiency, the artificial Kissingen water, prepared at the German Spa at Brighton, is of remarkable service in relieving from the sensation of weight after food, correcting the tendency to flatulent colic, and regulating the uterine function. It removes local congestion, especially of the uterus, and is peculiarly adapted to derangement of this organ associated with fibrinous catamenia. The affection of abdomen attending this form of the malady sometimes greatly resembles perito- nitis, but superficial is as painful as firm pressure. The countenance is less anx- ious and distressed than in peritonitis, and the variable and diffused character of hysteria is easily recognised. Sometimes, however, there is sufficient uterine inflammation associated with this state to authorize a single bleeding, though the effect must be carefully watched, and undue depletion avoided. Most of the neuralgic affections which we have seen associated with hysteria have been on the left side. For the relief of pain under the left mamma, between the cartilages of the fifth, sixth, and seventh ribs, and which appears to be of this character, Mr. Tate and Dr. O'Beirne place great dependence on tartar emetic ointment rubbed over that portion of the spine which supplies this part with nerves, and Dr. Copland has found benefit from the moistened inner bark of meze- reon worn for some time, so as to produce a superficial sore. The sesquioxide of iron is often serviceable after the other symptoms of irritation have subsided, but its efficacy is much promoted, in many cases, by the previous application of leeches. The painful affection of the abdomen may sometimes be relieved by a warm flannel dipped in spirits of turpentine. A careful observer cannot mistake for hepatic disease, the shifting and uncertain pain in the right hypochondrium which often attends this variety of hysterical complaint. When neuralgia of the uterus itself is present, according to Lisfranc, the cervix is tender, and possesses the form and size characteristic of the second month of pregnancy. Hysterical affections of the joints, which have been so well described by Sir Benjamin Brodie, are frequently but not invariably associated with the same variety. In some cases those of the knee so closely resemble in the symptoms ulceration of the cartilages, that it requires much time and care to form a correct diagnosis; but in hysterical affections the limb is often extended, whereas in dis- eases of the cartilages it is usually bent; in addition to which, the previous history of the case will frequently solve the problem. In these cases blistering is in general useless, and confinement injurious. The belladonna plaster is less useful in this than in other forms of hysterical neuralgia. Sir Benjamin Brodie has found the pain palliated by a tepid lotion, consisting of equal parts of Sp. Ros- marini and Mistura Camphorae; and when the limb is liable to alternate heat and cold, by a cold spirituous lotion during the hot fit, and during the cold one by a worsted stocking covered with oiled silk, so as to confine the heat and perspira- tion. The intermittent character of the symptoms indicates the administration of the sulphate of quinine. Marriage has been by some authors recommended as a remedy for hysteria; but the preceding remarks will show that it is quite as likely to aggravate the complaint as to cure it: and where it does prove a remedy, it is probably rather by satisfying the affections of the heart. Hysteria frequently occurs in persons of a gouty constitution, by which it is somewhat modified; and in these cases colchicum merits a trial. Those who have long suffered from hysterical complaints, have frequently a tedious convalescence, with various distressing affections of the stomach, nerves, mind, &c; but provided the recovery is progressive, it is better not to interfere Vol. II.—9 66 hystekia, (Treatment.) too actively. Exercise, country air, and useful occupations, gradually restore the health; and in the absence of any distinct indications of treatment, the advice of Sydenham is peculiarly valuable, " If you cannot do good, do nothing." In the moral management of hysteria it is important to temper kindness with firmness, and to avoid a parade of sympathy. A due intercourse with society, which diverts without exciting, is desirable. It is of great importance to remember that hysterical susceptibility is perhaps, in a majority of instances, the result of injudicious management in early life. The many excellent works published of late years on the subject of physical education, are already attracting deserved atten- tion and contributing to correct this evil; nevertheless, in the upper ranks of society, young females are still pampered with stimulating food, and injured by modes of dress which unduly compress the most important viscera. Too much time is still devoted to sedentary employments, and the perusal of the works of fiction is too often substituted for solid attainments, by which a fondness for injurious excitements is naturally promoted, instead of a salutary habit of self- control. It was never intended by Providence that every woman should be a musician or a painter, but it was undoubtedly designed that she should cultivate those substantial qualities of sense and temper which give permanence and fresh- ness to the charms of domestic life. During early youth, the mind must not be allowed to outstrip the body; exercise and fresh air strengthen both, and in favour- able weather the house should often be regarded rather as a retreat than as a dwelling-place* ( 67 ) TETANUS. Explanation of the term tetanus and its varieties'.—Trismus.—Opisthotonos.—Emprostho- tonos.—Pleurosthotonos.—Trismus nascenliuin.—General and local.—Acute and chronic.— Idiopathic and symptomatic.—Continued and periodic.—Premonitory symptoms of teta- nus.—Symptoms of the paroxysm of trismus, of opisthotonos, of emprosthotonos, of pleuros- thotonos.—Chronic forms of tetanus.—Predisposing causes.—Exciting causes.—Anatomical characters.—Nature.—Diagnosis.—Prognosis.—Treatment. This term (derived from rsiva, to stretch) denotes a disease, the principal cha- racteristic of which is tonic spasm of a certain number of muscles. Some authors have restricted its meaning to that form in which, by the mucular spasm, the trunk is kept perfectly straight, and employ other terms to designate the disease when any particular set of muscles are more especially affected. Thus, if the muscles which raise the lower jaw be in a state of contraction, it has been de- nominated trismus, (from rpiga, to gnash;) if those attached posteriorly to the spine be affected, so as to draw the body backwards, opisthotonos, (from ovto-Sev, backwards;) if the muscles of the neck and abdomen be contracted anteriorly, in such a manner that the trunk is inclined forwards, emprosthotonos, (from tfvrpo to produce the most frightful risus sardonicus; the tongue fixed and immoveable, and the whole countenance expresses the greatest pain and anxiety. Sometimes a frothy saliva is squeezed out between the teeth, and flows from the mouth; in other cases the tongue is thrust forwards and lacerated, giving rise to considera- ble haemorrhage. The larynx is raised; the articulation indistinct and painful; sometimes the power of articulation is lost, all attempts to speak apparendy aggravating the paroxysm. The muscles generally are tense, rigid, and often feel as hard as a board; the shoulders are drawn forwards, and the trunk and extremities firmly fixed in various positions, afterwards to be described, or violently thrown about by occasional momentary relaxations, followed by sud- den muscular contractions of longer or shorter continuance. The respiration is hurried, and performed with great difficulty and anguish, presenting to the spec- tator one of the most distressing forms of dyspnoea. The patient often feels great thirst, but all attempts at swallowing produce extreme agony, and spasms of the muscles of deglutition; symptoms allied to those of hvdrophobia being thus occasionally produced. The pulse at the commencement is full and hard, but gradually becomes feeble and frequent, sometimes intermittent or irregular, according to the continuance and severity of the attack. The temperature of the 6kin, is increased, and the surface covered with a profuse perspiration, which in certain instances is confined to the face and chest. Occasionally the urine is ex- pelled with violence, but sometimes there is retention. The sphincter ani in general is firmly closed, but in some cases the faeces have been expelled involun- tarily. In the midst of all these sufferings the intelligence is unaffected__a cir- cumstance which increases the distress with which the by-stander must naturally regard them. Such are the general symptoms which characterize the paroxysm in its severe acute form; but there is considerable variation, according to the peculiar eli^ of muscles more especially affected. When the disease is confined to the levators of the lower jaw, constituting trismus, some time may elapse before other muscles tetanus, (Symptoms.) 69 become affected; in this state the malady may disappear, or it may prove fatal. When the disorder, however, is more severe or advanced, trismus supervenes, which may be considered only as a mild or partial form of the general disease. Opisthotonos is occasioned by the posterior muscles of the spine being powerfully contracted, the effect of which is to draw back either the head and neck alone, or to curve the trunk into the form of an arch, the body resting only on the occiput and sacrum, or on the vertex of the head and heels, if the lower extremities be affected. The force and suddenness with which this is produced, is sometimes sufficient to throw the patient out of bed. Founder Pescay has seen dislocation of the second cervical vetebrae, and Desportes, fracture of the thigh bones from the excessive muscular action. Larrey and Curling also relate cases in which one of the rectoabdominalis muscles was ruptured. Emprosthotonos is produced by the muscles on the anterior part of the body being most powerfully contracted, so that the head is flexed upon the breast, the thighs on the abdomen, and the trunk curved forwards. In severe cases the head and knees approach each other, the arms are flexed, and the hands sometimes clasped together. According to Larrey the legs are rigid and flexed upon the thighs, but Aretaeus describes them as being extended. Emprosthotonos, however, is a very rare form of tetanus, and it is to the experience of Larrey in modern times we are chiefly indebted for its description. In pleurosthotonos, the neck and trunk is curved towards one side; this form is so rare, that some writers have doubted its existence. Occasionally the whole body is perfectly rigid and straight, no particular set of muscles apparently being more affected than another. To this state some physicians consider the term tetanus ought to be restricted. The dreadful symptoms described may terminate in death, or they may gra- dually cease, and the patient return to his natural condition, or to a comparative state of ease. In the former case the various symptoms increase in intensity: the dyspnoea becomes more urgent; an agonizing sense of suffocation is felt; the per- spiration becomes cold and clammy ; the pulse thready or imperceptible; a frothy, bloody mucus escapes abundantly from the mouth; the countenance assumes a livid hue; the spasms increase in frequency, and are renewed by the slightest attempt to move or swallow, or by any trivial circumstance, such as opening the door, a draught of air, &c.; delirium sometimes supervenes, and the patient sinks either asphyxiated or exhausted from the efforts and pain of the paroxysm. Some- times the individual dies suddenly after an amelioration of the symptoms. When the disease terminates favourably, the rigidity gradually lessens, the spasms are less frequent, the respiration becomes more free, and the pulse natural; and al- though there is for some time a feeling of stiffness or soreness in the muscles, the patient gradually returns to the state in which he was before the seizure. The duration of acute tetanus varies. A case is recorded of a negro, who, having scratched his hand with a piece of broken plate, died of tetanus in a quarter of an hour. (Recs's Cyc. art. Tetanus.) The fatal termination usually takes place from the fourth to the eighth day, but cases have been reported which continued to the fourteenth and even to the twentieth day. (Morgagni.) On the other hand the recovery is generally slow. Of 58 cases collected by Curling, which terminated successfully, 8 recovered in a week; 3, in 10 days; 4, in a fortnight; 4, in three weeks; 15, in a month; 4, in 5 weeks; 8, in 6 weeks; 3, in 8 weeks; 3, in 2 months; and 2 so late as 3 months. Greater or less rigidity of certain muscles may remain for many months, and in some cases a peculiarly aged character is given to the countenance. The chronic form of tetanus is characterized by the same symptoms, but they come on more gradually, and there are sometimes shorter or longer intervals be- tween the paroxysms for several months or even years. There does not seem to be any very clear division between the acute and chronic forms. Dr. Symonds thinks a sub-acute form should be constituted, including those cases which are of mild character, but which do not continue long enough to be designated chronic. 70 tetanus, (Symptoms.) But however we multiply the divisions, intermediate cases will always be found, which no arbitrary classification can comprehend. Many of the symptoms are liable to various modifications in particular cases, or at different periods of the disorder. The muscular system, as we have stated, may be so affected as to produce trismus, opisthotonos, emprosthotonos, or pleurostho- tonos. Cramp also is a slight modification of the disease, and during the parox- ysm all the muscles are more or less spasmodically affected. The contraction of the pectorals draw the shoulders forward, and the rigidity of the respiratory mus- cles preyent the free motion of the chest. In trismus, although the jaw is closed, the anterior muscles of the neck appear hard and contracted, and in opisthotonos the walls of the abdomen are stretched, and feel as hard as a board, showing that the peculiar distortion produced is not the effect of a particular set of muscles only being affected, but that then power is increased, or that they are acted on to a greater degree than others. The muscles of deglutition are peculiarly liable to be excited on the slightest contact, producing inability or difficulty of swallowing, and in severe cases horror of fluids, and symptoms resembling those of hydrophobia. In some instances it has been observed that the cremasters participate in the dis- ease and draw up the testes. The eyeball is always fixed, and sometimes from irregular action of its muscles drawn inwards. During sleep the muscles are re- laxed, and it has been observed in many cases that, during the whole course of the disease, those of the fingers have not been affected The voluntary muscles principally suffer, though several authors are of opinion that the involuntary are also occasionally affected. It must be evident, however, that tetanic spasm of the heart, diaphragm, &c, must soon be followed by death; and although certain symp- toms indicate that they are in some way or other acted on, the manner in which they are affected is unknown. The sensibility to touch is not increased in tetanus, but in many cases the slight- est contact, or even noise, is sufficient during the remission to bring on the spasms. The pain experienced in particular muscles is sometimes very great, especially in those which have been injured by a wound In a case however given by Sir G. Blane (Obs. on Diseases of Seamen) a pleasurable tingling sensation was expe- rienced. In almost every instance of tetanus, great pain is felt in the praecordial region or below the sternum, which has been denominated by Dr. Chalmers the pathognomonic symptoms of tetanus. It is described as being of a dragging na- ture, occurring suddenly, and darting towards the back, and not increased by pres- sure. In some cases it appears early in the disease; in others at a later period,and is attributed to the diaphragm partaking in the general spasm. The intelligence is in the great majority of cases clear and unchanged. Some instances are recorded however (and we have seen a remarkable one of this kind,) in which the consciousness wag completely lost. Under such circumstances the disease may be called epileptiform. The pulse in tetanus varies according to the stage of the disease. Morrison, Hennen, Macgregor, and others, have noticed that it was not much affected. In the early stage there is no remarkable acceleration; but during the spasms, it is somewhat quickened; and as the disease approaches its fatal termination, it becomes weak, frequent and thready. Dr. Parry thought that the patient was safe if the pulse did not exceed 110 beats on the fourth or fifth day. No dependence how- ever can be placed on this symptom as a prognostic, many cases having died when the pulse was more slow, while others have recovered when it was more frequent The temperature of the surface is generally increased, and sometimes the skin feels hot M. Prevost of Geneva had a case in whom the temperature at the axilla was 1109 (Fahrenheit.) and Dr. Bright another, in whom it was 105° The cutaneous transpiration is increased, which may be attributed to the violent muscular exer- tion into which the patient is involuntarily thrown. Sometimes there is a slieht miliary eruption. There is occasionally fever, more commonly in idiopathic cases, but sometimes also when it arises from wounds: many writers however who haw ietams, (Causes.) 71 seen much of the disease, have never observed this. The tongue is moist at the commencement, but becomes dry as the disease proceeds. Constipation is almost a uniform symptom in tetanus: this has been attributed to many causes, as spasm of the muscular coat of the intestines, excessive cutaneous transpiration, pressure of the diaphragm and abdominal muscles, loss of the voluntaiy power necessary for defecation, the use of opium, and other constipating remedies, &c. Retention of urine occurs occasionally, and in such cases there is much difficulty in intro- ducing a catheter, from the spasmodic action of the muscles at the neck of the blad- der. The urine is generally high-coloured and scanty. Causes. Men are more liable to tetanus than females, a circumstance which is accounted for by the former being more exposed to the exciting causes of the dis- ease. Tetanus is common in early infancy; the term trismus nascentium has been given to the disease, when it occurs at this epoch of life. After this period, how- ever, it occurs most frequently between the ages of ten and fifty. Extensive ob- servation has shown that it is very rare in advanced life, although Aretaeus thought it readily developed in old persons. It is a well-established fact, that notwithstanding tetanus may occur in all cli- mates, it is most common in those of an elevated temperature, and more frequent when the season is hottest. Army and navy surgeons, who have practised in the East and West Indies, have proved this, although we possess no statistics which enable us to speak decidedly as to its proportionate frequency. Moist situations also predispose to the disease. In the French hospitals at Cairo, which were erected on ground subject to the periodic inundation of the Nile, it was very frequent. It is said also to be more common in marshy situations and countries bordering upon the sea, than in dry and elevated places far from the coast. The strong, robust, and athletic, have been noticed as being more liable to the disease than weak persons, or those in ill health. It is also more common in individuals of a nervous, than in those of a lymphatic temperament. Campet, Dazille, and Anderson, have noticed that tetanus is much more common among the negroes than among the white population, a circumstance which has by some been imputed to an inherent predisposition, and by others to their more frequent exposure to the exciting causes. Insufficient nutriment, close and ill-ventilated habitations, uncleanliness, and neglect of the bowels, powerfully predispose to this disease. Drs. M'Arthur and Dickson have shown, that since these evils have been remedied, a marked diminution in the frequency of the disorder has occurred in the West India department of the navy. The most frequent exciting causes of tetanus are external injuries, and it ap- pears that the most unimportant superficial abrasion, and the most serious ope- ration may give rise to the disease. It has been occasioned by a bite on the finger from a tame sparrow (Morgagni,-) the stroke of a whip lash under the eye, although the skin was not broken (Reid, on Tetanus and Hydrophobia;) a fish bone sticking in the pharynx (Larry, Mem. Chir. Mil., torn. i. p. 254;) a seton in the chest (Andral, Clin. Med., torn. iv. p. 445;) the stroke of a cane on the neck and hand (Morgan, on Tetanus, p. 6;) flagellation; extraction of a tooth (Edin. Med. and Surg. Journ., vol. xv.;) cupping, venesection, &c. It has also followed severe fractures, lacerations, contusions, punctures, amputa- tions, excision of the mamma, tying arteries, gun-shot wounds, castration, injec- tion for hydrocele, &c. An instance is related where it followed the bite of a horse in the arm (Boyer, torn. i. p. 287,) and another in which it was occasioned by stretching a nerve. (Swan, on the Nerves, p. 541.) A wound in any part of the body may produce tetanus, although it has been observed more frequently from injuries of the extremities, than from similar injuries of the head or trunk. In 128 cases of traumatic tetanus, collected by Mr. Curling (Essay on Tetanus,) the wounds occurred on some part of the lower extremities in 64, and on the upper extremities in 46, and of these the feet and toes were the seat of injury in 35, and 72 tetanus, (Causes.) the hands and fingers in 34. Dr. Hennen observed it most frequently after wounds of the elbow and knee, and others when the thumb or great toe was injured. Some authors have noticed a peculiar state of the wounds in connexion with tetanus. Rush remarked that they were always free from inflammation (Med. Inquiries, vol. i;) Larrey, that they were either dry, or covered with a thin serous exudation; and Fournier Pescay describes them as being pale, livid, sometimes covered with an ichorous secretion.) (Diet, des Sc. Med., torn, lv.) Sir J. Macgregor and Dr. Hennen, however, after great experience in this dis- ease, conclude that there is no relation between the state of the wound and the occurrence of tetanus. They have seen it occasioned by all descriptions of sores, healthy and sloughing, incised and lacerated, simple and complicated. Neither does its accession produce any alteration in the wound, or retard its progress to- wards a cure; and in many cases it has been completely healed and forgotten be- fore the occurrence of the tetanic symptoms. Dr. Elliotson observes that the disease has sometimes declined and ceased, while the wound every day grew worse and worse. The interval between the infliction of the injury and the commencement of tetanus differs considerably. In a case related by Dr. Robison, (Recs's Cyc, art. Tetanus,) it followed immediately; the longest period on record is ten weeks; the case is detailed by Mr. Ward. (Facts establishing the Efficacy of Opiate Friction in Spasmodic and Febrile Disease*, 8,-c, 1809.) In the 128 cases of traumatic tetanus collected by Mr. Curling, it appeared from the fourth to the fourteenth day in 81, and this is the most common period of its occurrence. The time after which an individual may be considered safe from tetanus when he has received an injury, is undecided, and has been differently stated by authors. Fournier Pescay says he has seen it occur after a month. Sir J. Macgregor never witnessed an interval longer than twenty-two days, and Sir B. Brodie longer than seventeen. Larrey thought that in Egypt the French soldiers were safe after the sixteenth day. Exposure to cold and damp is a frequent exciting cause of tetanus, independent of any other circumstance. Numerous cases are related of individuals being af- fected after sleeping during the night in the open air, particularly in tropical cli- mates, where the dew is abundant, and the nights cold. Hennen and Larrey have noticed its occurrence in Egypt, when the nights were chilly and rainy, and when the troops were exposed to cold and moist breezes from the sea. Sudden changes of temperature have in like manner been noticed by the last named authors, and by Dazille, Campet, and Rush. The latter writer informs us, that while no case occurred among the soldiers who had passed a winter in Rhode Island in 1781, it was frequent in some troops newly arrived from the West Indies. Be- gin states, that after the battle of Muskowa, although the heat was verv intense, no cases of tetanus occurred; whereas, after the battle of Dresden, when moist and cold weather succeeded a great elevation of temperature, it was common. Dr. Chalmers gives a case where it was brought on by sudden change of weather in a man who slept without his night-cap. Going into the external air from the heated atmosphere of a ball-room has also occasioned it. Fournier Pescay gives two instances where it followed the action of cold water on the body when in a state of perspiration, and one where it arose from exposure to the north wind, when the individual laboured under fever. Intestinal irritation has occasioned the disorder: the presence of worms is one of its most frequent causes. Laurent (Mem. Chir. sur le Tetatanos 1797 ) con- sidered this almost the only cause of the disease; and in addition to the cases he has related, others have been recorded by Morgagni, Stoll, Fournier Pescav O'Beirne, and others, where tetanus was apparently produced by vormination It may also be occasioned by any other disorder of the digestive Vcran* trisine from improper food, irritating substances in the stomach or intestines indurated faeces, &c. In infants an acrimonious state or retention of the mecon"' f quent cause, as well as irritation produced by the milk of the nurse UUU 'S * ^ tetanus, (Anatomical Characters.) 73 Among the other exciting causes of tetanus have been observed great fatigue; terror; mental anguish; abortion; suppressed perspiration; cessation of the lochia, and other habitual discharges; intoxication; variola, typhus fever, gastric inflam- mation, and other acute diseases; retrocession of cutaneous disorders; lacerations and ulceration of the navel string; difficult and painful dentition; ulceration of the gums; irritation from the appearance of the dens sapiential; insolation; indigestion; constipation; rheumatism; hysteria; large doses of strychnine, mix vomica, &c. It should be observed, that in many cases it is extremely difficult to determine the exciting cause, inasmuch as one or more of those we have enumerated may exist in the same individual, and in some instances the disease may probably be occasioned by their conjoined effect. Thus it has been noticed by almost every writer that tetanus is more frequent when individuals suffering from external inju- ries are also exposed to cold moist weather, or to sudden changes of temperature. The occurrence of fear and mental anguish under the same circumstances has often been thought by Hennen to occasion it. We can also readily understand that intestinal irritation or other causes may prove exciting causes, and that it may be attributed to an accidental scratch received before the accession of the symp- toms. Hence many of those cases which are reported to have followed wounds several weeks after they have been received may have arisen from' other causes of irritation, connected with the internal organs; and, on the other hand, it is possible that the wound which occasioned the disease may be overlooked. Anatomical Characters. The morbid appearances found in those who have died labouring under tetanus are very various. Not unfrequently no morbid le- sion whatever can be discovered to which the symptoms can.be referred. With a view to illustrate the pathology of the disease,, we shall describe the morbid al- terations that have been- observed, 1. in the brain and its membranes;. 2- in the spinal cord and its membranes; 3. in the nerves; and 4. in other parts of the system. 1. Numerous cases have been reported in which the vascularity of the brain and its membranes was increased, the sinuses gorged with blood,, the pia mater more or less injected, and the arachnoid cavity and ventricles more or less dis- tended by serous effusion. These appearances have been, occasionally observed by authors, who have had much opportunity of investigating the morbid, anatomy of tetanus. Dr. Bright found an incysted abscess the size of a large nutmeg in the substance of the middle lobe of the brain(Hospital Reports, case 39,) and Bouillaud several tubercles, one of which was as large as an egg, in the right he- misphere (sur VEncephalite.) Generally speaking, the substance of the brain is found healthy. 2. Alterations in the spinal cord and its membranes are by far the most com- mon appearances found after tetanus, and. in such cases there have generally been traces of spinal meningitis. These instances are too numerous to be spoken of individually.. Several have been recorded.by Reid, Kennedy, Brayne, and others in Britain; Larrey, Broussais, Magendie, Recamier, Ollivier, and othecs,. in France; Bergamaschi, Brera, Bellingeri, Uralli,.Poggi, in Italy; and Frank, Funk, &c. in Germany. Thomson (Phys.. Obs. on the Topography, &c. Philadelphia, 1818,) and Goelis (Salz. Med. Chir. Zeitung, 1815,) have observed the same appearances in infants who have died of trismus nascentium. In some cases the inflammatory appearances were more or less diffused over the spinal cord, and in others recorded by Ollivier, Pelletier, and Curling, they were limited to particular portions of it. Burserius found' a large quantity of viscid yellow serum under the outer covering of the medulla spinalis. Ollivier discovered in the dorsal re- gion of a child a red, consistent fluid in the cellular texture, between the dura mater of the cord and walls of the spinal column, with serous effusion Avithin the membranes, and an albuminous concretion covering four inches of the medullaof the cord. Bellingeri gives a case where blood was effused in the cellular tissue, exterior to the dura mater. Poggi and Combette, in addition to evidence of spinal Vol. II.—10 74 tetanus, (Nature.) meningitis, have observed softening confined to the anterior columns of the cord. Bony and cartilaginous deposites have been occasionally found in the membranes covering the spinal marrow after tetanus. In some instances, on the other hand, no morbid appearances have been detected either in the cord or its membranes. 3. In traumatic tetanus, the nerves in the neighbourhood of the wound have often been found more or less injured, or to have undergone morbid alterations. In certain cases they have been contused, lacerated, partially divided, irritated by spicula of bone, or other foreign substances included in ligatures placed on arte- ries, or participating in the inflammation of the surrounding textures. In the latter case, the appearances have differed according as the inflammatory action was acute or chronic; injection, more or less intense, and softening, being evi- dence of the former, and thickening, induration, and discoloration of the latter. Lobstein (De Nervi Sympalhetici, p. 152,) and Andral (Clin. Med., torn. i. p. 49,) have observed signs of inflammation or redness in the semi-lunar ganglion, and Swan (Diseases of the Nerves) has often seen the ganglia of the sympathetic sys- tem in general considerably injected—an appearance which has been occasionally observed by other authors. 4. Dupuytren found in an individual who died of opisthotonos the muscles gorged with blood and lacerated. Larrey and Curling give cases where one of the recti abdominis muscles was torn across. The pharynx and oesophagus were often seen by Larrey contracted, and their mucous membranes red, inflamed, and covered with a viscid reddish mucus. The large papillae at the root of the tongue have occasionally been found thickened, and the mucous lining of the larynx in- jected and covered with frothy mucus. Andral gives a case where unequivocal marks of gastritis were discovered, and M'Arthur found in four cases inflamma- tion of the alimentary canal, with a peculiar yellow matter covering the mucous membrane of the stomach and oesophagus, which in one case effervesced on being exposed to the external air. Worms have been discovered in the intestinal canal by Sauvages, Laurent, Larrey, O'Beirne, and others. The last writer states that distention of the caecum and colon is a constant pathological appearance. In a case related by Mr. Howship the heart was much indurated; and presented consi- derable resistence to the knife.* Nature. Numerous theories have been advanced to explain the different phe- nomena observed in tetanus, but as none of them appear to have been deduced from a sufficiently extended series of observations, they have been rejected as inapplicable to the end in view. We are unacquainted with any series of facts which explain why in some cases there should be trismus alone, and in others opisthotonos, or empros- thotonos, although in some few cases the increased vascularity of the spinal cord and its membranes have been circumscribed so as to involve more particularly the origin of those nerves which are distributed to the muscles especially acted on. These cases, however, are very rare, and observation has shown that in the majority of instances no such limited lesion can be discovered. That the motor portion of the fifth pair is morbidly stimulated in trismus, is highly probable, because we ob- serve the muscles to which it is distributed are those principally affected. But the proximate cause producing the irritation is not always discovered after death. Larrey thought that emprosthotonos or opisthotonos was occasioned according as * As in the majority of cases no morbid lesion can be discovered, and the alterations when they exist are extremely slight and irregular, it is very clear that no structural lesion is con- nected with tetanus. The alterations of tissue are purely accidental. I have examined with great attention the brain and spinal marrow of ten or twelve subjects, dead of tetanus, and ceuld not detect any organic lesion. That is, there is no softening of the spine, or injection of its vessels beyond what is often found in the bodies of individuals who have dh-d without spinal symptoms. The little experience of most physicians in examining the spine has led some into error in this matter, and induced them to admit the evidence of organic all • t* slight grounds. tetanus, (Nature.) > 75 the wound injured the nerves on the anterior or posterior part of the body, and that if the nerves in both situations were wounded, complete tetanus was esta- blished. Numerous facts, however, prove that there is no relation between the situation of the wound and the form of the disease. Bellengheri has brought for- ward an elaborate theory which consists in attributing to the cerebral hemi- spheres the power of producing one kind of motion, and to the cerebellum that of producing another. He considers that the former presides over flexion and ad- duction, and the latter over extension and abduction. This is what he denomi- nates " nervous antagonism," by which he thinks all motions throughout the body are governed. Thus, according to this author, opisthotonos or spasmodic exten- sion depends on some irritation or disease of the cerebellum and posterior columns of the spinal cord; while in emprosthotonos or spasmodic flexion, the hemispheres and anterior spinal columns are more particularly affected. These views, though they have been maintained with great ingenuity, are not only opposed to the phy- siology of the nervous system established by Sir C. Bell, but to the majority of pa- thological facts with which we are acquainted. It has been stated in general observations, that irritation of any part of the ner- vous substance will increase the function dependent on the part irritated. In tetanus, the intelligence and general sensibility are affected, while the character- istic symptom of the disorder is referrible to an augmentation of motor influence. We are therefore led to conclude, that irritation of the tractus motorius is a patho- logical condition necessary for the production of tetanus. Partial pressure, it is well known, is capable of producing irritation, whether applied to the spinal cord alone, in the course, or to the extremities of a nerve, and we find that morbid alteration or injury of either has been known to induce tetanus. The present state of science, however, does not enable us to indicate what particular morbid lesion occasions this irritation, which, with a view to treatment, is a point of pri- mary importance. When treating of spinal meningitis, we have seen that mus- cular rigidity is a diagnostic symptom of that disease, and the dissection of indi- viduals who have died labouring under tetanus has shown, that a vascular state of the membranes of the cord is by far the most common morbid lesion discovered. In many cases, however, no appearance of inflammation or increased vascularity is to be discovered; and it has been thought by some, that these appearances are rather the effects than the cause of the disease. However we may speculate on this point, proofs are wanted to establish the correctness of either opinion; but as we know that congestion of the blood-vessels surrounding the cord will occasion partial pressure, and consequently irritation, although it may not leave any traces of its existence after death, it seems reasonable to suppose that such a state more frequently precedes than follows the tetanic spasms. Pelletier and Bergamaschi attributed the disease to inflammation of the nerves of the part injured, extending to the spinal cord; and Mr. Swan having found the ganglia of the sympathetic system of nerves preternaturally injected, thinks that the various predisposing and exciting causes produced disorder of the digestive organs, which was communicated by the ganglionic nerves to the other parts of the nervous system. Either of these views are fully capable of explaining how in certain cases irritation may be induced in the spinal marrowy but observation does not warrant us in considering either one or the other the true cause of the disease. Indeed modern researches have not revealed to us what is the nature of the morbid lesion which gives rise to the irritation, and whether it be allied to inflammation or congestion is equally unknown. It should be observed that tetanus rarely follows the infliction of a wound im- mediately, that its occurrence bears no relation to the severity or extent of the injury, and that it cannot be produced artificially, except by the administration of poisons containing strychnia or brucia. These facts lead to the inference that, besides the local injury, there is a peculiar state of the system hitherto unknown and unexplained, which favours the production of tetanus, inasmuch as mechani- cal irritation of the motor tract, or of a nerve, does not produce tonic spasm, but 7G tetanus, (Diagnosis—Prognosis.) convulsion. We have also been satisfied from experiments on the frog, that strychnia acts through the medium of the circulation, and not by direct influence on the nerves to which they are applied. A similar conclusion has been arrived at by other experimentalists. It appears therefore that the great point with regard to the pathology of tetanus, is to determine the essential distinction between tonic spasm and clonic convul- sion, and the agents which induce the one or the other. The exciting causes which occasion the first, including wounds, the presence of worms, and other sources of irritation, much more frequently give rise to the second. To what are we to attribute the different result? No answer can be given to this question: it is evidently better therefore to abstain from hypothesis, acknowledge our igno- rance of the subject, and recommend it as a subject of experimental investigation. Diagnosis. Tetanus is readily distinguished from other maladies, by the continued muscular rigidity often suddenly increasing, the distortion of the coun- tenance, and the peculiar pain at the scrobiculus cordis. It has been sometimes closely simulated by hysteria; but the latter disorder is general in females, while tetanus as has been shown, is most common in males. In hysteria also the globus hystericus, the absence of distortion of the face, and the dissimilar exciting causes, are sufficient to indicate the disease. We have stated that sometimes in tetanus there is difficulty of swallowing and horror of liquids. Hydrophobia, however, may be distinguished from these cases by the absence of continued rigidity, and the nature of the spasms which are clonic and of short duration. In general also there is great excitement, and a peculiar anxious expression of coun- tenance very different from the distortion in tetanus. It is scarcely possible to confound this disease with any other. It is of great importance to discriminate whether tetanus arises spontaneously, or is the effect of poisons containing strychnia. This, however, is very difficult, as the symptoms are identically the same. If the poison be taken internally, there may be signs of unusual irritation in the digestive organs. The sudden occurrence of the disease in its acute form, when the individual has not received any wound, or been exposed to cold and moisture or sudden changes of tempe- rature, are circumstances that should excite suspicion, the truth of which can only be confirmed, during the life of the patient, by strong collateral evidence. Care should be taken to distinguish the trismus arising from local causes, a? inflammatory affections about the face and throat, turnouts at the base of the jaw, rheumatism of the temporal and masseter muscles, or the local inflammation arising from the administration of mercury. Prognosis. The prognosis is more unfavourable in the traumatic than in the idiopathic form of tetanus. The danger must also depend on the violence and fre- quency of the spasms, and the extent to which the muscular system is affected. The great fatality of traumatic tetanus is spoken of by all who have had extensive opportunities of witnessing the disease. Sir J. Macgregor, who saw several hun- dred cases in the campaigns of Spain and Portugal, witnessed very few recoveries, and Dr. O'Beirne did not see a single recovery out of 200 cases which came under his observation. Hennen, Dickson, Morgan, and others also allude to the uniform fatality of the disease in its acute traumatic form. Several instances of cure how- ever have been recorded. Sir G. Blane mentions that of twenty cases which oc- curred in the West Indies, after the action of April, 1782, three recovered. Of thirteen cases witnessed by Mr. Dickinson, surgeon at Grenada, four were cured, and many other instances are recorded by various authors. The idiopathic form is not so dangerous as the acute, but the recoveries bear no proportion to the deaths. The trismus nascentium of infants is uniformly fatal. The favourable circumstances are, a long interval between the occurrence of the exciting cause and the accession of the disorder; the slow progress of the dis- ease, and the patient surviving beyond the fourth day; the muscular spasms not being general, frequent, or severe; the respiration easy, and the pulse natural The unfavourable symptoms are, quick accession; general spasms and rigidity tetanus, (Treatment.) 77 rapid progress of the affection; violent paroxysms occurring frequently; urgent dyspnoea; rapid, thready, and imperceptible pulse; inability to swallow; cold and clammy perspiration; livid countenance; delirium, &c. Treatment. When our ignorance of the pathology of tetanus is taken into con- sideration, we need not feel surprised that the treatment has in the generality of cases been strictly empirical. Neither need we wonder that, while the most oppo- site remedies have been occasionally employed with apparent success, they have each in turn been rejected as unworthy of confidence. Not unfrequently several plans of treatment even opposed to each other have been employed in the same case, and such frequent changes made, that should the patient recover, it is impos- sible to determine which remedy has produced the beneficial result. 1. Treatment of idiopathic tetanus. In idiopathic tetanus attention should be paid to the constitution of the individual, and especially to the state of the vascular system, in order that the principles of treatment may be duly regulated. As a general rule, if the pulse is full and hard, the system plethoric, the tongue foul and dry, the individual of a strong constitution, the skin hot, or other symp- toms indicate increased vascular excitement, general or local blobd-letting, or if the symptoms be urgent, both general and local bleeding should be employed. This treatment is evidently indicated if there be pain in the back, or other symp- toms of inflammation in the spinal cord or its membranes. At the same time acute purgatives should be administered in order to remove all sources of irritation from the alimentary canal, and repeated if necessary, so as to procure copious evacua- tions. These means will generally lessen the force of the spasms when tetanus is connected with increased vascular action, which is not uncommon in the idiopathic tetanus. If the spasms continue after these measures have been adopted, sedatives in full doses should be administered. The cold affusion or the cold bath has sometimes been beneficial. If, notwithstanding these means diligently employed and a restricted diet, the symptoms continue, and the disease become chronic, oc- casional cupping and counter-irritants on the spine should be employed; in short, a treatment adopted somewhat similar to that recommended for chronic spinal meningitis. If, however, at the commencement of the disease, the patient be feeble and of a weak constitution, or spare habit, with a quick and small pulse, pallid face, and evidence of diminished vascular action, a tonic and stimulating plan of treatment should be had recourse to, combined with sedatives, if the spasms be severe; a generous diet should be allowed, the bowels kept regular if necessary by purga- tives with aromatics, and other remedies of a stimulating and tonic kind em- ployed. When the symptoms assume the form of trismus, a wedge of soft wood should be placed between the teeth, in order to prevent perfect closure of the jaws, and during the progress of the disease every kind of irritation that may occasion an increase or return of the spasms should be carefully guarded against. By adopting a method of treatment on the general principles laid down, we consider that the practitioner will best guard himself against the charge of empiricism, and by stea- dily pursuing it, will at the same time be most likely to overcome this formidable disease. 2. Treatment of symptomatic Tetanus. When we reflect on the numerous trivial injuries which the body may occasionally receive, and to which perhaps the attention is not drawn until the accession of the tetanic symptoms; when moreover the numerous sources of irritation that may exist in other organs, and more espe- cially in the alimentary canal, are considered, it seems very propable that many cases which have been reported as idiopathic are only symptomatic of some dis- order which has been entirely overlooked. Mr. Mitchell (Med. Chir. Trans., vol. v., p. 25.) relates a case in which tetanic spasms of the tongue and muscles of the face were removed by abstracting some carious teeth, and he alludes to a similar instance, which occurred under the care of Dr. Thomas. We saw under the care of Dr. Graham, in the Royal Infirmary of Edinburgh, a man affected with opistho- 78 tetanus, (Treatment.) tonos of an epileptic form, there being loss of consciousness during the paroxysm. In the fit the whole body was powerfully drawn backwards, perfectly rigid, and formed an arch which rested only on the head and heels. Dr. Graham discovered that the dens sapientia; on one side had not room enough to descend. The next tooth was extracted, and the spasms for a time entirely disappeared. We have since heard that the attacks returned, but that after undergoing a variety of treat- ment he recovered. Aware, therefore, that the disease may not only be occasioned, but in certain instances kept up, or rendered more severe by local irritation, the utmost pains should be taken to discover its source, and every effort employed, not only to obviate its effects, but remove its cause. If the suppression of the lo- chia, leucorrhcea, or other chronic discharges have preceded the attack, we should endeavour to promote their return, or establish some artificial drain in the neighbourhood, while any disposition to plethora or increased vascular action should be combated by local or general blood-letting. If there are any symptoms of worms, acute vermifuge remedies should be given both by the mouth and in clyster. A case of powerful trismus, with spasms of the face and abdominal mus- cles, is related by Dr. E. Phillips, which was relieved immediately by an injection of half an ounce of turpentine with yelk of egg. The following morning there was a copious stool, in which a worm was discovered, and the patient got well (Med. Chir. Trans., vol, vi. p. 65.) If the disease can be traced to checked perspiration, diaphoretics are indicated. Wounds, however, are the most frequent cause of symptomatic tetanus, and should in all cases be carefully examined, with the object of ascertaining whether there be any foreign body, in order that it may be at once removed. Whenever the symptoms appear a short time after the reception of a wound, and there can be no doubt that the wound is the exciting cause of the disease, all nervous com- munication between it and the spinal marrow should be cut off as soon as possible. It is a singular fact, that this practice, which our knowledge of pathology and physiology shows to be necessary, and likely to be successful, has only (as far as medical records go) been performed four or five times, but in all these with perfect success. In a case related by Dr. Murray {Trans, of Med. and Phys. Soc. of Calcutta) occasioned by a wound in the left foot, the posterior tibial nerve was divided, and although the patient could not articulate distinctly before, from the closure of the jaws, he immediately opened his mouth with an exclama- tion, and expressed himself as being benefited. He rapidly recovered. Ampu- tation has also been employed with varying success: surgeons, however, generally condemn this severe proceeding, except when the parts are much lacerated. Should the tetanic symptoms be advanced, it is inadmissible; and as the indica- tion for which it is employed can be answered by dividing the nerves going to the injured part, it may appear extraordinary that it has ever been had recourse to. It should also be kept in mind, that the disease having been once called into action, often continues independently of its local origin. While, therefore, our attention is directed to the exciting cause, we must pursue the constitutional treat- ment on the principles already laid down. The numerous remedies which have been recommended in the treatment of this disease have tended to produce great perplexitv. Much, however, may pi^- siby be attributed to the indiscriminate manner with which our most powerful medicines have been employed, and to the total absence of anv principle in their administration. So far from considering our resources as insufficient, we con- sider they are fully capable of fulfilling all the indications, if used with perse- verance and judgment. The sudden and astonishing cures that have been occasionally produced, when by accident a particular therapeutic remedv has been rightly administered, prove that our present want of success is not to be attributed to the inefficiency of the remedies employed, but to our ignorance of those symptoms in the patient which should direct their application A few remarks, therefore, on the individual remedies that have been resorted to may not be inappropriate. tetanus, {Treatment.) 79 Blood-letting is indicated in those cases which are attended with increased vascular excitement, and whenever there are evidences of inflammation in the spinal cord or its membranes. Under such circumstances, it generally dimi- nishes the force of the spasms. In a case where the pulse was full and strong, beating 140 in the minute, Mr. Earle repeatedly bled the patient, and there was remission of the spasms after every venesection. Wine and porter, however, were given to him by the friends, and he died. Vascular depletion has been carried to an extreme extent by some practitioners. From fourteen to fifteen pounds of blood were abstracted by M. Pelletier with success in a few days. (Rtv. Med., 1827.) In one case which recovered, M. Lisfranc bled eight times, and applied 792 leeches over the spine. (Diet, de Med. et Chir. Prat., art. Tetanus.) In a case of severe opisthotonos published by M. Larrey {Mem. de Med. et de Chir. Militaire, torn, xxxiv,) in the acute stage, which lasted twelve days, he bled four times, and applied 120 leeches to the spine with a like result: M. Carron of Lyons has cured four out of five cases by the same means. In such cases as indicate bleeding, when the malady is acute, as often occurs in traumatic tetanus, venesection should be pushed to such an extent as to produce a marked effect on the system, while leeches are applied to the spine. Purga- tives, opium, and other remedies, should be afterwards administered; and when all symptoms of increased vascular excitement have disappeared, the collapse is to be obviated by tonics and stimulants. Purgatives are of great utility in all forms of tetanus, with the view of removing any source of irritation that may exist in the intestines. Drastic purgatives should be avoided, as instead of removing irritation they often induce it. When vascu- lar excitement exists, this class of remedies may be used freely, so as to produce copious evacuations, and thus promote the effect of other antiphlogistic measures. For this purpose the more active purgatives, such as jalap, gamboge, scammony, &c, may be given. When the powers are depressed, croton or castor oil with turpentine or camphor, both by the mouth and by injection, is best adapted. Turpentine is especially beneficial whenever there are worms in the intestines, and as they often prove the source of irritation, without the patient being aware of the cause, an enema, consisting of an ounce of oil of turpentine with a sufficient quantity of gruel, or formed into an emulsion of yelk of egg, should be one of the first reme- dies employed. The constipation is occasionally very obstinate in tetanus, and purgatives have been given in very large doses, before any evacuation could be procured. Dr. Briggs has recorded an extraordinary case of this kind (Edin. Med. and Surg. Journ., vol. v. p. 141,) in which, in forty-eight hours, the patient took 210 grains of scammony, 89 grains of gamboge, an ounce and four scru- ples of. jalap, two pounds and a half of infusion of senna, and eight grains of calo- mel, with decided benefit. If the sphincter be spasmodically closed, so as to pre- vent the free passage of the fasces, an injection of the infusion of tobacco will for a time diminish the contraction, and tend also to relieve the excited state of the nervous system. When constipation is great, the tobacco enema may be tried, as the purgatives given may possibly produce the desired effect during the temporary relaxation induced by the action of the tobacco. At all times purgatives should be among the first remedies exhibited, as very little impression can be made upon the disease, until the bowels are- freely opened. The action of other remedies is also favoured by a free state of the alimentary canal, which should be maintained during the whole progress of the disease. It sometimes happens that it is difficult to give medicines by the mouth, from the powerful closure of the jaws. In gene- ral, however, one or two drops of croton oil mixed with a little butter can be inserted between the teeth, but if this cannot be effected, we must have recourse to clysters. Sedatives have been extensively employed in this disease with a view of lessen- ing the irritation and pain that exists. Opium has been given in enormous doses, without producing its accustomed effects on the system. Mr. Abernethy found 30 drachms of undissolved opium 80 tetanus, (Treatment.) in the stomach of an individual who died of tetanus; 20 grains of this substance has been given every three hours for several days. According to Begin, M. Blaise administered in ten days, 4 pounds, 7 oz., and 6 drachms of laudanum, and 6 oz., 4 drachms, and 45 grains of solid opium. Numerous other cases have been recorded where inordinate doses of this drug have been administered. Yet, although our experience of this medicine has been greater than that of any other, it has been so indiscriminately employed, both alone and in combination with other measures, that great uncertainty prevails regarding its value. On the whole it seems to have been more beneficial in idiopathic than in symptomatic tetanus. Its use has been advocated by Larrey, and opposed by Fourneir Pescay, Rush, and Macgregor. Extensive experience, moreover, has shown that it is a remedy in no way to be depended on, while we are unacquainted with any particular indications that should render its use more applicable in one case than in another. There does not appear to be any necessity for administering the extravagantly large doses so often recommended, and when employed, one or two grains should be given every hour, and this quantity doubled in six hours, if no good effect be produced. In the form of laudanum the minute division favours its operation; from one to two drachms may be given every hour, this quantity being also doubled in six hours if necessary. It may also be given in the form of enema, in half an ounce to two ounces of the tincture, or from 10 to 30 grains of solid opium. The preparations of morphia have not yet been extensively tried in this disease, though there is every probability that they will prove of much service as opium, if not greater. M. Lambert has used it successfully in two cases by the endermic method, and M. Carioli has cured a case of traumatic tetanus in this way: the intense sedative action produced by tobacco has led to its administra- tion in tetanus, and its- effect seems to be more powerful and decided than that of opium in lessening nervous irritation, diminishing the force of the pulse, pro- ducing nausea, perspiration, and sometimes sleep. . Dr. O'Beirne administered it in the form of enema, consisting of a scruple of the leaves infused in eight ounces of water, with the effect of at once producing relaxation of the muscles. On dis- continuing the remedy, the spasms returned, but on resuming its use, ameliora- tion again took place. From this time the enema was repeated two or three times a-day, sometimes oftener, and continued for eighteen days. The patient completely recovered. (Dub. Hosp. Rep,, vol. iii.) Dr. Anderson, in addition to a decoction of the fresh leaves used as an enema, employed it in the form of bath. Of five cases treated in this way, four recovered. (Med. Chir. Trans. ofEdin., vols. i. and ii.) Several other cases have been recorded in which its beneficial effects have been well marked in tetanus; and so far as our present experience of it has extended, it appears to be the most efficient remedy of this class. The best form of administration is that of enema, of the strength used by Dr. O'Beirne, which should be repeated sufficiently often to keep the system under its influence. Care must be taken not to increase the dose too suddenly, as such prostration may be occasioned as to prove fatal. At all times a most distressing feeling of sinking and depression is induced. It should be remembered also, that some indi- viduals are more susceptible than others to its effects, and that sailors and persons addicted to its use require a larger dose. Antimony from its well known depressing effect has been employed in cases where vascular excitement is well marked. Its tendency to occasion vomiting is a powerful objection to its use, an effect which often aggravates the disease, and increases the severity of the spasms. Mr. Liston speaks of a case in which it was successful (Lancet, 1831-5,) and another is recorded by Mr. Woodward (Dub. Journ., 1835.) ^ Hydrocyanic acid has been recommended by Mr. Ward of Gloucester (Obs. on Tetanus, 1835,) who gave a drop and a half of it every half hour to a girl labour- ing under the disease, who ultimately recovered. We have very little experience of this remedy, and its sedative action is by no means so certain or manageable as tetanus, (Treatment.) 81 that of opium or tobacco. Digitalis, stramonium, belladonna, hyosciamus, and co- nium, have been tried, and found comparatively inert. The effects of the cold affusion are very similar to those of tobacco, namely, great prostration and temporary relaxation of the muscles. It has been strongly recommended by Drs. Wright, Currie, and Rush, who thought it a tonic remedy, and several cases have been recorded in which it has been the apparent means of recovery. Three in particular related by Dr. Doue {Nour. Bill Med., March, 1818,) shows its beneficial action when energetically employed. In other instances, however, it has failed, and in a few has occasioned sudden death. Dr. Elliot- son gives an instance, and Mr. Morgan relates another, in which the patient, on being plunged into the cold bath, died immediately. The most powerful effect is produced by pouring several buckets of cold water from a considerable height over the individual, in a continued stream. Syncope is often produced by these means, so that stimulants should be at hand, and the patient after being wiped dry, placed in warm blankets. As he recovers, the stimulants should be discontinued, and, if the spasms return, the cold affusion repeated. A less powerful effect is produced by plunging the patient into the cold bath, or dashing cold water on the body. In the present state of our knowledge cold appears, when properly applied, to be one of the most active and useful agents we possess. It has been most bene- ficial in the idiopathic forms of the disease. Tonics and stimulants have been recommended by Drs. Wright, Currie, Rush, Bright, and others; and whenever there are signs of debility, either at the com- mencement or in the course of the disease, they are directly indicated. Rush gave wine and bark liberally with occasional success. In a remarkable case given by Dr. Currie (Med. Rep. vol. i. p. 148,) the patient took 140 bottles of Madeira wine in less than a month, taking generally every twenty-four hours four or five bottles with two gallons of strong broth, some ale and brandy, and two drachms and a half of laudanum. Laudanum and ether embrocations with the tepid bath were also used. The recovery was slow. Spirits, wine, and ale, may be given in large quantities without producing their accustomed effects, although Dr. Cross is report- ed, when other medicines had failed, to have kept the patient for ten days in a state of intoxication with spirits, and, singular to relate, with the result of a perfect recovery. (Good's Study of Med., vol. iii. p. 268.) Fournier Pescay recommends musk, which he has used with success in doses of 10 or 12 grains every hour. Mr. S. Cooper however states, that 120 grains were given to a young girl in the space of twelve hours without producing any benefit. (Surg. Diet., art. Tetanus.) Fournier Pescay gives some cases which were cured by M. Francois with ammonia. Carbonate of iron has been employed by Dr. Elliotson from an analogy he considers to exist between this disease and hysteria and chorea. (Med. Chir. Trans., vol. xv. p. 161.) Recovery took place in two cases out of three. Dr. Dehayne of Wolverhampton gave a pound daily, and the patient got well. A larger dose than two drachms appears unnecessary, and in acute cases the remedy is inadmissible on account of the time necessary for its effects to be manifested. Quinine has also been given extensively in con- junction with stimulants and tonics. Dr. Bright has published a case that termi- nated successfully, in which in the course of twenty days the patient took two ounces of the sulphate of quinine, and drank daily from fourteen to twenty ounces of wine, besides taking brandy and ammonia. Guy's Hospital Reports, vol. i. p. 111.) In this as well as in the generality of cases where a tonic and stimulating line of treatment has been pursued, opium was also given, so that it is impossible to know whether the recovery is attributable to any one particular remedy, or to the com- bined treatment. Preparations of zinc and iron and other tonics have been re- commended. Sudorifics are indicated in chronic cases when the disease arises from any sudden check to the perspiration. The vapour bath has been recommended by Dr. Marsh (Dub. Hos. Rep., vol. iv. p. 567,) who has given two cases which reco- vered apparently by its use. We have seen a case successfully treated in this way Vol. II.—II 82 tetanls, (Treatment.) by M. Sanson at La Pitie, and other instances are recorded. (Journ. Heb. de Med., 1828.) Its trial has not been very extensive; for as it is necessary to keep the patient in the bath for a long time, its use seems inadmissible in acute cases. The warm bath may be useful in chronic cases, as it relieves the rigidity and un- easiness which is sometimes present. In acute tetanus it is of little service, and instances are recorded where it produced sudden death. It is highly spoken of by Bajon, Chalmers, and Boyer. Fournier Pescay and Stutz used medicated baths containing the deutoxide of potassium and lime, combined with the internal adminis- tration of opium. Dr. Latham recommended Dover's powder, which in some cases has also been beneficial. A diaphoretic treatment, with small doses of opium gradually increased, and alkaline baths, have proved successful in the hands of M. Fritz of Prague. Among the other remedies which have been employed, mercury has been ex- tensively given, although on what principle it is difficult to explain; for although it tends to lessen inflammation, and sometimes acts as a stimulant, we possess better and more powerful remedies for these purposes. Whenever success has attended the use of this mineral, it has been combined with opium or some other remedy, so that it is impossible to speak decidedly as to its effects. Mr. Curhng has seen two cases where the ptyalism it occasioned, produced great suffering and in which the patients were compelled to keep their lips constantly open with their fingers, in order to prevent the suffocating paroxysms consequent upon attempting to swallow the saliva. Camphor, from its combined narcotic and stimulant properties, may be given in some cases with benefit, particularly in the form of enema. Combined with opium it is much praised by Larry. Colchicum has been given with partial success by Drs. Smith and Dufresnoy, combined with opium. Injection into the veins of a watery solution of opium and stramonium has been employed by MM. Percy and Laurent. Dazille recommends ether. Counter-irritants applied to the spine are beneficial in chronic cases. M. Cru- veilhier apparently cured a patient in whom the hiccough and spasms were very distressing, by constant pressure on the abdomen. (Rev. Med. Avril, 1824.) Other remedies have been recommended and occasionally tried, such as phos- phorus, electricity, strychnine, acupuncture, &c, but we have no proof of their efficacy. In all cases of tetanus the diet should be light, consisting of soups, gruel. &c. It should be antiphlogistic when there are symptoms of excitement, and nourishing when the vital powers are depressed. It is not always easy to give the patient sufficient nourishment, as sometimes the teeth are so firmly closed, that no substance whatever can be introduced: in other instances all attempts to swallow bring on the most violent spasms. In the former case, liquid food may be introduced into the stomach through a tube passed into the stomach by the nostrils, and in the latter the spasmodic action should be overcome by tobacco injections, and advantage taken of the period of prostration to give food. Articles of nourishment may also be thrown into the intestines by the svringe. f 83 ) HYDROPHOBIA. Definition of the disease.—Premonitory symptoms.—Symptoms of the attack.—Various modi- fications observed in the symptoms in the human subject.—Symptoms of rabies in the dog. —Predisposing causes.—Exciting causes.— Nature.—Anatomical characters.—Diagnosis.— Prognosis.—Prophylactic or preventive treatment.—Curative treatment. The disease termed hydrophobia from (v$ap, water, and first recommended by Dessault, and afterwards by James, Kaltschmid, Du Choi- sel, Andry, Sebig, Konigsdorfer, Walther, and others. Its beneficial effects are wholly denied by Frank, Girtanner, De Moneta, Raymond and several other hydrophobia, (Treatment.) 97 writers, and experience has proved it has little power in controlling the symp- toms. Arsenic has been given by Dr. Marcet, combined with opium and iron, without benefit. Of sudorific remedies, sweating by means of heated air has been recommended, but the time necessary to produce any effect on the system by these means is apparently hostile to its use. Diuretics have been highly extolled, especially cantharides, which has been employed for many age3 in this disorder, and has been much praised as a prophylactic, by Axter of Vienna. Emetics have been occasionally given. Dr. Satterly thought them advantageous in a case in which they were employed by him. (Med. Trans, of the Coll. of Phys., vol. iv.) Purgatives should be given to procure the necessary alvine discharges, but do not appear to have been much relied on by practitioners. Injection of warm water into the veins has been tried by Magendie, from his having observed nervous debility produced in animals which had been subjected to it, and that the fluid parts of the blood were diminished by the impossibility of taking fluids, and the great cutaneous and pulmonary transpiration. A pint of water heated to 30° Reaumur was injected into the arm of a man labouring under advanced and violent hydrophobia. Immediately after the operation the patient became tranquil, and the pulse fell in twenty minutes from 150 to 80. The spasms ceased, and the individual drank a glass of water without difficulty. He conti- nued to improve until the fifth day, when swellings and acute pains in the wrists, knees, and elbows, appeared, and an abscess formed in the leg, occasioned by the broken points of two lancets, which remained in the foot, from former unsuc- cessful efforts to bleed. He died on the ninth day. The swollen joints, were found filled with pus, and it is probable these secondary purulent deposites were the cause of death. Dr. Pearson recommended the injection of warm water in small quantities, impregnated with narcotic substances, into the veins, in order to relieve the spasms which prevent deglutition, followed up by cathartics, antispas- modics, the mineral and vegetable tonics, and sponging the body with cold water and vinegar. Tracheotomy has been proposed by Mr. Mayo as an expedient in this disease. Dr. Hunter speaks of two cases benefited by running. Several other remedies, supposed to act as specifics, have been employed. The ash-coloured liverwort was formerly so popular, as to be admitted into the London Pharmacopoeia of 1721, under tiie name of Pulvis Antilyssus. The thalictrum flavum and angustifolium, and the delphinum consolida, are plants which were considered specific in some parts of Russia. (Med. Repos., vol. ii. p. 153.) The guaco juice has been recommended by Sir Robert Kerr, but has been found inert in several cases. In America, the sartellaria laterifolia has been extolled by Dr. Spalding. The bite of a viper has been tried in some cases, with the idea that the venom of this animal would counteract the rabid virus. (Diet, des Sciences Med.) The alysma plantago, ophiorrhiza mungos, genista tinctoria, have been praised, as well as phosphorated water, soap lees, and other remedies, which are now aban- doned. In the midst of so many remedies which have been lauded by partisans, and in turn found to be useless—with a knowledge that the most powerful drugs are apparently inert—overwhelmed with the sad conviction that the learning and talents of the most experienced and energetic physicians have utterly failed in arresting the progress of this dreadful malady, the practitioner, when called upon to act, must still respond to the awful question—What is to be done] It is in such a situation only that he can experience the benefit of having studied the whole train of nervous diseases, of being able to detect and appreciate the ana- logies and dissimilarities which exist between each respectively, and of having de- duced from the whole such general principles, as will enable him to act conscien- tiously in every case, as far as the present state of the art will permit. In hydro- phobia, therefore, as in tetanus, and several other nervous disorders, no exclusive line of treatment should be followed. If the patient exhibit signs of plethora, be Vol. II.—13 98 hydrophobia, (Treatment.) strong, of a vigorous constitution, and there be symptoms of increased vascular excitement, venesection, cupping, or the application of leeches to the occiput or back of the neck, and antiphlogistic remedies should be actively employed, so as to make an impression upon the nervous system. But if there be evi- dence of anaemia, and general depression of the vital powers, stimulants and tonics are indicated, and should be used energetically. With a view of overcoming the spasms, the tobacco enema, or cold affusion, may be had recourse to accord- ing to circumstances; and the same kind of treatment should be persevered in, as has been recommended for acute tetanus. (See Tetanus.) ( 99 ) NEURALGIA. Definition.—Symptoms.—Varieties.—Diagnosis.—Caure3.—Nature.—Treatment. The term Neuralgia (derived from nvpn, a nerve, and «Ay«s, pain,) is applied to a painful affection in the course of a nerve, not necessarily referrible to inflam- mation or to any appreciable organic change. The pain is in some instances confined to the trunk of a nerve, in others extends to the branches, and occasion- ally proceeds from the branches to the trunk. It is sudden in its onset, often commencing with, rather than acquiring by degrees, its full intensity. The patient is usually at a loss for words fully to describe the suffering, but often speaks of it as shooting, stabbing, or scalding. The pain is in most instances aggravated by a slight touch, but relieved by firm pressure. It may be inter- mittent, remittent, or without a distinct interval. Intermission is a more frequent characteristic than is usually supposed, and it commonly attends neuralgia from mechanical injury. The attack is often ushered in by numbness, or a sensation of creeping or pricking in the part affected; and its cessation may be preceded by itching. Exalted sensibility of the part, muscular agitation, cramp, and even tetanic stiffness, may follow. The phenomena are in some degree diversified according to the peculiar function of the suffering organ. In the intervals between the paroxysms, a sensation of obtuse pain or numbness may be experienced, or there may be perfect freedom from all uneasy feeling. The accessions gradually become more and more violent, and the intermissions less defined, till at last the patient enjoys no immunity from suffering, except when under the stupefying influence of sedatives. A severe case of this description probably occasions the greatest degree of anguish to which the human body is liable; and in its full ex- tent of duration and intensity, is perhaps " beyond the endurance of human for- titude." Hippocrates and Galen appear to have confounded tic douloureux with tooth- ach, and to have described other neuralgic affections as varieties of gout and rheumatism. Andre, in 1756, in a work on a very different subject, introduced remarks showing his knowledge of their separate character. Contunnius, in 1770, specified the discriminating marks between gout and sciatica, and described with considerable accuracy the cubito-digital variety of neuralgia. His observations were followed by those of Fothergill, Pujol, Thouret, and Fortsmann on tic douloureux. But the views entertained of the affection were very incomplete until Chaussier, in 1802, first introduced the name neuralgia, accurately described the disorder as affecting the nervous cords, and gave a faithful account of several varieties. Since the publication of Chaussier's remarks, the disease has attracted a degree of attention, in some degree commensurate with its importance. It is now generally allowed not to be limited to any particular part of the body; and evidence is continually accumulating in support of the opinion of M. Jolly, that as wherever there is blood there may be inflammation, so wherever there is a nerve, there may be neuralgia. We cannot deny even to the ganglionic system of nerves, a liability to exalted sensibility. Cruveilhier has shown by experi- 100 neuralgia, (Symptoms.) ment, that spasmodic cough may be produced by irritation of the pneumo-gastric nerve. Various affections, such as asthma, dyspnoea, pertussis, and nervous vomiting, have been referred to a similar condition by Pinel, Delens, Bland, and Lobstein. Laennec attributed angina pectoris to a similar source. Legond has written an interesting monograph on colica pictonum, describing it as a neuralgic affection of the sympathetic nerve. Gastrodynia, and various analogous dis- orders, have also been traced to a similar condition by Teale, Marshall, Griffin, and others, in our own country. On these interesting subjects it may be suffi- cient to mention, that such affections of ganglionic nerves are generally attended with altered or increased secretion of associated organs; that they are more fre- quent in women; and that the exacerbations, according to Jolly, instead of occur- ring, as in ordinary neuralgia, chiefly in the evening, appear at night or early in the morning. There is no reason to believe, that any of the nerves of the cerebro-spinal system, from the root to the ramifications, enjoy immunity from neuralgia. A severe variety of headach (termed cerebralgia) appears to depend on a neuralgic condition of the membranes of the brain. A similar state of the membranes of the spinal cord occasionally exists, and may be associated with alterations of the voice, spasm of the oesophagus, cough, dyspnoea, vomiting,, colic, cramp, &c. (Nouv. Biblioth. Med., 1827. Gassaud and Costa.) The sub-cutaneous nerves, especially those of parts provided with numerous muscles, are, however, most subject to the disease; and the most frequent seat of the intense form is the head and face, in consequence of the number and sensi- tiveness of the nerves in this situation, as well as their superficial arrangement, and perhaps, also, from their intimate connexion with the sympathetic, and con- sequent susceptibility of impression from conditions of the abdominal viscera. Bell and Shaw have questioned the liability of the portio dura to neuralgia, but there is reason to believe that its branches are occasionally affected, although much less frequently than those of the fifth pair of nerves. In forty cases related by Bellingheri, thirty-eight affected the fifth pair; only two the portio dura. It is the third branch of the fifth pair which is most liable to this distressing com- plaint in its most intense form; and to this variety, from the suddenness of its onset, the term tic douloureux was originally given by Andre. It constitutes the dolor faciei of Fothergill and Fortsmann, the dolor faciei typico charactere of Siebold, the neuralgia facialis of Chaussier, neuralgia spasmodica of Kerrison. It is denominated trismus clonicus by Ackamann, trismus dolorificus by Sauvages, hemicrania idiopathica by Darwin, rhumatismus canerosus by Vogel, febris topica by Van Swieten, opthalmodynia periodica by Plenck, and bv others proso- palgia, dolor faciei atrox, SfC. When the supraorbital branch is affected, we generally find redness, sensibility, and pain of the eye, shedding of tears,* swell- ing of the veins, and throbbing of the arteries in the neighbourhood. The attack generally comes on in the evening, and lasts most of the night: sometimes the affection is confined to the eyeball, constituting a severe variety of neuralgia, which has been well described by Mr. Middlemore: the pain is usually intermit- tent. There is great intolerance of light, especially during the paroxysms, and the pupil is in most cases contracted. When the suborbital nerve suffers, the pain may be confined to the eyelid, or it may extend to the dental branch, in- volving the maxillary sinus, palate, base of the tongue, and side of the face, and through the communications of this nerve with the portia dura, convulsive actions of the lid, cheeks, and upper lip, may be produced. Shedding of tears and ex- cretion of nasal mucus are common accompaniments,! but sometimes these parts are remarkably dry. r When the maxillary branch is the seat chiefly implicated, the teeth or their * It is remarkable that cases which have involved the lachrymal glands often leave a lia- bility to shed tears even during sleep and in the absence of emotion.—Author. t Dr. Macculloch on one occasion observed a pint of mucus to distil from the nostrils in a short space of time.—Author. neuralgia, (Symptoms.) 101 sockets, the sides of the tongue, the lips, and chin, suffer. This is said to be the least regular in its progress of all the varieties of facial neuralgia, and to affect the right more frequently than the left side. When associated with trismus, or with lateral distortion of the face, the disorder may be more obstinate, but the pain is generally less severe. Sometimes the complaint is limited to a single nervous twig, as to the labial, dental, or palpebral; but in other instances it ex- tends to the neighbouring parts: it is generally confined to one side, but some- times attacks both sides together, or passes alternately from one side to the other. In all these varieties the first attacks of pain may be so slight as to attract little attention, but their severity gradually increases. The duration of the paroxysm may be only a few seconds, and seldom exceeds a minute. Sometimes repeated attacks occur in a few minutes, at other times the intervals are considerable. The suddenness of the pain stops abruptly any conversation in which the patient may be engaged; and rocking in his chair, or writhing with anguish, he places his hand on the face, which he beats, rubs, or presses. He knits the brow, compresses the eyelids, draws up the lips into a sardonic grin, and fears either to speak or to masticate. When the complaint has been long protracted the appetite fails, a feverish state arises, the patient obtains no rest, except under the influence of opiates, and sometimes becomes delirious from the violence of the pain. The affection described by Itard under the name of Otalgia, and which is peculiarly apt to occur in infants and in children shedding the first set of teeth, evidently belongs to this class of disorders, differing from otitis in the lancinating and intermittent character of the pain and the absence of fever. The paroxysm is frequently accompanied with deafness, and when existing in adults, otalgia often associated with facial neuralgia. The cervical nerves have been occasionally affected with this disorder, in con- sequence of injury occasioned either by the application of leeches {Nouv. Bibl. Med., 1827,) or from a wound received in the operation of opening the jugular vein. Of the intercostal nerves, that which runs between the eighth and ninth ribs is most liable to suffer, particularly in women. A neuralgic condition of the lumbar nerves, constituting one of the most important varieties of lumbago, has been denominated illioscrotal and spermatic: the anus, spermatic cord, scrotum, and ureter, are the parts chiefly affected; and in women the vulva: the cubito- digital variety of neuralgia described by Cotugno and Chaussier is the most frequent to which the upper extremities are subject. The pain passes between the olecranon and tubercle of the humerus, and runs down to the fore-finger and to that adjoining. The femoro-popliteal (commonly called sciatica) is perhaps the most common, and the best known. The pain sometimes seems to arise from the ischiatic notch; at other times from the origin of the sacral nerves, some of the divisions of which it follows. It is particularly liable to occur in pregnant women, in consequence of the pressure of the gravid uterus. Neuralgia of the plantar nerve has been known to alternate with that of the facial. These varieties have been mentioned as among the most frequent affections of single nerves, and it is unnecessary farther to extend the enumeration. Parenchymatous, muscular, and membranous structures are also liable to be affected. Hepatalgia and hysteralgia may be mentioned as examples of neuralgia of parenchymatous tissue. The bruised feeling attending fever, and the muscular pains depending on atmospheric vicissitudes, are examples of muscular neuralgia. To the membranous variety may be referred some intensely painful affections of the pleura and peritoneum, occasional examples of wandering gout, and not a few of the affections of the periosteum, often attributed to syphilis or mercury. Neuralgic affections of the joints might be noticed as instances of membranous neuralgia, but they occur most frequently in persons subject to hysteria, and 102 neuralgia, (Diagnosis.) have therefore been described in the dissertation on that complaint. Some inter- mittent affections of the nostrils, bronchial tubes, and conjunctive membranes, as well as of the urethra, may be arranged in the same division. A tertian variety affecting the last-mentioned part, has been described by Professor Fulci. Neu- ralgia of the rectum occasionally occurs: in a case described by Busche, it existed only during the first three months of pregnancy. A neuralgic condition of the skin may present itself, sometimes as a symptom of internal disease, at other times as a primary disorder. The " epidemie de Paris," which occurred in the spring of 1828, and which is described by Chomel in the Journal Hebdomodaire, No. ix., affords a remarkable example of cutaneous neuralgia: it began in persons previously healthy, with sensations of pricking, severe pain, and acute sensibility of the integuments of the hands and feet; subsequently the sensibility of the affected parts was diminished or abolished, but in most instances was gradually and spontaneously restored. Herpes and other eruptions are occasionally preceded by pain of a neuralgic character. Glandular organs sometimes suffer severely from the complaint. The liability of the lachrymal gland to the malady has been already noticed. Sir A. Cooper has accurately described neuralgia of the mamma, under the designation of " the irritable breast."' It is almost confined to patients between the age of fifteen and thirty. Sometimes both breasts are affected, at other times onlv part of one. In cases of long duration, the gland is sometimes slightly enlarged, but in most in- stances is not visibly altered. The pain darts like electricity into the part, shoots to the axilla, shoulder, inner side of the elbow and fingers, or passes by the sides of the body to the hip. There are alternate feelings of heat and cold in the part. The patient is unable to rest on the side affected, and the weight of the breast sometimes occasions intense pain. One or more lobes are exquisitelv tender, and very severe pain, often of some hours' duration, is produced by handling them. Vomiting is sometimes induced by sympathetic disturbance of the stomach. The complaint may continue for months or years without intermission. An interesting example of neuralgia of the kidneys has been described by Dr. Macculloch. It assumed an intermittent character, and the secretion of urine during the fit was more abundant than in diabetes. When the testis is affected with neuralgia, some part of that organ, or of the epididymis, is exquisitely tender, so as to oblige the patient to rest in the recum- bent posture, and on the side opposite to that affected. The increase of pain pro- duced by pressure or motion, sometimes continues for a considerable time after- wards. Sympathetic vomiting is sometimes excited by the violence of the pain. A variety of neuralgia depending on a small tumor involving the nervous struc- ture has been remarked by Camper (Demonst. Anat. Pathol., lib. i.,) Cheselden and Bisset (Mem. of Med. Soc. of Lond., vol. iii; Med. Farts and Obs , vol vi,) but was first fully described by Mr. William W ood (Edin. Med. and Surg. Journ., vol. vm.,) under the denomination of "painful sub-cutaneous tubercle!" The pain occurs in paroxysms, lasting from ten minutes to two hours, gradually increasing in severity, and leaving a bruised feeling. The pain is increased by changes of atmosphere. It is also produced, or, if previously existing is much aggravated by pressure. The complaint is most common in women? and in a case related by Dr. Bisset, was invariably more severe during preo-naney Angina pectoris is probably a neuralgic affection of some of the^ardiac nerves, sometimes arising from mechanical irritation, occasioned by oro-anic diseise of the heart or its vessels; but this subject is still involved in uncertainty It may be questioned, whether any of the affections which have been desig- nated Gastralgia and Enteralgia can be stricuV considered neurale-ic Diagnosis. The exquisite form of neuralgia is readily distinffuished from every other malady by the nature of the pain, and by the suddenne W its onsd In less severe attacks, the situation of the pain in the course of a • rally sufficiently characteristic. In neuritis there is decided tenderness6 o/firm" neuralgia, (Nature.) 103 pressure, with heat, redness, and other signs of inflammation, and without the sensation of coldness, so common in neuralgia. It is, however, important to re- member, that inflammation of a nerve may occasionally precede or accompany neuralgia. The pain produced by otitis is less lancinating and intermittent than that of otalgia, and is not relieved by the introduction of anodynes into the ear. The pain of common toothach is more constant, is increased by touching with a me- tallic instrument, and is often attended with swelling of the gums. But it must not be forgotten, that the neuralgic variety of toothach is by no means uncom- mon: it may attend or alternate with other forms of neuralgia, is produced by the same causes, and resembles them in the nature of the pain. The pain of rheu- matism is usually gnawing, pungent, continuous, or remittent, while that of neu- ralgia is lancinating or thrilling, periodical, and often relieved by pressure. Causes. Among the predisposing causes may be mentioned the nervous tem- perament, adult age, residence in marshy countries, intellectual exertion, moral emotions, and long-continued watching. Dr Baillie and others agree, that the disease has lately become more frequent than formerly; and, although a more ac- curate diagnosis, by separating the disease from rheumatism, may have conduced to the apparent increase of frequency, yet there is good reason to believe, that the anxieties associated with a state of progressive civilization have increased the pre- valence of the affections. The question, whether one sex be more subject than the other to this disorder, must be considered as undetermined, Andre, Bailie, Samuel Fothergill, Sauvages, and Barnard, considering it more frequent in men, while Pujol, John Fothergill, and Hutchinson, regard it as more common in wo- men. The observations of Thouret, however, strongly support the former opi- nion. He examined the question with' considerable care, and found that of the cases which fell under his observation, the proportion of men to that of women suffering from the complaint was as two to one. The disease may be induced by any cause which deranges the digestive organs, or which disturbs the' balance of the circulation. Long fasting, or free bleeding for the cure of inflammation, may be followed by a paroxysm; occasionally, the opposite condition of plethora may produce it. Of the exciting causes most commonly enumerated, viz., blows, fright, suppres- sion of sanguineous discharges, currents of cold air and damp, the last is probably the most efficient. Of forty cases described by Bellingheri, two were attributed to fright, two' to wounds, two to suppressed discharges, and thirty-four to damp. All the forms of the complaint prevail most in spring, and during easterly winds. Neuralgic ophthalmia is most frequently met with in places where inter- mittents are common : it is, for example, prevalent on the coasts of the Mediter- ranean, at Tripoli, and on the shores of Barbary, at Rome, Naples, and Florence, and at Valentia and Albatera. In connexion with the relation existing between neuralgia and toothach, it may be interesting to mention the observation of Captain Smyth at Villa Cidro in Sardinia, that the women who cultivate the marshy plain are noted for bad teeth, while those of the men who reside on the mountains are remarkably sound. Haemorrhoids and stricture of the urethra sometimes in- duce a liability to neuralgic affections, particularly of the lower extremities. JVature. The opinion of Cabanis and of many of the ancients, that the dis- order depends upon an arrest of the nervous fluid, although founded on an as- sumption, has the support of many of the moderns, and is not without plausibi- lity. Whatever may be the nature of the nervous influence, its proportionate distribution among the organs of sensation, motion, and intelligence, seems to be es- sential to the healthy state. Many phenomena are most readily explicable on the supposition of a change in the direction of the nervous energy. It is, perhaps, through the intervention of such a change, that pain and convulsion tend to counteract each other, while delirium and drunkenness may suspend both; but we pass from these speculative views to notice the appreciable lesions which have been found associated with the disease. 104 neuralgia, (Nature.) Cotunnius, Dr. Sayer, and others, have observed a gelatinous secretion under the neurilemma of affected nerves. Cirillo attached importance to thickening of this structure; a condition which was also observed by Mr. Earle in the portion of the ulnar nerve, which he removed in a case of neuralgia of the arm. Such appearances must, however, be allowed to be only occasional, probably dependent on long-continued disease, and more frequently associated with rheumatic af- fections than with true neuralgia. Enlargement of the vessels of affected nerves is a much more frequent occur- rence. It was described as an accompaniment of the complaint by Bichat and Van de Keer, and, during the late war, was frequently detected in those who had suffered from sciatica. It is probable that in cases of shorter continuance, such a condition may have existed, but have disappeared after death. We have often observed venous congestion about superficial nerves, affected with neural- gia. The necessity for a balance between the arterial and venous system to pre- serve the healthy condition of nerves, and the fact that these affections are often relieved by warmth, are favourable to the opinion that this congestive state may frequently exist. At the same time it must be acknowledged, that such a state does not appear essential, since in cases of long duration, examined after death by distinguished pathologists, such as Chaussier, Desault, Cooper, Andral, and Rousset, the nerve has been found in appearance perfectly healthy. In several instances some irritating cause has been discovered between the part to which the pain is referred and the nervous centre. A case of fourteen years' duration is described by Mr. Jeffries, depending on irritation from a piece of china imbedded in the face, and which was immediately cured by the removal of the foreign body. Sir H. Halford, in his interesting essay on tic douloureux, has re- lated a case produced by exostosis arising from a sound tooth, and has referred to cases in which disease of bony canals through which nerves pass, or spicute of bone pressing upon nerves, have been associated with neuralgia. In an ex- ample of tic douloureux, which occurred at the Richmond Hospital, in Dublin, the gasserian ganglion was fibro-cartilaginous, and as large as a nutmeg. In some instances the irritation is communicated from distant nerves by sympathy, as in the case described by Mr. Lawrence, in which neuralgia of the thumb was occa- sioned by the pressure of a pivot tooth on the nerve of an old fang. Various causes of irritation affecting any part of the cerebrospinal axis seem capable of producing the complaint. Dr. Marshall has related some remarkable instances, in which aneurism of the aorta had occasioned absorption of the bodies of some of the vertebrae, and produced pressure on the spinal cord, but without oc- casioning any observable change in its structure. In one of these cases, in which the arch of the aorta was affected, and the bodies of the fifth, sixth, and seventh dorsal vertebrae were absorbed, the patient frequently suffered from a sensation, as though struck forcibly with the fist or by an electrical shock on the fifth, sixth, and seventh ribs of the left side, and afterwards felt as if burnt in that situation with a hot iron. In another case, in which the descending aorta was affected, similar shocks, followed by a burning sensation, were experienced to the left of the luiea alba It is worthy of notice, that, in both these patients, drawing a silk handkerchief, however lightly, over the affected parts from the mesial to the dorsal aspect, occasioned intense agony, whilst drawing the handkerchief in the opposite direction was- not attended with suffering. Several other practitioners, particu- t'lrZJ? fT"' and, TeaJe' haVe traCed an important connexion between a morbid state of the spinal cord and various neuralgic affections; and we have wit- nessed some remarkable phenomena resulting from blows upon the back favoura- ble to the same view. In some of these cases there was an alternatton of neural- gia with cutaneous eruptions of a scaly character. AJternaSonTthe £SS wi h herpes has been noticed by Dr. Bright (Reports of Medical Cases ^Tc^e of intercostal neuralgia, and by M. Jolly in the cubito-digital vaiietv?^ i,S et Chir;) and M. Recamier mentions two cases of «iaffi w^^';^ but m four days entirely vanished. This is not the place to a^i^vlSSof nkuralgia, (Treatment.) 105 connexion between certain cutaneous eruptions and affections of the spinal cord; but it may be advanced as a plausible opinion, that when there is disorder of many parts in succession, there is some focus of irritation, and it is reasonable to suspect the medulla spinalis as the great medium of metastasis. Although the researches of pathologists have failed to prove that any organic change is necessarily con- cerned, yet we feel authorized to conclude, that some cause directly interfering with the functions of the brain or spinal cord, is generally present in neuralgia, and that the causes of the complaint commonly exert their influence through the me- dium of these organs. Treatment. Few parts of the records of medical practice are more unsatisfac- tory than those which relate to the treatment of this distressing affection. The long list of remedies, alternately recommended and discarded, furnishes a forcible evidence of their inefficacy. External applications of every kind, tar, cantharides, and even the smoking entrails of'live pigeons, have been successively employed. The internal use of every variety of anodyne and of numerous metallic salts, has led to repeated disappointment. Lentin honestly confesses, that of fourteen cases which he treated, he did not succeed in curing one. Dr. Baillie observes, that he has known medicine produce an intermission of some months or even a year, and the division of a nerve suspend the complaint for two years, but that he had not witnessed a case of permanent cure; and Dr. Fothergill closes his melancholy list of unsuccessful remedies with the remark, that we must look to the influence of moral agencies. Dr. Fothergill's observations on the subject of magnetism, a mea- sure adopted in his day in the treatment of neuralgia, may not be without interest at the present time. His words are, " In some few cases where the disease was recent, and the pain slight, the use of magnetism certainly procured ease, but merely, I should conceive, by forcibly acting upon the imagination like the modern tractors and all such absurdities with which the credulity of the public is daily gulled and deservedly duped. Indeed, it is much safer and more prudent to ease people of their superabundant cash with a patent, than to dive into their pockets without one: the one practice is attended with riches and honour, the other with infamy and disgrace." It must be acknowledged that the power of the imagina- tion over the complaint is often considerable. Dr. Macculloch, for example, has related a case which the gibberish of an old woman charmed away, after the failure of arsenic. Although, from the effect of modern improvements, the disease is now found often to yield to scientific treatment, yet we have too frequently to deplore the inefficacy of remedies. There can be no doubt that the probability of successful treatment must in a great degree depend on the accuracy with which we discriminate the peculiarities of the individual case, and adapt our remedies to them. With a view to this ob- ject, it will be important to distinguish the disease into the idiopathic and the sym- pathetic forms; the first depending on a primary derangement of some part of the nervous system, the second on derangement of some other organ. In every instance it is important to examine the parts in the neighbourhood of affected nerves, and also to investigate the condition of the spinal cord. If any part of the spine be found particularly tender, it will generally be expedient to ab- stract a little blood from the neighbourhood, and subsequently to employ counter- irritation by means of blisters or tartar emetic ointment. If there be pain of head, flushed cheeks, and dizziness, the loss of blood will be desirable; and this measure will often convert irregular into regular neuralgia. Mr. Teale has related many cases, some of considerable severity, in which this plan proved remarkably effi- cacious. We have adopted the same treatment with similar success, and have occasionally derived great advantage from the subsequent use of spirit of turpen- tine in doses of 3j twice or thrice a-day, especially in cases in which psoriasis had also existed. This treatment proved rapidly efficient in a case of hysteralgia of some years' duration, recurring daily in severe paroxysms, in which tender- ness and pufhness, previously unsuspected, afterwards ascertained to have been Vol. II.— 1 4 106 nki'ralgi.v, (Treatment.) produced by a blow, existed over the upper lumbar vertebras. When concurrent causes of irritation are removed, such as constipation of the bowels and torpor of the liver, it will be important to ascertain whether the attacks partake of an in- termittent character. Should this be the case, whether the pain be superficial or deeply seated, attended or unaccompanied with fever, sulphate of quinine will be found the most effectual remedy. It may be advantageously combined with ano- dynes: those of a milder character, as the tincture of henbane, occasionally prove sufficient, and should first be tried; but if they prove inefficient, the sedative solution of opium, or the black drop, should be substituted. Dr. Bardsley pre- fers the acetate of morphia to all other preparations of opium, and has related several cases of neuralgia cured by that remedy alone. (Hospital Facts and Observations.) Small doses of quinine often prove adequate to the relief of the symptoms, but they sometimes require to be increased even to the extent of a scruple or half a drachm several times a-day. An interesting case illustrative of this fact, and having a manifest relation to intermittent fever, is described by Sir B. Brodie in one of his lectures on nervous affections. In cases not characterized by distinct intermissions, the sesquioxide of iron is a more suitable remedy, and is perhaps peculiarly efficacious when there is a deficiency in circulating energy. There is probably no medicine, the claims of which to attention in the treatment of common neuralgic affections are founded on so many recorded instances of success; and the liberal manner in which .Mr. Hutchinson published his observations on the subject, affords one of the many examples of disinterested devotion to the public welfare of which the Medical Profession may be justly proud. In some instances a dose of ten or fifteen grains several times a-day will be found sufficient; in others the quantity may be increased even to half an ounce for a dose. We are disposed to consider arsenic as inferior both to quinine and iron in the scale of remedies for neuralgia, and to regard it as less safe and less effectual; it will, however, occasionallv succeed after the failure of those medicines, where Ave wish to produce an alterative effect rather than to make a strong impression on the system. The pills of Meglin require some notice in consequence of the importance attached to them by some French physicians. They consist of equal parte of oxide of zinc, powdered valerian, and extract of henbane. Meglin in one cw gave forty pills night and morning; but in others only three could be borne twice a-day. Many instances of their successful employment are recorded in the French periodical,. {Journ. de Med. et Pharm., t. xxii. xxvii; Biblioth. r * u --'K Conslderable expectations were once entertained from the trial ot strychnia; it has, however, been given to the extent of producing subsultus tendinum without any relief to the symptoms. Anodvnes must be regarded ™ZZ?7 °l* S>rmPtom' than of a disease; we have rarely found" them Lt belladonn, r " ^P0!^ advantage, although we have reason to think Werable va^ne Z'T" * ^ ?** ^ if ^ PrePared' ™' prove of con- "d^ occasionally appeared a-darTallmeW11™' " *?? ?f fr°m half a ^ain to two grains three time, extort o"D2„7 Pve?rel"*but at other times it has been carried to the ^72^!?™ ^r* any ad™*8*- (-V'* Chir. Rev., vol. i a\v J Fott (Lcn' Me(L and phys- Journ., Sent 18S2 ^ has -m- ffit^zzzz^r* feu inKdoses •*"*»—•' - «™ Bev vol xx » Pd Sir T* ' °ther .am"ics in ,his ""'"plaint Mferf. Chir. Theecan beUtfle dm h,"b ,° 2T a,,thora.h»™ recommended extract of aconite. safe and efficacious than when administered bv the mourn Th^ °T "', of the Hvcr and otW digestive o^K ?$£ Z^^T^ neuralgia, (Treatment.) 107 vous structure: many obstinate cases have recovered under its use. It is scarcely necessary to observe, that the advantages of the water may now be secured at the German Spa at Brighton, almost as effectually as at the natural spring. The experiments of Flourens, showing the production of conjestion of different parts of the nervous system by different remedies, encourage us to hope that means may eventually be discovered, of acting on the nervous functions without dis- turbing other processes. External applications of various kinds have been strongly recommended. Mr. Scott sometimes employs a combination of mercurial ointment, and tartarized an- timony—in other cases an ointment of iodide of mercury; but the irritation pro- duced by these applications is considerable, and the benefit derived doubtful. Blisters have been occasionally applied, but the opinion of Heberden, that they are calculated to aggravate superficial neuralgia, is supported by recent experience, and their employment is now almost confined to the treatment of sciatica. The application for a few minutes of lint dipped in strong solution of ammonia, co- vered so as to prevent evaporation, is recommended by Dr. James Johnson. The production of pustules by means of friction with croton oil has been occasion- ally useful, as, for example, in some cases of sciatica related by Andral. The application of the moxa proved useful to patients treated by Dr. Duncan and others in this country, and also by several French practitioners. Most of these cases, however, were affections of the sacro-ischiatic nerve. In ordinary neuralgia little could be expected from the remedy unless severe spinal irritation were present, and the moxa be applied near the affected part of the back. Electricity has been occasionally recommended, but Dr. Macculloch tried it in vain for many years, notwithstanding all the facilities afforded for the experiment by a military hospital. During the last thirty years, the Indian practice of acupuncture has been some- times adopted in this country; and Dr. Osborne {Dub. Med. Journ., vol. xii.,) who regards the disease under consideration as a modification of paralysis, has made many experiments on the subject, which lead him to be sanguine respecting the efficacy of this measure in many cases of neuralgia, and to consider it as the most valuable addition made of late years to European practice. In sciatica, Dr. Osborne rarely found acupuncture fail to relieve, excepting in cases in which, from the aggravation of the pain on coughing, there was reason to apprehend dis- ease of the theca vertebralis or in the pelvis. The experiment is perfectly safe, since it appears from the experiments of Cloquet, Bretonneau, and Carraco, that well-tempered sewing needles may be thrust with impunity through any structure of the body, through the liver, lungs, intestines, or arteries. Various external applications of a soothing character have been used with un- certain advantage. Distilled cherry-laurel-water has been occasionally found an efficacious lotion. Dr. L. Broglia del Persica has given an account of its success- ful employment in ten cases. (Annali Univers. di Med., 1832.) Its use is per- fectly safe and easy, and it deserves a more extended trial. The application most depended on by many of the French practitioners, is the cyanuret of potassium: it was particularly recommended by Buttigny, Roubiquet. Villaumy, and Bally; and Lombard of Geneva has given a favourable report of its virtues. He some- times employs an ointment containing from two to five grains of the cyanuret to the ounce of lard, but prefers a lotion containing from one to four grains in an ounce of water. He considers it inefficient in sciatica, and in neuralgic cases complicated with inflammation. The few experiments made with the remedy in this country have not prepossessed practitioners with any very strong opinion of its efficacy. A lotion composed of equal parts of prussic acid and solution of acetate of lead is sometimes useful, and, in the less exquisite cases, relief may often be derived from a solution of extract of belladonna, or of opium in camphorated oil. Sprinkling half a grain or a grain of morphia on a blistered surface is often found productive of great relief; but caution must be observed in the employment of a 108 nkcrai.cia, (Treatment.) remedy, which, even when applied in the endermic method, is capable of pro- ducing a very powerful effect upon the system. Some French physicians have in- troduced the remedy by inoculation into the affected part with advantage: it may be mentioned, as an interesting result of this procedure, that a tubercle surrounded by an areola is formed upon each puncture. The application of steam by means of a suitable apparatus to the part affected is strongly recommended by Dr. Mac- culloch, who has found it invariably alleviate and often remove pain. We have made occasional trials of veratria ointment, and concur with those who believe it to be an application of little value in neuralgic complaints. We entertain, however, a different opinion of aconitine, having found it, in the pro- portion of one or two grains to two drachms of lard, peculiarly effectual in arrest- ing the pain in several instances of cubito-digital and frontal neuralgia. Some cases illustrative of its utility, have also been narrated by Mr. Skey, (Med. Gaz., Nov. 1836.) the one of nine, the other of eight years' duration. Although we cannot expect any local application to effect a radical cure, yet the arrest of pain has advantages beyond those of mere temporary relief. Pain increases the sensi- bility of a nerve; the sooner, therefore, the habit can be overcome, the greater is the success likely to be produced by measures adapted to the constitutional con- dition. The practice originally recommended by Galen, of dividing nerves or amputa- ting limbs affected with neuralgia, after the failure of remedies, although on a few occasions successful, as in the cases treated by Kelson, Cooper, Thomas, and Cruikshanks, derives no support either from philosophical reasoning, or from the average results of the experiment. Some very affecting cases are recorded, in which a succession of amputations was resorted to in vain. Whilst, on the other hand, instances in which a proposed operation has been deferred, have sponta- neously recovered. When, as often occurs, many parts are involved in the complaint, the presump- tion for its constitutional origin is strong; and the disease being in common in- stances so often connected with the condition of the nervous centre, we can readily understand that, although a severe operation may by the violence of the shock suspend the affection, yet that is not a measure calculated to ensure permanent relief. Treatment of Sympathetic Neuralgia. The most important of the causes of sympathetic neuralgia are derangements of the digestive organs, hysteria, and rheumatism. 1. A slight degree of gastric or intestinal irritation in persons of nervous tem- perament, will sometimes prove sufficient to induce neuralgic affections, which in the commencement may be slight and variable in their seat, occurring some- times in a tooth or in the face, at other times in an extremity, and recurring under the influence of any cause which depresses the strength or disturbs the stomach, as fatigue, anxiety, fasting, or injudicious diet. The tongue in such cases often presents elevated red papillae; flatulent distention of the abdomen is apt to occur after food, especially if digestion be interfered with by anxiety or study. These cases require mild and careful treatment. Powerful remedies, whether of the purgative or tonic class, aggravate the local as well as the general irritability, while opiates give only temporary relief, and add the inconvenience of their own effects to the original malady. A considerable proportion of such cases, neglected or violently treated, gradually assume the exquisite form, and become unmanage- able; but if, on the contrary, the diet be judiciously regulated, and be nourishing, unstimulating, and taken at regular intervals; if the powers be husbanded, and a due proportion of sleep ensured; if acidity be corrected by small doses of soda or magnesia; and if other symptoms, as they arise, be met with prompt and mild measures, the neuralgic tendency will generally be overcome. In paroxysms of pain, associated with the condition just described, even after the failure of laudanum, we have known decided relief produced in a few minutes by the administration of two or three grains of carhonate of soda. The impor- xt-.riui.GiA, (Treatment.) 109 lance of these facts is here peculiarly insisted on, because the habits of medical education are perhaps calculated to engender a bias in favour of the employment of powerful remedies. In the management of acute inflammatory diseases, such a bias may be safe and useful; but in the treatment of nervous affections, which constitute an increasing proportion of the cases which fall under our care, the secret of success will probably be found rather in the accurate adjustment of mild measures, than in the bold adoption of heroic plans. In the instances above referred to, the successive employment of quinine, arsenic, mercury, iron, and other powerful medicines, too often produces an almost incurable condition of the intestinal mucous membrane, while the original disorder remains unmitigated; and the administration of opium for the purpose of temporary relief becoming more frequent and excessive, an alternation of torment and torpor constitutes the remainder of a life, at last terminated by apoplexy, the production of which these measures may accelerate. Doubtless the vacillation of patients impelled by the urgent desire for immediate relief frequently to change their medical attendant, by depriving any one plan of treatment of a fair trial, materially contributes to these lamentable results. A more confirmed derangement of the digestive organs, attended with de- praved hepatic secretion, and a deposite in the urine of the brickish red sediment of purpurate of soda, is sometimes connected with neuralgic maladies. There is not necessarily any peculiarity in the nature of the pain in this or any other variety of symptomatic neuralgia, but when depending on chronic disturbance of the digestive organs, the complaint perhaps affects some situations more than others, especially the head, shoulders, and hypochondriac regions, the treatment of these cases resolves itself into the careful adoption of measures adapted to the peculiar form of indigestion. But the occasional use of mercurial pill, followed by a combination of bitters and aperients, will generally prove useful; and when there is much nervous pain of the head, a combination of valerian and iron will sometimes give relief. In other instances, in which the derangement of the digestive organs is more protracted and severe, the urine deposites the white earthy sediment of the triple phosphates, and the general strength is extremely reduced, a complete change of scene and habits will often be found essential. The diet may be as generous as the digestive functions will admit; and wine, though gene- rally inexpedient, will sometimes be desirable. Mr. Carmichael, who suffered severely from this form of the complaint, in the interesting detail of his own case, mentions having derived benefit from the use of the Lafitte and Chateau Margaux claret. He also had recourse to the baths of St. Sauveur and Bardges, which are well deserving of a trial.* Active exercise must not be ventured on too soon. In cases characterized by torpor rather than irritability of the intestines, a decided impression by means of purgatives will sometimes prove useful. In support of this opinion it may be mentioned, that Sir Charles Bell administered small and repeated doses of croton oil in several obstinate examples of neuralgia with great success. When the disease has been seated in the hip or scrotum, he has fre- quently observed a scalding sensation of the lower extremities exceedingly like what is often felt during the passage of a purgative through the intestines; and he has always regarded this symptom as a sufficient indication that the source of the complaint is in the bowels. 2. The second division of sympathetic neuralgia, namely, the hysterical, most frequently affects the intercostal nerves, especially on the left side, the hip and thigh, and the inner part of the knee joint. This subject having been already treated of in the article Hysteria, does not now require a lengthened notice. It will be sufficient to mention that the treatment consists chiefly in the correction of uterine irritation, the improvement of the constitutional condition, and the local * Some of the effects of the internal use of the Bareges water may be obtained by taking in the morning 60 grains of tartarized soda and 20 of the bicarbonate with 2 of sulphate of iron, in a pint of warm water.—Author. 110 neuralgia, (Treatment.) application of belladonna or other soothing remedies. In some of these varieties the sesquioxide of iron possesses considerable efficacy, but its use sometimes requires the preliminary application of leeches to subdue local congestion. 3. Rheumatic neuralgia is apt to occur in gouty or rheumatic subjects after exposure to wet; the pain is induced by slight exercise, and is dull, aching, or gnawing, rather than stabbing or plunging. In these instances there is reason to believe that the neurilema is more or less affected. If the attack be acute, cup- ping or bleeding will be necessary, followed by the use of antimony, colchicum, and purgatives. Plasters of opium or belladonna may be advantageously applied, and an occasional night dose of calomel combined with James's powder, guaia- cum, nitrate of potash, and opium, followed by an aperient in the morning, will sometimes prove singularly efficacious. If the complaint be decidedly intermittent, quinine will be found almost a spe- cific. In the chronic form, especially if benefited by the application of warmth, the administration of turpentine will sometimes give relief; but the ammoniated tincture of guaiacum, in doses of from twenty drops to two drachms every four hours, is probably the most efficacious remedy. Stimulating applications con- taining mustard, pepper, or salt, the hot douche, sulphuretted baths, and espe- cially those of St. Sauvier and Bareges, may be had recourse to with advantage. In this form of neuralgia, acupuncture is often surprisingly efficacious. These cases are remarkably influenced by the state of the mind, which must therefore receive a due share of attention. Neuralgic complaints have occasionally occurred, apparently produced by- syphilitic exostosis, and which yielded to mercury. Dr. Corkindale adminis- tered this mineral with success in a case in which this origin was suspected. The late Dr. Warren was indeed accustomed to treat most cases of neuralgia with blue pill combined with extract of belladonna; but though the mercurial plan has occasion- ally succeeded, yet as a general rule it may be stated, that except in instances depending on a syphilitic origin, the continued use of mercury is more likely to increase the nervous irritability than to cure the complaint. Dr. Rowland mentions having derived great benefit from the application of nitrate of silver to the vesicles in cases of neuralgia depending on herpes. When the complaint is produced by the irritation of old cicatrices, he applies the same remedv to the cicatrix, and also insulates it from the surrounding skin by a circle of the* caustic. It is worthy of notice, that when the insulation is incomplete, the pain, although checked in its usual course, shoots thiough the opening and attacks the neighbouring parts. (On Neuralgia.) In neuralgia of the urethra, the occasional introduction of a bougie constitutes the most effectual treatment. In neuralgia depending on sub-cutaneous tubercle the local application of belladonna often gives considerable relief, but the only effectual remedy is excision. The application of caustic has been tried, but with unsatisfactory results; and the sore produced has proved difficult to heal. ( 111 ) PARALYSIS. Explanation of the term.—Varieties and distinctions—Symptoms.—Mode of accession.— Description of the various forms and varieties of paralysis.—General paralysis.—Hemiple- gia.—Paraplegia.—Various forms of local paralysis.—Paralysis of particular muscles.— Strabismus.—Ptosis and lagophlhalmia.—Aphonia.—Paralysis of the face.—Paralysis of a limb, or particular muscles of a limb.—Paralysis of sensibility.—Amaurosis.—Cophosis.— Anosmia.—Ageustia.—Anesthesia.—Paralysis of motion.—Paralysis of the insane.—Para- lysis from metallic poison.—Mercurial palsy.—Lead palsy.—Paralysis agitans.—Causes of paralysis.—Anatomical characters.—Nature.—Crossed effect from lesions above the me- dulla oblongata.—Direct effect from lesions below.—Diagnosis.—Seat of the lesion.— Nature of the lesion.—Prognosis.—Treatment. By paralysis (from irctpcckvru;, dissolutio, resolntio) is understood a diminu- tion or loss of motion and sensibility in one or more parts of the body. By the older writers it was confounded with apoplexy, with which it is often compli- cated, but they are quite distinct and independent of each other. Varieties and distinctions. It unusually happens that both motion and sensi- bility are affected together; but the one may be lost or diminished, while the other is unimpaired. Hence the necessity of distinguishing paralysis of motion from paralysis of sensibility. The former is called acinesia (from «>t the memDranes 0r by pressure upon them. Dry mucous J J ' C produced by a bub- i Moist; Mucous . < bling passage of > liquid in the bronchi. £ air through j Sub-mucous .... a liquid in the finer bronchi. Sub-crepitant .... liquid in the smallest bronchi. _ S viscid liquid in compressed smallest Crepitant • • • • ) bronchi. Cavernous .... liquid in a morbid cavity. SOUNDS OF THE VOICE TRANSMITTED THROUGH THE CHEST. Natural Sounds.—heard in a healthy chest. Tracheophony, in the neck and at the top of the sternum. Bronchophony, near the top of the sternum, between the scapula, in the axilla, Sfc. Pectoral fremitus, in many parts of the chest. Morbid Sodnds, transmitted or produced by a diseased chest. Bronchophony, transmitted by condensed pulmonary tissue. ^Egophony, the same vibrating through a thin layer of liquid. Pectoriloquy, resounding in a cavity in the lung. Tinkling, a changed echo of the voice or cough in a large cavity. SOUNDS PRODUCED'BY THE MOTIONS OF THE LUNGS. Sounds of friction, when the pleurre are dry, or rough from deposites. Emphysematous crackling, by the irregular passage of air between the lobules. We shall now describe shortly the methods of auscultation or the means which we use to obtain a cognizance of those acoustic phenomena which we have found to be signs of the condition of the organs within the chest. We have already described the methods of percussion; and we have now to study the best mode of listening to the signs of the motions of the chest. All these signs can be heard by the direct application of the ear to the chest, and this immediate method of auscultation is so easy and simple, that it commends itself strongly to us, and in many cases is used with advantage. The sounds proceeding from the walls of the chest are communicated to the ear, and especially to the air contained in the external meatus, and are thus propagated in the most direct and unmodified manner to the organ of hearing. Immediate auscultation is exclusively practised by some, both at home and abroad; and as it is much more easily learnt than the mediate method, it will probably always have its advocates among those who prefer ease to exactness. But if we can hear the signs so well by the unassisted ear, it may be asked, what is the use of the stethoscope ? We shall first men- tion some positive objections to immediate auscultation; and on examining the principles of the stethoscope, we shall find that it has, in many cases, considera- ble positive advantages. To apply one's ear, and, therefore, the nose, face, and so forth, to the chest of a patient who is dirty, blistered, or wet with perspira- tion, would be disgusting. To apply it to the chest of a patient labouring under an infectious disorder would be unsafe. To apply it to the person of a young female would scarcely be delicate. Moreover, it is difficult to apply the ear well to some parts of the chest, such as the arm-pit, and below the clavicles or between the scapula? in thin persons. Besides this, disturbing noises sometimes arise from the contact of one's hair or clothes with the patient's chest; and unless the practitioner's neck be pretty long and flexible, this easy method will be found, after all, more fatiguing than the mediate method; still, in a great many instances, it may be used with advantage, especially in examining the regions of the back, STETHOSCOPE. 215 and in children where the stethoscope might cause alarm, and could not be so steadily or quickly applied. In practice the chief advantages of immediate auscultation are the great facility and quick- ness of its application. The whole chest can be explored with nearly the same accuracy and with much greater quickness than if the stethoscope be used: and in no case is there any objection to the direct application of the ear to the posterior parts of the thorax; the simple expedient of throwing a thin towel, or muslin cloth, over the shoulders of the patients, removes the observer from direct contact with the body of an uncleanly patient; which constitutes the only objection to this method of auscultation. For this reason those who arc really fami- liar with auscultation, and use it as an ordinary every-day means of exploration, almost always prefer the immediate application of the ear. There are, however, many decided advantages in using the stethoscope for the examination of the anterior parts of the chest. A better idea may be obtained of the sound and impulse of the heart, and the hollows about the clavicles may be all examined more accurately, and the exploration of the chest of women is freed from the objections which are obvious enough in direct auscultation. G. We want an instrument, then, to transfer the sounds from the chest to our ear, which must be a good conductor of sound; and as the power of bodies to con- duct sound depends on the strength and uniformity of their elasticity, and their capacity to vibrate like the body that produces the sound, we must have an elastic material, of density resembling that of the sources of sound within the chest, and of the walls of the chest through which they are transmitted. But the sources of the pectoral sounds -vary: some, as the voice and respiration, or at least the hollower sounds of respiration, are produced in air; whilst in others, such as the sonorous rhonchus, the rubbing sound, and the sounds of the heart, the solids are chiefly concerned: we shall, therefore, need a varied capacity in our instru- ment to receive these sounds. It should be a uniform solid, and the lighter it is the better, provided it be thoroughly rigid. Now nothing answers to this description so well as wood; and in the light kinds of wood with a stiff longitu- dinal fibre, such as pine-wood, deal, cedar, and the like, we find these qualities in perfection: through a cylinder of such wood, about eight inches long, and an inch and a half in diameter, adapted to the ear at one end, most of the pectoral sounds may be heard: but those best which originate in solids, such as the sounds of the heart, of friction and sonorous rhonchi. The sounds of respiration and of the voice are also heard through it, but not nearly so distinctly as with the naked ear. We need, therefore, an aerial conductor for these sounds, because they ori- ginate in air, and can best be transferred through air. By perforating the cylin- der with a bore a quarter of an inch in diameter, it becomes a tube through the column of air in which the respiration and voice may be heard with increased distinctness. But as this column of air is in contact with only a small spot of the chest, it can transmit only the sounds produced under or very near that spot, and the instrument thus prepared is well-adapted for the exploration of small parts of the chest. But we want the instrument also to transfer the sounds of larger spaces: the sounds of so limited a space are often too weak to be heard alone; and besides, it would be very tedious to go over the whole chest, dotting in this way a quarter of an inch at a time. Now, if the column of air be enlarged at the base where it is in contact with the chest, by hollowing out the wooden cylinder into a funnel shape, it will conduct the sounds produced on this greater extent of surface, which are reflected by the funnel into this central bore, and conveyed concentrated to the ear. This also gives the instrument the power of concentrating or magnifying the sounds; they are thus heard as strong at the dis- tance of several inches or even a foot or two from the chest as they are to the 216 DIAGNOSIS OF DISEASES OF THE LUNG1?. ear in close contact with it; nay, in some cases they are even stronger. The best shape for the excavated end is that of a long funnel or cone, with its apex terminating in the central bore; for this directs the sound at once in the right direction without repeated reflections, which may modify it. As we still sometimes want to explore small spots of the chest, by means of a perforated plug the excavated end can be filled and the instrument reconverted into a simply perforated cylinder. To make the instrument more portable, the upper part of the cylinder may be reduced to a stem half an inch or less in diameter, leaving only at the top a sufficient width for the ear; or this top may be made of a harder wood, or of ivory. Wood is so excellent a conductor of sound, that when once the vibrations are in it, they can be conveyed by a very small body of fibres.* Thus the stethoscope, although a simple instrument, performs several offices in relation to sound, the chief of wThich may be enumerated as follows: 1. To conduct sound by its solid walls. 2. To conduct and concentrate sound by its closed column of air. 3. To transfer sounds from its column of air to its solid walls, or the converse, when circumstances impede their transmission by one of these ways. 4. To diminish this power of transfer, and contract the field of hearing when small spots are to be explored. We have now only to add a few words on the method of using the stethoscope. It is quite necessary that the instrument should be applied in close contact with the chest and the ear; the least tilting uncloses the column of air, and occasions great loss of sound outwardly as well as a confusing entrance of extraneous noises. To prevent this tilting, it is best to hold the stethoscope by its pectoral end firm on its base, and then to apply the ear flat on the top. If the inequalities of the ribs leave chinks between the chest and the instrument, a fold or two of linen will fill these, or the stethoscope may be used with the stopper in. For the sounds gene- rally, it is better to use the instrument without the stopper; but when it is an ob- ject to determine, whether a sound is produced in a limited space, or over some extent of surface, the circumscribing power of the stopper is wanted. Thus it is often of importance to determine whether a local resonance is produced in a small cavity, or merely transmitted by consolidated lung from several bronchial tubes distributed over some extent of surface. The simply perforated cylinder will often do this by showing the size and shape of the limited spot in which the resonance or pectoriloquy of a cavity can be heard in its full strength, while the broncho- phonic resonance is transmitted less strongly and may be traced over some extent of surface, generally in the known direction of these tubes. The stopper is also useful in shutting out the sound of respiration, when it is an object to listen to the sounds of the heart or arteries, and in many other circumstances which will be noticed in the history of special diseases. In conducting physical examination, due care should be taken to avoid fatigue or annoyance to the patient. There are cases in which a complete physical exa- mination will do more harm than the information which it may bring can do good; but they are few, and it must be left to the discretion of the practitioner to hold the balance between too much and too little examination. Experience soon points out that the observer must also consult his own ease in the act of auscultation ; for a constrained or painful posture impedes the hearing and disturbs the atten- * A flexible stethoscope is extremely convenient for the examination of the heart, and will answer well for the lungs, it does not conduct the impulsion of the heart whilo the sounds are perfectly conveyed through the tube. This instrument, which is nothing but an acoustic tube fitted with a proper end piece—answers admirably in the examination of the heart of animals and was used for that purpose by Dr. Pennock, of this city, in his interesting expe- riments. All stethoscopes limit the spot from which the sounds arise, but diminish their intensity; these advantages and disadvantages both belong to the flexible as well as the com- mon instrument. G. DYSPNffiA. 217 tion. For this reason, it is sometimes easier to hear with a flexible ear-tube than with the straight stethoscope, although the latter is by far the best instrument for general purposes. H. Examination of the Chest through the Vital properties or Functions of its Organs.—Analysis of the General Symptoms of Diseases of the Chest. We have been hitherto occupied in considering the physical properties of the chest and its organs, and the manner in which these properties may become signs of the condition of these parts. We have now to examine them through their vital properties, which, combined with certain physical and chemical powers, con- stitute/uncfion. Physiology teaches us that the elementary vital properties imme- diately concerned in the function of respiration, are sensibility and contractility, to which may be added, the power of secretion. These properties are closely linked together with the chemistry and mechanism of the organs of respiration, so as to constitute their healthy function. Any excess, defect, or disorder, of any of these properties, will be more or less felt throughout the links of this chain, and hence may arise not only derangement of the function of respiration, or dyspnoea, but also new phenomena proceeding from a loss of due balance of the properties, such as cough, expectoration, and pain; and linked as the vital properties are with those of other organs, there may be added disorders of these in the form of disturbance of the circulation, and its sign the arterial pulse, general fever, disorder of the secre- tions of the kidneys, liver, and intestines, and of the digestive, nutritive, and sen- sorial functions. The phenomena arising from these several disordered properties are what are called the vital or general symptoms of disease, whieh we now have to consider in relation to the organs of respiration. It may be inferred, and will be more apparent as we proceed, that these general symptoms, dependent as they are on such a linking together of many properties, the laws of which are but imperfectly understood, must be far less simple and in- telligible than the physical signs; and the variable measure of the vital properties also renders general symptoms far more uncertain than these signs, in their de- gree, and even in their presence. We cannot with any certainty, as with the physical signs, from a knowledge of the phenomena, and the laws which regulate those phenomena, deduce the condition of the parts which produced them, nor, from knowing the condition of parts and physical laws, deduce what phenomena the parts ought to develope. For example, the^solids of the body have sensibility, which varies not only in different parts, but in the same parts at different times, and this for reasons which we cannot discover; therefore we cannot calculate on it. The contractility of moving parts also varies in a similar manner; and we can by no means gain, from the character of their motions, a criterion of their true condition. Instead, therefore, of pursuing the synthetic as well as the analytic method, which we have done with regard to the physical examination of the chest, we shall shortly analyze the chief general symptoms of diseases of the chest, and by that examination endeavour to determine their nature and varieties, and their value in teaching us to discover, to measure, and to treat these diseases. Dyspnoea, difficult or disordered breathing, is the most important general symptom of disease of the chest, inasmuch as it implies some interruption to the due performance of some part of the great function of the chest—respiration. Dyspnoea may be caused by circumstances affecting any one or more of the seve- ral elements concerned in the function of respiration, viz. the blood in the lungs, the air, the machinery of respiration by which these are brought together, and the nervous system through which the impression which prompts the respiratory act is conveyed from the lungs to the medulla oblongata, and thence to the muscles which move the machinery ; in fact, all the causes which in excess produce as- phyxia, in slighter degrees occasion dyspnoea. Subjoined is a table which exem- Vol. II.—28 218 diagnosis of diseases of the lungs. plifies these causes of dyspnoea; but the character of the symptom itself must first be described. When any thing interferes with the sufficient action of the air on the blood, the impression which prompts the acts of breathing not being relieved, causes a quicker and fuller repetition of this act, and if the interference still remain, the breathing will continue to be more or less hurried and forced, until the sensation or impres- sion is reduced to the ordinary standard of almost unconsciousness. An indi- vidual in whom the breathing is hurried may not be sensible that it is accelerated; whilst in another who feels the oppression, there may be little appearance of short- ness of breath. Again, the feeling of dyspnoea must greatly depend on the condi- tion of the sensorium; for whilst some patients are conscious of the slightest in- fringement on their respiration, others, particularly in congestive fevers, are brought to the verge of asphyxia without complaining of any oppression. So, too, we are sometimes astonished to find, on opening the bodies of the dead, a whole lung diseased, or one side of the chest full of serum, v/here the patient had not complained at all of dyspnoea ; while, in other cases, a much smaller lesion of the organs has been attended with the most distressing orthopnoea. It is, however, rather to the sensation of breathlessness than to merely accelerated breathing, that the word dyspnoea is generally attached, for, translating it as difficult breathing, this expression can be hardly applied when the difficulty is overcome by accele- rated movements of which the patient may not be conscious. But we shall here advert to frequency of breathing, as well as the feeling of dyspnoea. The number of respirations in a healthy adult male at rest, generally ranges about twenty in a minute. It is more in children and in females, and it becomes increased in all cases, not merely from affections of the lungs or connected organs, but also from general weakness or depressing causes, which, diminishing the strength of the muscles of respiration, oblige them to make up by the frequency of their contractions what is wanting in their energy. Probably there are some ner- vous conditions of the system also, in which the breathing becomes accelerated, from what Cullen called mobility, a greater readiness to move than power to com- plete the motions. We have seen the breathing hurried in some cases of hysteria, without the patient being conscious of it, and without either real weakness or pec- toral disease to account for it. These cases are of no consequence in themselves, but should be known, that they may be separated from those of true dyspnoea. In many other cases, especially those, we believe, where the nervous system is affected, the breathing is not accelerated, but suspirious, a sigh or deep breath being taken from time to time; yet the patient is often not conscious of any op- pression or unusual effort. This may be called irregular breathing, and there are several other varieties, which we have not time to consider in detail. The rhythm in breathing probably depends entirely on the chain of influences which we before described as concerned in the act, and not on any peculiar periodicity, such as that which seems to reside in the heart; and therefore irregular breathing must depend on a change in one or more of the links in that chain. The feeling of dyspnoea is one of a very peculiar and distressing character. Even when slight in degree, its permanent oppressive influence is very wearing; and when severe, it causes the most indescribable suffering, with such a feeling of impending death, that the most courageous are often unmanned by it The con- strained postures of the patient, the anxious or even desperate expression of his countenance, the painful straining of all the muscles that can in any way, however distantly, assist in the respiratory movements, bespeak the intensity of the feeling, which is far worse than the most acute pain. It is worthy of remark, however, that this feeling is experienced in its severest degrees only by those in whom the dyspnoea comes on rather suddenly, especially when the sensibility is entire, and the lungs are not diseased, as in obstructions in the trachea or large bronchi, spasm or swelling of the glottis, and spasmodic asthma. In these cases the sensibihty is not gradually blunted by the circulation of imperfectly oxygenated blood; nor has the activity of the functions, which require arterial blood, been lowered by previous DYSPNOEA. 219 depressing causes. Opium, belladonna, camphor, and other narcotics, will some- times relieve the symptoms of dyspnoea not only by deadening the sensibility, but also by diminishing the activity of those functions and secretions which require oxygenated blood, and therefore a free supply of air. If we could temporarily produce a state approaching to the torpor of hybernating animals, we might di- mmish the bad effects, as well as the painful feeling of dyspnoea; and we believe that such a state is actually induced in those who are habitually asthmatic, in whom all the functions are brought to a lower standard, and who thus suffer with im- punity such an encroachment on the function of respiration as would be fatal to an individual of a common standard. The feeling of want of breath has been used as a means of testing the condition of the respiratory organs. A person whose respiration is free and unembarrassed, can hold his breath longer than one whose lungs are diseased. Dr. Lyons has proposed to measure the condition of the lungs by the time which he can hold the breath, after a full inspiration; and to ensure accuracy, the patient is desired to count numbers during this time. A healthy person with a good chest can con- tinue counting for forty-five seconds without taking breath, whilst those with dis- eased lungs often cannot keep on for twenty seconds. The same objection may be made to this test that we made to the measuring of the exhaled air proposed by Mr. Abernethy, that it is a test as much for the strength of the muscles of respira- tion as for the condition of the lungs. Besides, both the feeling of want of breath, and the power of augmenting the respiratory movements, vary considerably in different healthy subjects. It it well known that divers acquire the power of re- maining under water for two or three minutes (it has been said more) without taking breath. In diving animals there is a structural provision to enable them to continue some time without air. The chief venous trunks are very tortuous, and admit of dilatation, so that the venous blood can accumulate in them, instead of distending and embarrassing the right cavities of the heart and the lungs. Per- haps some change of this kind may be somewhat produced in divers by the often repeated practice of holding the breath. Professor Faraday has described another mode by which a person may be enabled to hold his breath for a minute and a half, which is double the time usually practicable. This is by making in succes- sion five or six full and forcible inspirations, which seem to so completely change the air in the lungs, that there is left in them a stock of pure air capable of lasting during that time. The knowledge of this fact may be useful, if ever it is wanted to hold one's breath for a time in going into the suffocating atmosphere of a sewer, a mine, a house on fire, or the like, or in diving. Dyspnoea is often a symptom demanding great attention in diseases of the lungs; but it must be studied in conjunction with the other general symptoms and the physical signs, for in itself it is most vague and inconclusive. This may be per- ceived on inspecting the subjoined tabular view of the causes of dyspnoea, which is founded on the physiology of respiration. This table deserves attention, not only in showing the varied nature and origin of the symptom, but also in contrast with the tables of the physical signs, the causes of which are much less varied, and far more appreciable. But when, through the means of the physical and other general symptoms it has been made out on what cause the dyspnoea depends, then this symptom often becomes a valuable measure of the increase or diminution of the disease, and a useful guide of practice. proximate causes op dyspnosa, or difficult breathing. 1. By impeding the access of pure air to the lungs. a. Mechanical. Rigidity of parts of the ) J Ossification of cartilages; induration of the pleura; respiratory machine \ '*' ( rickety distortions. Pressure on ditto . e.g. Tumours or dropsies of the abdomen. Obstructions of the air- ) ^Effusions in, swellings of, tumours pressing on, the tubes .... \e-8-\ air-tubes. 5 f Spasm of the glottis; spasm of the bronchi. 220 diagnosis of diseases of the lungs. Alterations in the tissue > e. g. of the lungs . . ' f Pleurisy, _ . - , , S Effusion or tumours in \ Hydrothorax, Compression of the lungs c.gr.j pleural sac . . . . ) Pneumothorax, ' Aneurism, &c. ' Engorgement of the vessels. C GSdema, Effusions.....< Hepatisation, / Tubercle, &c. C Emphysema, Altered structure . . < Dilated bronchi, I Vomicae, &c. b. Chemical. Detheeairy °f 0Xyge" '" \ e'g' MePhitic S^^> 'defied air. c. Vital. Pare\°raPtton m°Ved "* [ e^' Pleuroa>e5 P^uritis; peritonitis, &c Paralysis of muscles off* S Injuries of the spinal marrow in the neck, &c. ditto.....\ e,g'l Paralysis of the bronchi (?.) Weakness of ditto . . e. g. . Excessive prostration from ataxic fevers, &c. Spasm of ditto . . . e.g. Tetanus; spasmodic asthma, &c. 2. Br THE STATE OF THE BLOOD. a. Mechanical. Obstruction to the pas- 1 y Diseases of the heart and great vessels; tumours sage of the blood . \ e' &" ( pressing on them. b. Chemical. AnstaeteCeSBiVel7 Ven°US ( *'* VioIent exertion5 idiopathic dyspnoea (?.) Deficiency of red particles e.g. Anaemia; chlorosis. 3. By the nervous relations of respiration. Excessive sensibility of) Hysteric dyspnea; cerebral fevers; neuralgia (?.) the par vagum S Defective ditto . •• . e. g. Coma; narcotism, &c. (breathing slow.) Cough. Another symptom, which is even more common in diseases of the chest than dyspnoea, is cough. The act of coughing consists in one or more abrupt and forcible expirations, accompanied by a contraction of the glottis, trachea, and upper bronchial tubes. The expirations being more complete than usual, especially when there are several of them, are followed by a deep forcible inspiration, the force of which is shown by the loud respiratory murmur, which, by the ear applied to the chest, may be heard to accompany it. The muscles chiefly concerned in the act of coughing are the abdominal muscles and intercostals, the combined contraction of which effects a strong pressure on the contents of the chest. The common cause of cough is phlegm, or some other matter irritating the air- passages, and the object or final cause of the cough is to expel or expectorate this matter. The proximate cause of cough may be said always to be some irri- tation, either direct or by sympathy, of the sentient parts of the air-tube, or of the nerves which render them sentient. Some parts of the bronchial membrane are much more sensitive than others; that lining the glottis and larynx is excessively so, and the least irritation of it is enough to excite coughing. That of the trachea and large bronchi is less, for foreign bodies have been known to lodge in them for some time without causing any coughing, so that some have supposed that they have nothing to do with the production of this symptom; but when the sensibility of these parts is increased by inflammation or nervous excitement, any thing ir- ritating them will also excite coughing. It is easy to see why the sensibility of the air-tubes should be greatest at their entrance; it is the door-keeper placed there to exclude, or, by calling other forces to its aid, to expel any thing improper which COUGH. 221 may intrude. But the other parts of the tubes have also a preserving sensibility, which may bear a little, but is soon roused into activity by continued irritation. We find the parallel of this in the alimentary canal in the natural state. The sen- sibility that excites the action of vomiting is peculiar to the fauces at one end of the tube; and that which induces the striving of defalcation resides chiefly in the termination of the rectum at the other end: but uncommon degrees of irritation, or an exalted sensibility, will occasion the same actions to be excited by impressions on other parts that are usually insensible: hence arise the vomiting caused by an over-irritated or inflamed stomach or duodenum, and the tenesmus and purging excited by a similar state of the colon. We shall see this more fully on consi- dering the various causes of cough. As other irritations, cough may be excited either by an unusual irritant acting on the tubes in their natural state, or by the ordinary circumstances, which, al- though not usually irritating, yet become so by the exalted irritability of the tubes, Or, as is the more common case, by a combination of these causes. We have an example of cough excited simply by an unusual irritant, when a portion of food or of bronchial mucus lodges on the membranes of the glottis; and an irritant may act by sympathy as well as by direct application, as when we excite cough- ing by introducing a probe pretty far into the ear. The cause by increased irri- tability is exemplified in the cough of early bronchitis and nervous asthma, which the mere inhalation of air is sufficient to excite. There are both an unu- sual irritant and increased irritability, in the secreting stages of bronchitis and other affections, where an unusual quantity, and sometimes an irritating kind, of mucus is poured out on an over-sensitive membrane. This more complex cause of cough is frequently induced by the continuance of the other causes; thus, the continued application of an irritant-will develope an increased sensibility; an in- creased sensibility and irritation will be followed by inflammatory excitement and the secretion of matter, the quantity and quality of which add to the irritation. Thus we see how the physiological causes of cough become identified with the pathology of bronchitis, or inflammation of the membrane of the air-tubes; and, in common parlance, a bronchial inflammation is called a cough, this being the most prominent symptom. But although this inflammatory condition is often developed by the continuance of causes which produce cough, yet it is not necessarily so, and there may be irritation or increased sensibility, or both, enough to cause cough, and which may yet be short of the degree or the conditions requisite to produce inflammation. It has been stated that the irritation which causes cough may not be applied to the bronchial membrane itself, but may be exerted from a part more or less dis- tant. Thus cough may be excited by tubercles in the parenchyma of the lungs, by inflammations or irritations of the pleura, peritoneum, stomach, liver, and so forth; and although we may conjecture that these irritations are conveyed through the nervous branches which connect these several organs and the air-tubes with one common sensitive centre, yet we cannot explain why they should be some- times conveyed, and at others not; for although cough does frequently accompany the pathological conditions to which we have just adverted, yet irritations and inflammations of the stomach, liver, peritoneum, nay, sometimes even of the pleura and pulmonary parenchyma, often arise without any cough whatever. It has been attempted to explain these discrepancies by assuming that there must be bronchitis present to produce cough, and that, when these several distant irrita- tions do not excite bronchitis they are unaccompanied by cough; but this view increases instead of diminishing the difficulty, for it leaves unexplained the reason why this supposed bronchitis should occur in some cases and not in others; and bronchitis, although including cough, is more than cough, and needs something more to produce it. We may conjecture about local weaknesses, constitutional peculiarities, and irregular sensibilities, as causes of these differences, and this is all that we can do towards explaining them: but this is not what an explanation ought to be; this is referring phenomena not to known general properties, and the 222 diagnosis of diseases of the lungs. laws which govern them, but to individual peculiarities and undefined influences, the laws of which are not known. These considerations furnish another proof of the uncertainty of general symptoms as means of diagnosis. Still, when cough does occur, and its cause has been made out by the aid of other signs, it deserves attention, not only as a symptom, but as a morbid action of a distressing and hurt- ful kind, which sometimes may require remedies expressly to relieve it. This illustrates what has been said before, that general symptoms, although much less constant and instructive than physical signs with regard to the diagnosis of orga- nic lesions, yet, when positive, often tell us more of those general conditions of the system, which become our guides in the employment of remedies. Under this impression we shall examine some of the varieties of cough which present themselves in different cases, and trace the connexion between their cha- racters and variations in the elements that constitute thenL Of course the study of a symptom in any individual case must be conjoined with a proper survey of its functional or organic cause; but as we have also (sometimes only,) to treat the symptom, it is highly useful to study its varieties, and thus to render it more practically instructive. The cough may vary according to, 1. The irritant exciting it; 2. The sensi- bility feeling the irritation; 3. The movements thereby excited, which consist of (a) the contraction of the muscles of respiration, and (6) the contraction of the air-tubes; 4. The condition of the bronchial membrane and its secretion. Under these heads, we shall meet with the varieties of cough with which every practitioner is familiar. 1. The violence of a cough will, cseteris paribus, be in proportion to the degree of irritation that excites it. For example, a healthy person whilst eating or drink- ing incautiously, suffers some food to enter the glottis; the cough thereby excited will be more severe with wine or any thing peppered, than with water or any bland food. So in the early stages of catarrh, although the sensibihty of the membrane is increased, yet the thin saline-tasted secretion also acts as an unusual irritant upon it, and keeps up a short teasing tickling cough, with continued attempts to clear the throat. When the irritation is more moderate, but irremovea- ble, like that occasioned by incipient tubercles in the pulmonary tissue, the cough will generally be of that slight hacking kind, with little or no expectoration, that is so well-known as one of the first symptoms of pulmonary consumption. The irritant here remaining the same, the circumstances which increase this cough are those that augment the sensibility of the lung and air-tubes, such as a quickened state of the circulation from exertion, heated rooms, or during the assimilation of stimulating food. 2. We have already adverted to increased sensibihty as being concerned in the cough of recent bronchitis or bronchial irritation. It becomes, however, more developed when the cough has lasted several hours, and instead of being short and tickling only, it comes on in more violent and prolonged fits, which are quite irresistible, and often accompanied by a feeling of soreness. The heightened sensibility of the air-tubes is farther manifested by the readiness with which breath- ing air at all cold, or swallowing any thing at all irritating, will excite cough. We have before remarked how this increased irritability of the inflamed air-tubes is commonly joined with the augmented irritation of their secretion; but we do sometimes meet with cases in which the increased* sensibility is purely nervous, unaccompanied by any secretion; and the cough is brought on by the slightest cold or irritating matter in the air. Even strong odours will sometimes cause it These nervous coughs are to be treated chiefly by various remedies which dimi- nish the sensibility of the nervous system, such as narcotics, or sometimes by those which excite stronger impressions in other parts, such as epispastics and the application of heat. 3. Besides the sensibility of the bronchial membrane, another property connected with the nerves, muscular mobility, may be the source of some varieties of cough. We cannot here examine the circumstances under which a change of proportion-! coughing. 223 ate relation takes place between the action of the motory nerves in general, and the impressions which excite them. It is sufficient for us that the fact is well known, that in certain conditions or states of the system, an ordinary impression will excite inordinate motions; while in others the motions resulting from similar impressions will be imperfect, and below the natural amount. It is thus also with the motions of muscles concerned in coughing; they may be excessively mobile, so that the least irritation will set them a going; and, like a clock without its pendu- lum, they continue their impetuous motions, until their strength has fairly run out. This is the convulsive cough which we meet with in some hysterical and nervous subjects, and its convulsive character is the more evident from the fact, that it sometimes alternates with chorea, or convulsive affections of other sets of muscles. The same uncontrollable character is, however, often communicated, by a nervous temperament or peculiar nervous affections, to coughs arising from common causes, which thus shake and exhaust the patient in an unusual degree, and require appropriate modifications of treatment to subdue them. Hooping-cough in its after stages is of this kind, and from our experience we should say, that the shaking uncontrollable nature of the cough is more characteristic of per- tussis, than the hooping, which is not always present, especially in adults. This leads us to consider on what hooping depends ; and here again we shall find the use of our physiological divisions, which explain some other varieties of cough that are sometimes met with. In considering the physiology of respiration, we are led to believe that the act of expiration is aided by the contraction of the circular fibres of the air-tubes. In the forcible expirations which constitute ordinary coughing, there is also a simul- taneous contraction of the air-tubes, and especially of the aperture of the glottis, through which the air is driven with the greatest force, in order to expel any irri- tating matter. Now the contraction of these tubes may be excessive, defective, or irregular, and this will occasion other varieties of cough. When their con- traction is excessive, being also generally irregular, they give the wheezing cha- racter to the cough, so remarkable in asthmatic subjects. A wheezing cough does not always depend on contraction of the circular fibres, for other constrictions of the bronchi will also cause it; but if we listen to the chest of a nervous asthmatic, we may often hear, in the forcible expirations of a fit of coughing, sibilant and sonorous rhonchi, which are too transient to be produced by the thickening or secretion of the tubes. Where the irritability of the bronchi is great, their con- traction may not, as usual, cease during the act of inspiration; and it is this spas- modic constriction affecting particularly the upper part of the air-tube during the forcible inspiration which succeeds to coughing, that causes the hooping sound. This state of things happens chiefly in the iiritable frames of children when affected with convulsive cough; and the violence and repetition of the expiratory efforts of this cough occasion the back draught to be more forcible, sonorous, and prolonged. If we apply our ears to the chest of a child during a fit of hooping- cough, we are surprised to find how little sound we can hear there with all these noisy external efforts; in fact, the continued constriction of the bronchial tubes permits very little motion of air into and out of the tissue of the lungs: in the convulsive cough of adults, again, in which there is seldom hooping, the respira- tory murmur of the long inspiration, or back draught, is pretty loud, whilst the succession of coughs here also consists more of external than of internal move- ment. In all these kinds of cough, antispasmodics will often give more relief an any other class of remedies. But we have an opposite condition of the circular fibres of the bronchi, a weak- ness or deficiency of action, a paralysis, so that they do not contract as usual during the expiratory efforts of coughing. This constitutes the hollow or bark- ing cough which we sometimes hear in chronic bronchitis, and now and then in febrile and nervous affections. This cough is, as we shall presently find, accompa- nied with a difficulty of expectoration; hence it is sometimes very distressing, and 224 DIAGNOSIS OF DISEASES OF THE LUNGS. particularly so when, as it occasionally happens, it is combined with a mobility of the external muscles of respiration, rendering the cough convulsive and paroxysmal. The tearing and exhausting fits of this kind of cough are sometimes quite ago- nizing; and we may judge from the bloated, congested appearance of the lips and face, how much these fits impede the respiration and circulation, and how much they may thus tend to increase and perpetuate the diseased condition of the bron- chial tubes. In some such cases we have seen the terebinthinaceous medicines, with external counter-irritation and occasional emetics, give most relief; but the treatment will depend on various circumstances, which cannot be entered into at present. 4. Besides the sensitive and motory apparatus concerned in the act of cough- ing, we have the secretion of the air-tubes, which may also by its qualities mo- dify the character of the cough. According to whether this secretion is present or not, the cough may be humid or dry; and according to the relation of the qua- lities of this secretion to the powers of expectoration, the cough may be loose or tight; and these varieties may be combined with the other species of cough, as those may with each other; and thus are produced the endless host of different kinds of cough that we meet with in practice. Without pretending to affirm, that it is always possible to classify these by the division now pointed out, we may state that we have often found this analysis useful in drawing attention to the predominant changes of vital property, as manifested by symptom, and in thus distinguishing cases which require different modes of treatment. Expectoration. The expectoration is another symptom of thoracic disease," which must be considered as the result of vital as well as physical properties, and therefore it is included under the head of general diagnosis, although it some- times approaches in character to a physical sign. The word expectoration strictly means the act of expelling any thing from the chest; but by a figure of speech it is also applied to the matter so expelled. We shall find that both the act and the matter of expectoration may present us signs of the condition of the pectoral organs. If we consider the structure of the bronchial tree, we shall perceive that natu- ral breathing tends to prevent the accumulation of matters in its tubes, in spite of gravitation. The area of the smaller divisions of the bronchi is considerably greater than that of their trunks; and it may be represented as the divided base of a hollow cone or funnel, which is concentrated gradually in the trunks, and completely in the windpipe. The air, in the more sudden act of expiration, passes with greater rapidity and force as it converges into these trunks, and there- fore tends to carry through them any superfluous matter that may be present on the bronchial surface. This will explain how the finer bronchial tobes of the most dependent parts of the lung are, in health, kept clear of any accumulation. Possibly the ciliary motions of the mucous membrane may, as MM. Purkinjie and Valentin have surmised, tend to the same effect But it is the forcible acts of special expectoration, hawking, and coughing, that tend most effectually to clear the air-passages; and they do this by both in- creasing the force and fulness of the expiratory effort, and at the same time con- tracting the upper tubes and trachea, so that the air acts with greater force on any superfluous matter in them. The repeated closure of the glottis in coughing in- creases the expulsive effort by letting out the air in successive sudden jerks, which are more forcible than any continued act of expiration would be. We see this exemplified in cases where the operation of bronchotomy has been performed. The patient often cannot expectorate effectually so long as air can pass out from the artificial opening, and he is in danger of suffocation in consequence; but on closing this during the act of coughing, the force of the air can be directed in the natural way against the accumulated matter. By attention to this particular, suffocation has been averted in more than one instance after this operation. In certain diseased conditions of the larynx, the patient cannot close the glottis; and EXPECTORATION. 225 hence also expectoration may be difficult, while the cough assumes a continuous uncontrollable character, which we might have added as another variety to those before enumerated. This is what M. Trousseau calls a belching cough. There is another element essential to the proper performance of the act of expectoration—the capacity to make such a full inspiration as shall carry the air in beyond the accumulating matter, so that it may on its forcible passage out again, carry this matter before it. Hence we see why weakness, which prevents a sufficient inspiratory effort, or obstruction of the terminal and most expansible parts of the air-tubes, vfrhich renders this effort ineffectual, may stop the act of expectoration, and by permitting the accumulation of matter in the air-tubes may speedily conduce to a fatal result. Inability to expectorate is the immediate cause of death in many cases of various diseases; in fact, it is a part of the article of death itself; and when we hear the rattle in the throat of the dying, we hear the sign of the accumulating barrier which is shutting out the breath of life. Some- times, even at this stage, there are sensibilities enough in the system to feel the force of a stimulant which may excite the sinking powers to another struggle; expectoration is once more accomplished, and breath once more renewed; and where there is no irrecoverable alteration of structure, this act of expectoration may in some few instances turn the balance in favour of recovery. It is unne- cessary to say, then, how important it is to study the act of expectoration, and to acquaint ourselves with those means that may excite or promote it. Most prac- titioners have seen instances in which a patient has been snatched from the jaws of death by the timely administration of a diffusible stimulus, such as a warm aromatic draught, with carbonate of ammonia or ether, together with such a change of posture and other circumstances as might most favour the explosion of the matter that was suffocating him. A great deal may often be done in less ur- gent cases by attention to the posture of the patient. This is particularly the case with children, and with aged patients who have nearly as much difficulty in expectorating as children. They should never be suffered to lie for many hours in the same position, and children should not even be permitted to sleep many hours at a time if the secretions of the lungs are retained. G. In most instances the act of expectoration is easiest in that posture in which the respiration is most free, which is commonly the semi-erect posture: but some patients expectorate more freely when lying on one side; and we remember a phthi- sical patient who really appeared to be several times saved from suffocation by alter- nating his posture from lying down to sitting up in a particular manner, suggested by a knowledge of the condition of the lungs in that case. When this expedient was neglected, the patient was so shaken with frightful fits of fruitless cough, and so oppressed with the accumulating matter, which they could not expel, that speedy suffocation seemed inevitable. In some cases, the act of expectoration may be favoured by another kind of action, in which the expiratory muscles are concerned, that of vomiting; and we shall find hereafter, that some emetics may exert an influence of an important nature on the bronchial tubes, besides this mechanical one. The character of the expectoration frequently furnishes us with very instructive signs. It is the product of diseased action, and in its physical or chemical qua- lities it may inform us somewhat of the nature of that action, of the condition, and sometimes of the position of the parts from which it comes. As, however, we have seen that the effort of expectoration is sometimes unsuccessful, there may be no expectoration to judge of; and besides this instance, most children and some adults cannot spit out what they expectorate, but swallow it. The basis of expectoration generally is the secretion of the mucous membrane of the air-tubes. This is naturally a transparent, colourless, slightly glutinous liquid, like thin mucilage. The chief animal matter which it contains is that called mucus, which seems to be a sort of imperfectly coagulated albumen, and Vol. II.—29 226 DIAGNOSIS OF DISEASES OF THE LUNGS. the varieties of sputa presented by disease commonly depend on an unnatural condition or quantity of this animal matter. There is also saline matter, which may vary in quantity, and so may the proportion of water. From the recent ex- periments of Dr. Golding Bird, as well as those of Dr. Babington and Mr. Brett, it would seem that the condition of animal matter in the expectoration depends in great measure on the proportion of saline matter with which it is combined, this being in abundance in transparent and viscid expectoration, and defective in the opaque kind, with little viscidity, and least of all in that which is absolutely purulent. Dr. Babington found, that on mixing pus with a solution of common salt, after a time it became converted into a nearly transparent viscid mass like mucus; and Dr. G. Bird rendered the physical and chemical resemblance perfect by adding a little soda, and then passing a current of carbonic acid gas through it. (Guy's Hospital Reports, No. vi.) Mr. Brett, in a valuable communication to the medical section of the British Association in 1837, states that he found the saline matter of transparent viscid mucous expectoration to amount to from 20 to 33 per cent, of its solid matter, whilst that of the opaque viscid mucus of chronic bronchitis was from 16 to 23, and the puriform expectoration of the last stage of phthisis was only from 9 to 10 per cent. These researches confirm the opinion we have long held, that the difference between mucus and albumen seems to con- sist in their physical condition, rather than in their chemical constitution. Mucus is a transparent glutinous matter, not coagulable by heat, as liquid albumen is, and not solid and opaque like coagulated albumen; but on ultimate analysis it is not found to differ from this principle. When, therefore, we see expectorated matter opaque and solid, or liquid and coagulable by heat, it loses the only dis- tinguishing characters of mucus, and is strictly albuminous. For this reason, we submit the following general classification of expectorated matter:— 1. Mucus, more or less transparent and viscid. 2. Albuminous, opaque without viscidity. 3. Watery, thin and transparent. 4. Compound, composed of combinations of the preceding kinds, 1. Mucous expectoration is that most like the natural secretion, being trans- parent, and more or less viscid. It is the general result of simple acute inflam- mation of the mucous lining of the air-tubes, in which case it is increased in quantity, and particularly in viscidity; in fact, the glutinous character of the sputa, and the tenacity with which they stick together and to the containing vessel, or fall out in a ropy mass, was described by Andral, and we think correctly, to be a mark and, in some degree, a measure of acute bronchitis. From the researches just alluded to, it would appear that the viscidity of these sputa depends on their quantity of mucus, which is albumen combined with saline matter, to which is sometimes added free uncoagulated albumen. In the most intense forms of in- flammation, and where the disease occupies the finer tubes, to the glutinous cha- racter of the mucus is added a frothiness, arising from the mixture of those air- bubbles in the tubes, which in their breaking cause the mucous and sub-mucous rhonchi. But the most intense bronchitis is that accompanying inflammation of the parenchyma: here we have the most viscid form of sputum, through which air driven produces the crepitant rhonchus; and the blood in the distended ves- sels of the engorged parenchyma communicating a little colouring matter to it, gives it that reddish or rusty tinge which is so characteristic of the sputa of peri- pneumonia. The transparent or semi-transparent condition of these viscid sputa distinguishes them from the albuminous kind, into which, however, they pass in the advanced stages of all the more inflammatory affections of the bronchial membrane. The mucous expectoration has commonly a saltish taste, and with its saline matter is probably connected its irritating quality, so marked in the early stage of bronchitis. 2. The varieties of albuminous expectoration are pretty numerous, for under this head are comprehended the opaque kinds of sputa which have no remarkable viscidity, such as the purulent expectoration of chronic bronchitis, the fibrinous or polypous sputa of plastic bronchitis, and the more compound combinations of EXPECTORATION. 227 these with caseous and other matters, which are voided in the advanced stages of pulmonary phthisis. This class of sputa denotes an error of secretion, farther than the mucus from the natural standard, there being a defective proportion of saline matter, as well as an excess of albuminous; but their production generally announces a decline of inflammation from its most acute form. Probably, the very throwing off of so considerable a mass of animal matter, is the means of re- lieving to a certain extent the inflamed vessels; for we frequently find the puru- lent or polypous expectoration in intense bronchitis attended by a remarkable diminution in the signs of local and general excitement. This remark has been made also by Dr. Stokes. But such an expectoration ceases to be a favourable sign when it continues, either with undiminished irritation, or with proofs of general weakness; for then a change is implied, either in the structure, or in the habitual action of the membrane, which, secreting pus instead of mucus, goes beyond the mere removal of a temporary congestion, and proves itself a cause of irritation and exhaustion. Much has been written about the modes of distinguishing pus from mucus in the expectoration. On these formerly the diagnosis of pulmonary phthisis was supposed to depend. These tests are not now much attended to, not only because it is well known that pus may be produced without any ulceration or consumption of the lung, but also because these distinctions cannot be complete between mat- ters that pass by insensible gradations into each other. The chemical composition of pus resembles that of the colouring globules of the blood, and differs from mucus in containing a notable quantity of iron. 3. Watery expectoration is that kind in which a liquid of only slightly glutinous quality is coughed up in greater or less abundance. This appears to contain very little animal matter, and to be rather a diluted mucus than to have in it any thing peculiar. It is often covered with a froth, particularly when it is coughed up with much effort. This secretion is to be regarded as the result of irritation, with a relaxed state of the vessels, rather than of inflammation; but it may occur as a con- sequence of this lesion, as well as of congestion or obstruction to the circulation of the blood in the lungs. It is the expectoration of what is called humid asthma and pituitous catarrh. Some persons of a relaxed habit have it during a common cold, or any form of bronchial inflammation. It sometimes tastes more salt than usual, and in this case it commonly causes a more incessant teasing cough. 4. Under the head compound expectoration, are classed various combinations of the preceding kinds, which we meet with in almost every form of pectoral dis- ease. They are either products of different parts, in distinct pathological condi- tions, although coughed up at the same time; or they may in some cases proceed from the same part in an intermediate pathological state, and capable of secreting differents kinds of matter. An example of the latter is the opaque or muco-puru- lent expectoration of the latter stages of bronchitis, in which the opacity and colour of albuminous matter is apparent, whilst it is held together by a mucus of some tenacity. In the concocted sputa of declining acute bronchitis, the mucus predomi- nates; whilst the loose albuminous matter is more abundant where the inflamma- tion tends to pass into a chronic state. The sputa of chronic bronchitis, and in fact of most chronic diseases of the lungs and air-tubes, are almost always more or less mixed; for it generally happens that the different parts of the membranes and tissues are variously affected: and when, as in the advancing stages of phthisis, there is structural lesion or destruction of parts, there is the greater reason for a more heterogeneous kind of expectoration. In these cases, however, the albumi- nous kinds mostly predominate, in the form of muco-purulent, purulent, caseous, or tuberculous matter, and coagulable or fibrinous lymph, occasionally tinged or mixed with the colouring matter of the blood: these constitute the bulk of the expectora- tion of the consumptive. In catarrhal diseases of a chronic kind, we commonly see very opposite forms of sputa expectorated together. Thus in a spitting-dish full of thin, frothy watery expectoration, we often find portions of tough and almost solid semi-transparent mucus, as if some parts of the tubes were throwing off the 228 DIAGNOSIS OF DISEASES OF THE LUNGS. water, and others the animal matter, in a separate form. When the subject of catarrh is treated of, we shall find that these opposite products do not imply an equally opposite pathological condition. After hemoptysis, it is very common to see fibrinous concretions, together with purulent and mucous matter, all more or less tinged with blood. In other affections it is not uncommon to see the sputa streaked with blood; and this sign is of less importance when the cough is violent, because it may then merely proceed from a slight abrasion caused by the force of this mechanical action. When, however, there is often blood present, without much force of cough, and especially if there be pus with it, we may suspect the presence of ulceration in some part of the air-passages. The colouring matter of the blood in an altered state, may also be combined with other forms of sputa. Thus, in scorbutic persons affected with humid catarrh or bronchitis, the expectora- tion is a thin, reddish-brown liquid, like prune juice or diluted treacle; and in the last stages of pulmonary disease, the colouring matter, from the final pulmonary congestion which precedes death, is seen in the dirty reddish-brown or greenish tinge of the purilaginous sputa. It is evident then, that the matter of expectoration will often inform us of the pathological condition of the lungs and their tubes; and its quantity or quality may sometimes suggest proper remedies. In some cases we may learn other things from it. Thus, when in consumption, tubercular matter with portions of pulmo- nary tissue is expectorated, the conclusion is obvious. We also sometimes see the expectoration present physical signs of the state of the interior by its containing albuminous or compound matter, moulded into the shape of the tubes or cavities from which it comes. The large rounded flocculent muco-purulent sputa of ad- vanced phthisis are often such as could only accumulate in a cavity; and that the tubular or vermicular albuminous matter which is coughed up in the plastic kind of bronchitis, sufficiently explains whence it comes, by its being an exact mould or cast of the bronchial tubes, sometimes in an aborescent form, from several of their divisions. We must not omit to notice a test, which is erroneously used to determine the nature and source of sputa, whether they float or sink in water. The floating of a sputum merely depends on the number of air-bubbles, retained in it, and although pus alone, or tuberculous matter alone, will not retain these bubbles, yet a small addition of tenacious mucus will enable them to do so. Again, although the sputa formed in ulcerous cavities are less likely to contain air and to float than those formed in the tubes, yet we not unfrequently find the concocted ex- pectoration of acute bronchitis, which is formed exclusively in the large tubes, sink in water; whilst the mixed product of a vomica and the adjoining tubes, which has been churned together with air, floats. This hydrostatic test of expectora- tion is then a very inconclusive one; but it may be useful in sometimes causing a rough separation of the albuminous matters from those of a more viscid mucus kind. Other details regarding the matter of expectoration might be given; but enough has been said to illustrate how it may prove useful in diagnosis and practice. From this it will appear how much more valuable its indications may become when conjoined with the physical signs, by which we may often detect the position, and measure the amount of the local disease, of which the matter expectorated is the product. We shall find many exemplifications of this position hereafter. Pain. The only other morbid phenomenon, connected specially with the modified vital properties of the organs of respiration, is pain. We know that pain may arise either from an excessive impression on the nerves of sensation, or from an excessive sensibility of these nerves, to which common circumstances of position, motion, &c, then become painful. The latter is the more common cause of pain in internal diseases; but it is not unusual to find them combined, as when a tumour, or effused matter, presses on or stretches parts morbidly sen- sible. The most common causes of pain are inflammation, and those kinds of vascular excitement that are allied to it: this vascular excitement is generally PAIN. 229 attended, in the first instance at least, with exaltation of the nervous function. But the nervous function may be primarily excited; and although the increased sensibility thus produced seldom lasts long without more or less stirring up the function of the vessels also, yet we may for a time have pains purely nervous, such as pleurodyne and pectoral neuralgia. Farther, as inflammation is not the only cause of pain, so the pain present in inflammation is by no means an index of the extent of the inflammation, nor even of its situation. Most extensive in- flammations have been known to occur, not only in the parenchyma of the lungs, but in the bronchial membrane and pleura also, without producing any pain; and it frequently happens in phthisis, that the pains chiefly complained of are low down in the sides, when the disease is almost entirely in the upper lobes of the lungs. So likewise in bronchitis and pneumonia, the pain is often confined to the sternal, lateral, or scapular regions, whilst the disease occupies other parts. There are, nevertheless, some general characters with regard to pain, which may render it useful as a symptom of disease of the chest. It is commonly re- marked, that the pain of parenchymatous and bronchial inflammations is dull and diffused, whilst that of inflammation involving the serous and fibrous membranes of the pleura and pericardium is of a sharp lancinating character. This is gene- rally but not constantly true; and we may find it explained by the circumstance, that the par vagum, which supplies the bronchi and lungs, is by no means so sensitive a nerve as the spinal intercostals, which are distributed on the pleura and pericardium. For this reason, too, there is more apt to be acute pain when the costal pleura or the coverings of the great vessels are inflamed, than when the pulmonary pleura is the chief seat of disease. A farther distinction in the variations of these divers kinds of pain will confirm the opinion, that they belong to different orders of sensibility. The dull, heavy, or aching pain of bronchitis, or pneumonia, is generally pretty constant, although it is increased by full inspi- ration, exertion, or the breathing of cold air; yet even then it gives the feeling of soreness under the sternum, rather than of severe pain. It often resembles the pain of dyspepsia, which is probably seated in a branch of the same nerve, and is also usually referred to the sternum. The degrees of pleuritic pain, on the other hand, are sudden, extreme, and intolerable. If it be not felt in ordinary breathing, a long breath, or a cough, just sufficient to bring the membranes to a requisite degree of tension, causes that sharp stitch of the side—that sudden catch of the breath, that has been considered so characteristic of pleurisy. When it is constant, the patient is obliged to hold his side to diminish its severity, by restraining the motions of the chest; and thus placed in opposition to the sensa- tion which prompts the act of respiration, this sharp pain may cause such a voluntary restraint of these acts, as to bring the patient to the verge of asphyxia. It is under these circumstances that the breathing becomes partial, as formerly described, and patients whom pain constrains to breathe only with the diaphragm or with one side, will perform this supplementary respiration so well, that they are completely free from pain, although the inflammation is as acute and the membranes as tender as ever. Sometimes we may detect the latent tenderness by pressing between the ribs of the affected side; but we are more likely to suc- ceed if we restrain the supplementary respiration by pressing on the abdomen or on the healthy side, and then desire the patient to cough, or to take a sudden long breath. If there be any exalted sensibility or tenderness, it is pretty sure to be discovered by this means; and we have several times met with patients who denied having any uneasiness or tenderness, yet they winced at the pain developed in this way. As a general rule (not however without some exceptions,) we may consider a fixed permanent pain, or a permanent tenderness, which depends on the same pathological cause, an indication of inflammation, or congestion, or some analo- gous condition of the vessels; and when present it deserves attention, not only as an object of treatment on its own account, but also as an index, which together with the pulse, cough, fever, and other general symptoms, shows the increase 230 DIAGNOSIS OF DISEASES OF THE LUNGS. and diminution of the complaint, and the effects of remedies, even before these become manifest from the physical signs. Still, if we trust to it alone, it will negatively deceive us in those numerous cases of extensive disease in which it is absent, or scarcely complained of; and it will positively deceive us in those cases in which modified nervous sensibility—a mere neurosis—is the only or the chief disorder. We come now to examine shortly the nature and value of the symptoms which diseases of the organs of respiration develope in other functions. Physiology indicates the close relations which subsist between the organs of respiration and those of circulation; and prepares us to expect that the disease in the former should disturb the latter, and develope symptoms in the function of circulation. Accordingly we find such symptoms in the state of the arterial pulse, and in that of the superficial capillary and venous parts of the circulation. The pulse. The pulse has for ages been relied on as a guide in the diagnosis and treatment of all diseases; but those who have had much experience, know how fallacious it sometimes proves; and those who have had little experience must acknowledge that it is very difficult to distinguish the varieties of the pulse from one another. Some of the fallacies and difficulties connected with the pulse as a sign, appear to arise from our studying it too empirically,—from our not rationally considering those elements on which its varieties depend, and a know- ledge of which would enable us to understand and to foresee the circumstances which are capable of producing these varieties. To guide the student to this knowledge, we will give a brief analysis of the nature and varieties of the pulse of arteries. The arterial pulse is caused by the jets of blood thrown at certain intervals of time into the arteries by the contractions of the ventricles of the heart. The mo- tion originates exclusively in these contractions, although it may be modified by the blood which is moved, and by the tubes which convey it. Now here are three elements:—1. The heart; 2. The blood; and, 3. The arteries;—and va- riations in the condition or action of each of these cause varieties in the arterial pulse. Let us consider a few of these variations. 1. Without noticing the modifications in the action of the heart resulting from disease of that organ—a subject to be considered hereafter—it is plain enough, that if the other elements be equal, the strength and frequency or rhythm of the contractions of the left ventricle of the heart, will determine the strength and fre- quency of the arterial pulse. But the contractions may have another quality— that of abruptness: being rather brisk and short than strong and complete, they communicate to the pulse that character which is called sharp. Now what pro- perty in the heart gives it this abruptness of contraction? what but an extreme irritability? There is sometimes this irritability in inflammations and fevers; but we find it also in conditions of mere nervous irritation, of which it is more distinctive. And it is when these coexist with inflammation or fever, that the pulse presents a sharpness, in addition to other qualities more peculiar to inflam- mation. In sthenic irritation, or those connected with fulness and tone of the vascular system, which may tend either to acute inflammation or to active haemor- rhage or other discharge, the heart's contractions are strong as well as sharp; and so is the pulse. In these cases, although the original irritation were local, it has now reached the centre of the circulation, and thence, distributed through the whole system, becomes general. But let us see how the other elements modify the pulse. 2. There can be no doubt that the blood in the heart and vessels determines by its quantity the character of the arterial pulse: very possibly it does so by its quality likewise; but this is not so easy to prove. The fulness and strength of the pulse in the arteries depend materially on the quantity of blood in them; and when the pulse is frequent as well as full, there is the greater proof of plethora, inasmuch as it shows that there is a considerable jet thrown into the arteries at each contraction, notwithstanding that the contractions are so frequently repeated. PULSE. 231 But there may be a full system of blood-vessels without a large or strong pulse,— as when the heart is acting feebly or faintly; and where its irritability is lowered, such a mode of action may be actually caused by the congestion or distention which for a time oppresses the function until it is roused into reaction. Under these circumstances, blood-letting will often increase the fulness and strength of the pulse. The opposite condition—a defective quantity of blood—will modify the pulse differently according to the state of the other elements, the action of the heart, and the arterial nerves. When the irritability of the heart is reduced, to- gether with the quantity of blood, the pulse will become softer, weaker, and less frequent. But it frequently happens, especially is nervous temperaments, or where the depletion has been carried to excess, that the diminution of the blood is accompanied with an augmented irritability of the heart, and the pulse becomes not only quicker, but sharper than usual; and the effect of the abrupt jets into a small bulk of blood contained in imperfectly distended tubes, is to give to the pulse that jerking or bounding character, as if a mere ball of liquid were suddenly shot through the empty tube, which is so remarkable in the irritation of inanition and chlorosis. 3. But we cannot fully understand the variations of the pulse without attending to the properties of the tubes in which it is felt If the arteries were tubes of an un- yielding or an unvariable character, then the pulse in them would more uniformly represent that of the heart, which would be transmitted through them unmodified. But we know that they are not so: they possess properties of elasticity and toni- city, which vary according to circumstances, and which modify the pulses from the heart, by changing the size of the tubes, and the yielding or the resisting nature of their walls. It is plain that the impulse of a jet of blood must be differently transmitted by vessels when they are large and yielding, and when they are con- tracted and tense: in the first case the pulse would be soft and full, in the latter hard and small. We know but imperfectly what are the circumstances which affect the tonicity and elasticity of the arterial coats, and thereby the pulse: farther experiments are wanted to elucidate them, but the following are pretty well-ascer- tained, and they should not be forgotten in estimating the signs of the pulse. Cold causes the arteries to contract, and therefore renders the pulse smaller. We know how a cold lotion will often diminish the fulness and throbbing of the arteries of an inflamed part; and we have seen the same effect of cold more strikingly produced in the large arteries. In the experiments on the sounds of the heart carried on in February 1835, we repeatedly observed, that when the aorta of an ass, recently killed, was plunged into cold water, it contracted, so as not to permit the introduc- tion even of the little finger, and its coats acquired an increased thickness and rigidity: the pulmonary artery did not contract nearly so much. The circum- stance of temperature must therefore be taken into account in judging of the pulse; for cold may render the pulse of an artery small and hard, or, if severe, small and weak, when the action of the heart and the condition of the system would give it the reverse qualities. Heat, on the other hand, within certain limits tends to diminish the tonic contraction of the arteries; so that under its influence they receive more strongly and fully the pulse from the heart We know how warmth restored to a limb makes it throb with these expanded pulses. But there is another circumstance that may modify these actions of heat and cold on the pulse, besides proving by itself a cause of modification—the condition of the capillary circulation. When this is not free, the artery will be more dis- tended, and therefore the pulse harder and stronger than usual; and thus in fevers, where the surface is pale and constricted in the cold stage, and dry and unrelaxed in the hot stage, the pulse often preserves through these changes of temperature a hardness and strength which would be much more varied were the capillary ves- sels free and exhaling their usual excretion, and which is actually diminished under the influence of a warm bath or temporary moisture of the skin, although the fever still continue. Again, whatever view we take of the nature of inflammation, we cannot, in the present state of pathological knowledge, doubt that the circulation 232 DIAGNOSIS OF DISEASES OF THE LUNGS. through the inflamed vessels is to a certain degree obstructed; whilst, either as a consequence of this, or from some co-operating influence, the vessels leading to the part become dilated, and being thus more open than others to the pulse-wave from the heart, which their distended coats cannot temper as usual, they become the seat of that throbbing hard pulse, that has been mistaken for increased action of the vessels themselves. And there are many other variations in the pulse expli- cable on these principles, but this is not the place to consider them farther in There is, however, one more cause of variety connected with the arteries, so frequently occurring, that it must not be overlooked, viz., the difference in the arteries of different individuals. Without any adequate difference in the action of the heart, in the quantity of blood, or in the temperature, we find a very remarka- ble variety in the character of the pulse in different healthy individuals; and the same difference extends to the modifications of disease. Some have always a soft large pulse; in others it is small and feeble; in others small and hard: others, again, have habitually a hard strong pulse, which scarcely becomes soft under any circumstances. The first depends on the arteries being large, with thin elastic coats. The small feeble pulse may result from their small size and thin coats: this is common in females, and may coexist with inordinate action of the heart The hard wiry pulse is connected with small arteries with rigid coats; and the same rigidity or deficiency of elasticity in the coats of arteries of larger size gives that unvarying hardness and strength to the pulse which we so often meet with in old people, and which renders it so uncertain a sign in these cases. We may often, in the radial artery, feel the permanent thickening and hardness of its coats, which thus, like a tube of glass or metal, rigidly transmit the heart's pulses, without tem- pering them by any yielding or spring. With these peculiarities of pulse there are often connected characters of constitution or temperament, and proclivities to dis- ease or health, which are of great importance in guiding us in practice. Besides the general causes which modify the pulse, which we have now briefly considered, there are some specially connected with diseases of the pectoral organs. Those arising from diseases of the apparatus of the circulation will be treated of in the article devoted to that subject. But severe affections of the respiratory organs also sometimes signally modify the pulse, and that in a manner which may tend to confuse its indications. We know how closely the heart is linked with the lungs; by the circulation even more closely than by mere positions; for the lungs may be said to lie between the two compartments of the heart, and any considerable obstruction in the lungs will derange the usual relations of these compartments. There is then a distention or over-stimulation of the right side of the heart; while the left, receiving a diminished quantity of blood from the lungs, and that not thoroughly aerated, is less excited than usual, and may give to the arterial pulse a character of weakness and smallness that by no means represents the condition of the whole vascular system, and which often is remarkably con- trasted by the action of the right side of the heart, as felt or heard under the sternum. These varieties are produced by any of those affections of the chest which infringe far on the respiratory function. These are more commonly those of the bronchial and parenchymatous kind, which have accordingly been described to be accompanied by a softer and weaker pulse than those affecting the serous membranes. But a pleurisy may occur also with a small weak pulse, when the effusion or pain is such as to interfere largely with the function of the lungs. Neither is it to be supposed that the pulse in severe pneumonia or bronchitis is always weak, even when these affections infringe considerably on the function of the lungs. Even under asphyxiating influences the left ventricle may sometimes become excited, together with the right, and give a sharpness to the pulse, which, combined with the arterial tension of fever, may be readily mistaken for hardness and strength. But this character is seldom permanent; and we generally find in all diseases, when the function of respiration is much impaired, that the pulse «oon loses its body and strength. These considerations suggest the expediency FEVER. 233 of examining the state of the circulation not only by the arterial pulse, but also by the pulsations of the heart itself, and by the condition of the veins and capillaries. Under the circumstances just mentioned, when the indications of the arterial pulse are most variable and deceptive, we may often find useful signs in the con- dition of the venous and capillary part of the circulation. The distention of the more superficial venous trunks, especially the jugulars, in which a double pulsa- tion often shows also the retropulsive action of an over-distended right ventricle,— the fulness of the capillaries of the lips, tongue, throat, cheeks, eyelids, nails, and other parts at first having a florid and flushed appearance, but afterwards, as the respiration becomes more injured, assuming a purple or livid hue,—are signs of great practical importance, and of a constancy more approaching to that of the physical signs. They do not, however, present themselves in the early and more tractable stages of disease; and they are always less distinct in pallid persons with small superficial vessels. Intimately connected with the state of the circulation is the symptom of general fever, or increased heat, which attends many diseases of the chest. It depends on increased force and rapidity of the circulation, with diminished perspiration. When the perspiration is restored, the heat always falls. This exhalation of fluid not only lowers the temperature by its physical agency of evaporation, but being in itself a sign of a relaxing of the superficial vessels, it implies an abatement of the vital irritation. In the more transient forms of fever, such as the intermit- tent and hectic, the profuse perspiration sometimes reduces the animal heat to be- low the natural standard, just as the circulation is proportionately enfeebled; and the same chilling influence is illustrated by the cold sweats which succeed to tem- porary and irregular excitement. There are degrees of vascular irritation in which the increased heat of skin is partial, and determined by the structure of particular parts. Thus in the asthenic excitement of hectic fever, the heat is most felt in the palms of the hands and soles of the feet, because the circulation is not strong enough to drive the perspiratory excretion through the thick cuticle of those parts, which become consequently dry and hot. The same thickness of cuticle, on the other hand, when once imbued with perspiration, often keeps these parts soft and moist, when there is no sensible perspiration, on other parts. Not unfrequently the unequal state of the circulation is exhibited in febrile and inflammatory disor- ders by the heat of the abdomen, back, chest, or head, whilst the extremities are cooler than usual; and occasionally the same locally increased action is manifested by partial sweats, which prevent the increase of heat, and tend to reduce the ex- citement. We have known a patient with pleurisy perspire profusely only from the affected side, for several days; and nothing is more common, in slight abdo- minal inflammations, than to find the pungent heat of the belly relieved by a per- spiration equally confined to that part. But we practice on the same principle, in applying to irritated or inflamed parts poultices, fomentations, and partial baths, which tend to bring the skin and superficial vessels to the same relaxed and expanded state which they have in a perspiring part. Heat of skin, therefore, is an uncertain symptom; for it depends on a condition of the superficial circulation that is by no means constantly associated with disease of the internal organs. When present, it may as much result from a general cause— an idiopathic fever—as from a local inflammation; and cases are not uncommon in which severe, and even fatal, visceral inflammations are attended, through a great part of their course, by free perspiration; nay, the same may be said of some fevers which are called idiopathic. Still the heat and condition of the skin be- come valuable guides, when taken in conjunction with other signs, inasmuch as they indicate the constitutional disturbance, which is an important part of the dis- ease, and which is sometimes as much to be considered in the treatment as the local disease which has excited it. So, likewise, when the presence of a disease has been established by other signs, the condition of the skin may prove a mea- sure of its increase or diminution more delicate and sooner appreciable than can be found in the physical signs. Thus an increased heat of skin, coming on Vol. TT.—30 234 DIAGNOSIS OF DISEASES OF THE LUNGS. during a bronchial or pulmonary inflammation, either indicates an increase of that inflammation or the addition of some abdominal or other irritation, which tends to aggravate the condition of the patient. So, too, perspiration breaking out in the hitherto dry and hot skin of a pleuritic patient, occasionally does prove critical, whether that word be applied to the excretion as a cause or as a sign of the amendment. Where there is disorder of the circulation, especially of a febrile kind, we may well expect alteration of the secretions, which are so intimately connected with it; hence we find the urine is scanty and high-coloured, and the secretions of the liver and intestines variously deranged. As a natural consequence, too, there will be disorder of the digestive and nutritive function: the tongue will be furred, or florid: the appetite will fail; the stomach will cease to digest; thirst will torment; the blood, no longer fed with chyle, will not duly nourish the textures, nor support the functions: the strength will fail; absorption continuing active, if time permit, emaciation will ensue; and various complications of these disturbances may diffe- rently modify the character of diseases of the chest. The sensorial functions, too, may be deranged, either in consequence of the secondary visceral disturbances, or more rarely by a more direct influence of the imperfect respiration on the brain and nervous system. A knowledge of the causes of asphyxia suggests also how certain states of the nervous system may tend to develope disease of the lungs. Thus insensibility, or coma, causes imperfect respiration, and consequently con- gestion of the lungs; and, as we shall hereafter see, a long-continued congestion of the lungs only requires the addition of vascular reaction to convert it into inflam- mation. Persons rarely recover from an asphyxiated state, without suffering more or less from the injury which it leaves in the vessels of the lungs; and not a few who have been recovered from suspended animation, have sunk under the pneumonia, or bronchitis, which supervened. We have thus rapidly glanced at some of the pathological relations of the organs of respiration to other functions, to give the reader an opportunity of considering rationally the nature and value of general symptoms. Dyspnoea, cough, pain, and signs of the circulation, with its concomitant, temperature, although often equivo- cal, yet when strongly marked sometimes assist us in diagnosis. It is just the reverse with the symptoms arising out of disorder of the other functions. The altered secretions of the kidneys, the liver, and the intestines, cannot inform us of the nature or presence of a disease of the chest; and still less will gastric derange- ment or sensorial disturbance. Not only will they not direct, but they tend essentially to blind us to the presence of pectoral disease; for they set up prominent symptoms of a new character, that may take the attention entirely from the real source of disease, and fix it on the brain, the liver, the stomach or intestines, the affections of which are only secondary, and often trivial. How often do we find peripneu- mony, or bronchitis, disguised by delirium or stupor, or by vomiting, a loaded tongue or diarrhoea. How often pleurisy, masked by jaundiced skin, a tender right hypochondrium, and clay-coloured faeces; or by lumbago, or nephralgia. How often tubercular consumption, obscured by sundry bilious, dyspeptic, or nervous symptoms. It will be happy for the practitioner (for his credit at least, if not always for the success of his practice) if he detect the enemy through its false colours, ere it triumph, and before the scalpel shall proclaim the delusion of his unwary mind. Tho physical signs will enable him to do this, and again we recommend them to the best attention of the student On taking a rational review of the general symptoms in comparison with the physical signs, we must come to the conclusion that as diagnostic means, the general symptoms fall far short of the physical signs. But it is not to be supposed that, because the general symptoms are often com- paratively of little aid in diagnosis, we are to neglect the study of them. They are almost always of great importance in prognosis and practice. The physical signs more surely show how the pectoral organs suffer; but having discovered this, to the general symptoms we must look for how the system suffers; and as LARYNGITIS. 235 the symptom often closely sympathizes with the injured organ, we may through them often watch the first turns of the disease before the change in the organ becomes physically appreciable. In the general symptoms we seek for those criti- cal phenomena, which, although sometimes deceptive, yet generally announce the tendency of the disease to one or other mode of termination. In them we study the vital forces and properties with which nature works, and the signs of what nature can do; and in our methods of treatment these become the standards to which we direct, and by which we modify, our remedies. When we treat a patient with peripneumony or catarrh, we do not apply our remedies merely to the local lesions, inflamed vessels, or a discharging membrane; we study the system at large, we examine other functions through the general symptoms, and we direct our treatment with due reference to indications from all these several sources. We see, then, that the mere stethoscopist is but ill-fitted to practice medicine. He may justly boast of his skill in diagnosis; his place of triumph will be the dis- secting-room, where he can show the lesions that he had detected ; but his prac- tice at the bed-side will be unsuccessful in proportion as local lesions vary in their general relations, and in the conditions of the constitution, or of other functions that may accompany them. The judicious physician will not omit to study the condition of the vital properties, which are exhibited in the general symptoms, as well as the local physical changes which have been already produced; and whilst he chiefly confides in the physical signs to indicate and measure the present local lesions, he carefully watches in the general symptoms the tendencies of those properties and functions which are capable of increasing or modifying these lesions, and are equally liable to be affected by them. The general symptoms being less intelligible and certain than the physical signs, need more experience to enable us to appreciate them; but we have found that even these also may be rationally studied, and may derive a light from a knowledge of physiology and the physi- cal signs, which experience alone could never throw on them. LARYNGITIS. General observations.—Two forms of Laryngitis—the Acute and the Chronic.—Symptoms of the acute.—Anatomical characters.—-Diagnosis.—Causes.—Prognosis.—Treatment.—Chro- nic Laryngitis—its symptoms.—Anatomical characters.—Diagnosis.—Causes.—Prognosis. —Treatment. Mucous or catarrhal inflammation not unfrequently affects the larynx, and is the cause of the hoarseness which often attends both mild and severe bronchitis. There are, however, other inflammatory affections of the larynx of a very serious and fatal tendency—those, namely, in which the inflammation affects the sub-mu- cous cellular membrane, and causes cedematous effusion into this tissue. The swelling which results, narrows the caliber of the larynx, particularly at the glottis, impedes the respiration, and often destroys life. To this form of inflammation the term Laryngitis is generally restricted. It may occur under the different forms common to other inflammations, varying according to its exciting causes, and to the state of the constitution. Dr. Cheyne has specified no fewer than nine varie- ties of Laryngeal inflammation, including the catarrhal form. For practical pur- poses, however, and for the sake of conciseness, we shall comprehend all the varie- ties under the Acute (which may be sthenic.or asthenic) and the Chronic. 236 LARYNGITIS—ACUTE. I. Acute Laryngitis. Symptoms. The sthenic form of acute laryngitis often begins with symptoms of tonsillitis, with difficulty of swallowing and fever, which is generally preceded by rigours. In this case the extension of the inflammation to the larynx, or its establishment in other cases, is announced by hoarseness, a frequent husky, and sometimes convulsive cough, followed by tenderness, pain and constriction in the larynx itself, with difficult, prolonged, and sonorous inspiration, the chest being free from signs of disease. On examination the fauces generally, but not always, are red and swollen, and sometimes, by pressing the tongue forwards and down- wards, the epiglottis may be seen erect, thickened, and of a bright or deep red colour. In this state the epiglottis no longer protects the glottis from the contact of matters passing into the pharynx; hence the act of swallowing not only is pain- ful, but often causes convulsive fits of coughing, and increased difficulty of breath- ing. At first the fever is decidedly inflammatory; the face is flushed, the skin hot, and the pulse full and hard: but this state is soon changed under the depressing in- fluence of the obstructed state of the respiration. A frightful train of symptoms then ensues, induced by the rapidly increasing impediment to the supply of air. The countenance becomes anxious in the extreme, and pallid; the lips livid; the eyes staring and watery; the nostrils raised; the voice is reduced to a whisper; the in- teguments in the fore part of the neck are sometimes oedematous; the pulse be- comes quicker, feebler, and less uniform. To quote the expressive description of that experienced observer, Dr. Cheyne, " the patient is restless and apprehensive, often changing his position, in the vain hope of obtaining relief; walking, or rather staggering to and fro in great distress; feeling that he is on the point of suffoca- tion, he cannot be ignorant of the danger to which he is exposed; hence he is wil- ling to submit to any means of relief, and is impatient of delay. In this stage, the sufferer seldom sleeps for many minutes at a time; when he begins to dose, he starts up in a state of the utmost agitation, gasping for breath, every muscle being brought into action, which can assist respiration, now a convulsive struggle. He is quite enfeebled, becomes delirious, drowsy, and at last comatose, the circulation being more and more languid, and he dies on the fourth or fifth day of the disease, or even earlier." Death has been known to take place seven hours after the at- tack ; in some cases it has been delayed for two or three weeks. The asthenic form of laryngitis differs from the sthenic in the absence of symp- toms of inflammatory fever, and sometimes of pain in the larynx and difficulty of deglutition. In other respects the symptoms are similar; with the same hoarse- ness and cough at the commencement, difficult and stridulous respiration, rapidly amounting to a feeling of strangulation, as if the upper part of the windpipe were closed, often with fits of convulsive coughing and increased difficulty of breathing, apparently of a spasmodic kind; and after inducing symptoms of partial asphyxia in one of these paroxysms, the disease may prove fatal suddenly or more gradu- ally, by the patient after repeated attacks falling into a state of insensibility. In one of the asthenic forms of laryngitis, the inflammatory symptoms are by no means prominent; and the affection has long been termed osdema of the glottis, because an effusion of serum or pus into the cellular tissue of the lips of the glot- tis is the destructive lesion, and few other traces of disease are found after death. In other cases, particularly those arising from erysipelas, whether propagated from other parts or at first attacking the throat and larynx, and those of laryngitis supervening on continued fever, small-pox, scarlatina and measles, the symptoms of local inflammation are more severe, pain and difficulty of swallowing are pre- sent, and after death, the epiglottis and other parts of the larynx are found in- flamed and swollen by the effusion of lymph or pus into their cellular texture. The course of all these forms of laryngitis may be as rapid as that of the sthenic kind, but it is seldom so uniformly progressive, particularly in the cedematous va- riety, in which the attacks of difficult breathing are sudden and rather severe at laryngitis, (Anatomical Characters.) 237 first, and may prove rapidly fatal; or they may subside for awhile after the ex- pectoration of a little glairy mucus, and recur again with increased severity; in the interval the breathing being pretty free, but the voice still hoarse, and the sen- sation of a tightness or lump in the throat remaining. In the cases in which the obstruction is chiefly cedematous, it generally occupies the cellular tissue of the glottis, and from thence to the ventricles, the epiglottis being comparatively free, and there being little or no difficulty of deglutition; but in the erysipelatous cases, as in the sthenic form, the epiglottis is frequently thickened, the patient experi- ences difficulty and pain in swallowing, the attempt to swallow liquids sometimes causing a spasm so violent as to resemble that of hydrophobia. Causes. Acute laryngitis may follow exposure to cold and wet. It may ori- ginate in cynanche tonsillaris, and, according to Dr. Stokes, incynanche parotidoea, which he has found to be inflammation of the cellular membrane only, and not of the parotid gland itself. Acute inflammation of the larynx has been brought on by swallowing scalding or corrosive liquids by the convulsive action which these excite in the throat; they are in part thrown on, and even into the glottis. Children accustomed to drink from the mouth of a tea-kettle or tea-pot have often attempted to do this when these vessels contained scalding water; the result has been violent inflammation of both pharynx and larynx. Instances of this accident were first recorded by Dr. M. Hall. Mr. Porter observes, that when a person attempts to drink by mistake a corrosive liquid, a similar convulsive action takes place, closing the pharynx and throwing the offending matter violently backwards through the mouth and nostrils, under the epiglottis, and thus this accident be- comes a cause of acute inflammation of the larynx. Mr. Ryland has with good reason placed the inhalation of flame or of very hot air among the causes of acute inflammatory injuries of the larynx. Persons who die from severe burns, if it be only about the head and face, generally suffer from severe dyspnoea, and the mouth and larynx are found in a highly inflamed and congested state: these ef- fects he very rationally ascribes to the great heat of the air inhaled at the moment of the conflagration. The inhalation of very acrid vapours might possibly have the same effect. As exciting causes of asthenic laryngitis, erysipelas, scarlatina, small-pox, and measles, have been already mentioned; and we may add, that in- flammation of the tongue from the excessive use of mercury, and diffusive cellu- lar inflammation from punctured wounds, have been known to extend to the cel- lular tissue of the larynx and cause death. M. Bayle and Dr. Tweedie have noticed that cedematous laryngitis sometimes suddenly supervenes without any ob- vious cause during and after typhoid fevers. It occurs also not unfrequently in the course of chronic disease of the larynx, and is sometimes the cause of death in these cases. We have known it to come on and hazard life in a patient with aneurism of the arch of the aorta, before the tumour had well shown itself out- wardly: Mr. Lawrence has adverted to similar cases. Habitual intemperance, long courses of mercury, frequent and long-continued exertions of the voice, are supposed to predispose persons to attacks of laryngitis. Except in cases of scarlatina, measles, and small-pox, and of the accidents before alluded to, laryngitis never attacks children; and of those advanced in life, Dr. Cheyne states that it most frequently occurs in such as are liable to indigestion connected with a disordered state of the liver. In most instances, the subjects of it had previously been liable to sore throat. Anatomical characters. The effects of laryngitis are commonly found in the red injection and thickening of the lining membrane of the larynx, and an oede- matous state of the cellular tissue underneath, particularly at the upper portions, from the epiglottis to the ventricles, the parts beneath being nearly or quite free from disease. In the more sthenic cases especially, the epiglottis is very red, thickened, and erect, instead of lying over the glottis. The folds forming this chink are generally also red, and much swollen. On cutting into them, serum, or if the disease have not terminated very rapidly, a sero-purulent liquid or pus, exudes. In a few instances, lymph has been found in the cellular textures, and 238 LARYNGITIS--ACUTE. in two or three there have been small patches of lymph on the glottis and under surface of the epiglottis. Rarely these parts have been found ulcerated, even in acute cases. In the erysipelatous disease, and that arising from diffusive cellular inflammation, the matter effused in the sub-mucous tissue of the epiglottis, vocal ligaments, and ventricles, is a sloughy kind of lymph with serum, sometimes mixed with pus; and the longer the case has lasted, the more purulent the liquid is. This effusion is often found to extend to the cellular texture at the root of the tongue outside the larynx, and even among the muscles of the neck and throat. In the cedematous variety the epiglottis is nearly free from disease; the mucous membrane is little injected, but the folds of the glottis are so distended, as nearly to close the orifice, and on cutting into them a clear or purulent serum flows out. It can scarcely be doubted, that in most cases this serous effusion is the result of a low form of inflammation; but it may be favoured by the existence of a dropsi- cal diathesis, or by the pressure of a tumour on the neighbouring venous trunks: to the latter cause we would chiefly ascribe the laryngeal symptoms which occa- sionally show themselves in cases of aneurisms of the great vessels or other tu- mours at the lower part of the neck. Dr. Stokes notices the occurrence of oede- ma of the glottis in a patient labouring under a cancerous tumour below the jaw. Diagnosis. The symptoms of acute laryngitis are generally sufficiently cha- racteristic to separate it from other diseases affecting the breathing. The stridu- lous or hissing inspiration, heard most distinctly at the larynx, which is drawn down at each act, the seat of the sensation of pain or constriction at that part, often the visible condition of the epiglottis, and the absence of pectoral signs, suffice to distinguish it from diseases of the chest. Abscesses external to the larynx and compressing it, may cause difficulty of breathing and swallowing: sixteen years ago we saw a fatal case of this kind, which was mistaken for laryn- gitis, until the first incision of the throat after death gave issue to a quantity of pus which had formed among the numerous muscles of the tongue and larynx. A careful examination will generally distinguish these cases by the partial or general swelling at the upper part of the neck, often with tenderness, and an inability to open the jaw. Mr. Porter thinks that they differ from those of laryngitis in the breathing, although obstructed, being less sibilous, and more gradually oppressed, and in the diminished mobility of the larynx when pressed from side to side against the spine. We should conceive that the absence of the peculiar cough and hissing hoarseness of laryngitis might in some cases better assist the diagnosis. Spasmodic affections of the larynx may generally be dis- tinguished by the complete absence of fever and by the suddenness of the attack; but they may not be so easily distinguished from the oedematous laryngitis super- vening on chronic diseases, which is in effect generally combined with spasm: still in this case there is usually a previous slight access of fever and increase of the chronic symptoms. Spasm of the glottis is a very rare affection in adults, and occurs only in hysterical or highly nervous subjects. Prognosis. Laryngitis has been considered by Dr. Cheyne and others to be the most fatal of all the inflammations. Of seventeen cases observed by Bayle during six years only one recovered. Of twenty-eight cases collected from vari- ous authors by Mr. Ryland, ten recovered, which he justly considers to be above the average. In most of the fatal cases, death took place between the first and fifth days. The prognosis must, therefore, in all cases be unfavourable; and the more so, as the disease has lasted longer and with progressive increase of the difficulty of breathing. When the face loses its colour or becomes livid, and the faculties obtuse, from the circulation of black blood, the danger is extreme. On the other hand, decrease of the difficulty of breathing and of swallowing, a re- turning freedom of expectoration, with an improved expression and colour of the countenance, give rational hopes of recovery. Treatment. In no disease is an early and energetic use of remedial measures more essential to their success, than in acute sthenic laryngitis. There is a period during which free blood-letting and the administration of calomel and laryngitis, (Treatment.) 239 antimony may arrest the inflammation before considerable effusion has taken place; but this period is very short, and has often elapsed before medical aid is resorted to; and when once the effusion has taken place, antiphlogistic measures become worse than useless, and unless artificial means of supplying air to the lungs be employed, the disease generally destroys life before there is time for ordinary curative measures, however energetic, to produce their effect. The chief indica- tions of treatment, therefore, are,—1. To prevent effusion by reducing inflamma- tory action:—2. Effusion having taken place, to prevent the obstruction which it causes to respiration from producing mortal injury to the functions:—3. To promote the removal of the effused matter. 1. In endeavouring to fulfill the first indication by free blood-letting, we cannot do better than by quoting the directions of Dr. Cheyne. He recommends free blood-letting but not to syncope, as advised by Dr. Baillie, for this may deprive the patient of strength sufficient to struggle against the next spasmodic paroxysm of dyspnoea. " We would bleed the patient freely during the first twenty-four hours:—we should be disposed to do more: as long as the complexion of the patient is good, we would have recourse to venesection, keeping a finger on the artery while the blood flows, and closing the orifice when the pulse is reduced; we would have leeches applied or blood removed from the nucha by cupping; and we should be disposed to bleed again or even a third time, so as to abstract forty or fifty ounces of blood, and at the same time let the patient have a powder containing two or three grains of calomel, three or four of Pulv. Jacobi Verus, and one-half or one-third of a grain of opium should be taken every third or fourth hour till the gums become affected." We would not hesitate to give double this quantity of calomel. Dr. Cheyne justly objects to blistering on ac- count of its trifling advantages in comparison with the additional suffering which it occasions, and possible interference with the operation of bronchotomy. Per- haps the same objections would not apply to the speedy and energetic counter- irritation by the strong liquor ammonia?, which, if applied at the side of the neck in the manner directed by Dr. J. Johnson, may produce vesication in two or three minutes. Dr. Cheyne also deprecates the use of tartar-emetic, lest it should excite vomiting, which with the erect state of the epiglottis would throw matters on the unprotected glottis, and cause a frightful convulsive irritation. For a similar reason we would object to the direct application of leeches to the tonsils, a measure proposed by Dr. Cheyne. We can testify of its utility in tonsillitis, for which it was first recommended by Mr. Crampton; but the irrita- tion from the bites, and the blood proceeding from them, could scarcely be tole- rated with an exposed glottis. Active depletory measures employed early, may, for a time, relieve the symp- toms without removing the inflammation: they often only delay the effusion, which with its resulting permanent increase of difficulty of breathing and appear- ance of lividity, instead of taking place in the first day, may not come on for . several days. Hence the importance of attempting, from the first appearance of the disease, to fulfil the third indication by the free use of mercury both by calo- mel internally and by external inunction; for if the gums can be made sore, a secretion from the throat is established which generally reduces the swelling of the glottis. We have more confidence in the power of mercury to cure laryngi- tis than in that of blood-letting; and would consider the great utility of the latter to be in so far retarding the progress of the inflammation as to enable the mer- cury to act before a fatal obstruction is produced Some few cases have yielded to bleeding alone, and its employment should never be neglected when the strength can bear it, and the conditions so well stated by Dr. Cheyne indicate it. But if the strength have already failed, or these conditions cease, and the undiminished dyspnoea and commencing lividity announce the approach of asphyxia, blood- letting becomes worse than useless, and the second indication by the operation of bronchotomy must then be attempted without delay. Dr. Baillie considered it advisable to resort to bronchotomy if no considerable relief be obtained from 240 LARYNGITIS--ACUTE. other measures in thirty hours. Dr. Cheyne more rationally takes as a criterion the condition of the patient rather than the period; and says that if the symp- toms be such as to contra-indicate bleeding and yet asphyxia is imminent, thirty minutes' delay may be too" much: but if the complexion is good and asphyxia not threatened, the operation may be delayed thirty days. Surgical writers strongly urge the early performance of the operation. Louis observes, " as long as bronchotomy is considered an extreme measure (a denier resort) it will be al- ways performed too late;" and Mr. Lawrence says that it should be done, " as soon as the symptoms enable us to determine the nature of the disease." It is because we are convinced that it should be resorted to early, that we have in- cluded it in the second indication. If free bleeding produce no relief, or be not borne, and serious difficulty of breathing have become established, we would not wait for the appearance of pallor or lividity as recommended by Dr. Cheyne, and still less for the lapse of a certain number of hours as proposed by Dr. Baillie, but we would urge the performance of bronchotomy without delay. To defer the operation on account of the difficulty or danger attending it, is most unreason- able ; for experience has proved that these are increased rather than diminished by delay, and the danger from the operation is at no period to be compared with the danger from the obstruction to the breathing that it is calculated to remove. Laryngitis destroys life, not by the extent or the vitality of the organ which it oc- cupies, but by closing as it were the door of the breathing apparatus: by open- ing another door we render the disease comparatively trivial; and it may then be deliberately attacked by mercurial and other remedies, or if slighter, even be allowed to run its course, which commonly ends in muco-purulent secretion. When the operation has been delayed until asphyxia approaches, it will have less chance of success; but should still be tried, for a very few instances are on re- cord where it succeeded at almost the last extremity. It is not within our pro- vince to give directions for the mode of performing the operation; but we may state that we have seen reasons for making a free incision between the thyroid and cricoid cartilages, and' keeping them separated for the first half hour by the thin handle of a scalpel, and afterwards by a short tube half an inch in diameter, with a projecting rim to button into the opening, and a ligature passing round the neck to prevent its slipping in too far. Such a tube may be made in a few mi- nutes of a piece of hollow reed or elder stick, by winding a few turns of waxed twine around the end to be inserted, and passing the ends of the twine through the two holes bored across the outer extremities of the tube, whence they are passed and tied round the neck. The less of the tube that is introduced within the windpipe the better; for the presence of a foreign body often excites terrible paroxysms of coughing. The act of expectoration is often impossible with the opening free; it should therefore sometimes be closed after a long inspiration, that the patient may forcibly expel the accumulating matter by a full expiration through the glottis, which is sufficiently free to the exit of air: varying the posture will aid this act Until and after the mercurial action is established, it is often useful to apply leeches or a blister, or other counter-irritants, to the upper part of the chest; for' there is a tendency to bronchitis as the laryngeal inflammation subside*; and this extension of disease has, in not a few instances, caused death where bronchotomy had saved the patient from the laryngeal affection. The treatment of the after stage of laryngitis is much the same as for the same period of bronchitis. The great difference to be remarked in the treatment of acute asthenic laryn- gitis, whether of the cedematous or erysipelatous kind, is in the total absence of a phlogistic period in which general blood-letting may do good. Leeches freely applied to the sides of the larynx, and speedy blistering the sides and back of the neck by the strong liquor ammonia? or acetum lyttae, may sometimes diminish or retard the effusion until the system can be brought under the influence of mer- cury, which here, as well as in the sthenic form, is the only remedy to be relied on for dispersing the swelling. But if, as it more commonly happens, the pro- gress of the disease towards causing a fatal obstruction be more rapid than the LARYNGITIS.--CHRONIC. 241 influence of the remedies, the obvious resource will be in the early performance of bronchotomy. These cases will bear even less delay than those of the sthenic disease; for besides that they are still less under the control of remedies, they occur in weakly subjects, which are sooner injured by an obstructed state of the respiration: and it has repeatedly happened that a late operation has relieved the breathing, but the patient has sunk from the injurious influence of imperfectly arterialized,blood, which had already circulated in the lungs, brain, and other organs. Hence, too, even if this influence be not immediately fatal, it may lead to secondary congestions of these organs, which in the form of asthenic bronchi- tis, pneumonia, or arachnitis, may ultimately endanger, and even destroy life. In case of the secondary laryngitis, supervening in erysipelas, scarlatina, measles, typhus, and other "febrile diseases, due regard must be paid to the origi- nal disease, which, according to circumstances, may require a stimulant or an opposite plan of treatment. II. Chronic Laryngitis. This form is of more frequent occurrence than the acute, and presents itself in a great variety of degrees. As acute laryngitis is a comparatively trivial disease as long as it is confined to the mucous membrane, and produces no swelling of the tissues beneath, so chronic inflammation may affect the internal surface of the larynx for many months, and produce little inconvenience except hoarseness, habitual husky cough, and perhaps some feeling of soreness at the top of the windpipe. This affection not unfrequently succeeds to a neglected catarrh, espe- cially in those persons who are continually exposed to cold and wet, and are habitually intemperate; for example, hackney-coachmen and street porters. The purple faces of many such individuals give evidence of a congested condition of the capillaries, that in all probability extends to the lining membrane of the larynx; increasing its sensibility and injuring its nice adjustments in the production of the voice. This form of disease may exist long without inducing farther change, and tends rather to induce thickening of the membrane and vocal ligaments, than to end in ulceration. It is different with the serious disease which more commonly goes by the name of chronic, laryngitis, or phthisis laryngea, which, like the acute disease, reaches to the sub-mucous cellular tissue, from whence it may extend to the other constituents of the larynx, and involve them in the intractable and destructive effects which inflammation induces in these less vital textures. The chief of these are, erosion and ulceration of the mucous and sub-mucous tissues; softening, thickening, oedema, induration, contraction, and dissecting abscesses of these textures, and of the ligaments and muscles attached to them; ossification, caries, and necrosis of the cartilages; warty and fibrinous excrescences; scirrhous and tuberculous formations in the different structures. These several lesions may be variously combined, and produce disease of very different degrees of severity, those being the worst forms in which the cartilages are diseased, or extensive ulceration of the other tissues already produced. These more destructive changes may follow simple inflammation; but they are more commonly either the result of a scrofulous diathesis, and often complicated with tuberculous disease of the lungs and other parts; or they are the product of a syphilitic taint, or much more rarely of scirrhous or other malignant disease. Symptoms. Chronic laryngitis is generally a very insidious disease, often beginning as a common catarrhal cough with hoarseness, and not attracting par- ticular attention until it has lasted for a long time, and seriously injured the gene- ral health as well as the tissues in which it is seated. The chief symptoms are hoarseness, a husky dry cough, with soreness or pain in the larynx, felt sometimes on pressure, or rubbing it against the spine, sometimes only in the act of swallow- ing. Of these, the most constant sign is the change of the voice, which varies very Vol. II.—31 242 laryngitis, (Symptoms—Causes.) much in degree and kind. The dry, stridulous, or squeaking kind of hoarseness, if permanent, generally implies a worse form of disease than the deep, loose, or mucous hoarseness which may proceed more from relaxation: sudden loss of voice may occur with slight diseases affecting the thyro-artenoid ligaments, or a nervous affection of the muscles, and may not be permanent; but where a voice gradually becomes more and more cracked until it is at last lost, there is probably a pro- gressive destruction of the vocal apparatus. In some cases the defect of the voice is perceptible only on speaking loud, or in any attempt to vary the tone; for the patients instinctively acquire the habit of speaking in that tone and degree in which the voice is best produced. Pain is so uncertain a symptom, that Trousseau and Belloc state than in more than half the cases of laryngeal phthisis which fell under their observation, there was no pain throughout the disease. There is, however, generally increased sensibility of the larynx, so that the inhalation of cold air, or any hurry of the circulation, very readily excites coughing. The cough, which in the early stages is commonly short, dry, and hacking, is described by MM. Trous- seau and Belloc to assume in some instances in the later stages a very peculiar loose continuous character, like eructation or belching, which they ascribe to an inability to close the glottis, its closure being the first act of an ordinary cough. As the disease advances, there is often abundant purulent and sanious fetid expec- toration, sometimes streaked with blood; but not unfrequently the sputa are scanty and chiefly mucous. The occurrence of purulent expectoration is sometimes ac- companied by relief to the breathing, although the voice may suffer more, and there may be more pain or soreness in coughing; this marks the formation of an ulcer, the discharge from which diminishes the constriction of the air-passage. In- stances have occurred of the expectoration of dead and ossified portions of the arytenoid and cricoid cartilages, and of calcareous concretions formed within the larynx; and in more than one case, such solid fragments have fallen back into the trachea, and caused much irritation and consequent disease in one of the large bronchi. The respiration generally becomes affected sooner or later in chronic laryngitis; the difficulty of breathing commonly coming on in the night, and on any exertion sometimes in very severe spasmodic paroxysms, leaving the patient only with a short breath in the interval. The attacks of dyspnoea afterwards in- crease, and prevent the patient from lying down; and in the interval, the hissing sound of the laryngeal breathing'indicates some degree of permanent impediment to the passage of the air. After the orthopncea has once commenced, death gene- rally ensues in a fortnight or three weeks; but at an earlier period the patient may be suddenly carried off by an attack of acute cedematous inflammation of the glot- tis. Of nine fatal cases of oedema of the glottis, examined by MM Trousseau and Belloc, five occurred in the course of chronic laryngitis, hi many instances, chronic inflammation and ulceration of the larynx are accompanied by progressive emaciation, hectic fever, night-sweats, and other signs of phthisis, without marked dyspnoea; and the patient is ultimately worn down by cough and weakness, and is perhaps carried off by diarrhoea or some other superadded disorder. In by far the greater number of these cases, tubercles are formed within the lungs, either before or after the laryngitis begins, and become the chief cause of the decline, although too gradual in their effect to affect the breathing in a marked degree. In a few instances recorded by Trousseau, Belloc, Ryland, and others, the laryngeal lesion was uncomplicated with any pulmonary disease, the consumption having been purely laryngeal. In most of these cases the cartilages of the larynx were diseased. Chronic inflammation and ulceration of the larynx and trachea are very common with tuberculous consumption of the lungs, and are the cause of the loss of voice, and smarting or pricking sensation in the larynx, so often occurring in the advanced stages of phthisis. Ulceration was found by Louis in upwards of a fourth of the cases of phthisis noted in his work. Causes. Chronic laryngitis may succeed to the acute disease; but it much more commonly arises from the frequent recurrence of catarrhal inflammation, particularly in those who are addicted to ardent spirits. Excessive exertions of laryngitis, (Anatomical Clmraclers.) 243 the voice, repressed eruptions, wounds or contusions of the throat, foreign bodies introduced into the larynx (among which may be mentioned the habitual inhala- tion of air loaded with dust,) and the extension of syphilitic disease from the throat, may be enumerated as occasional exciting causes. A scrofulous or tuberculous constitution particularly predisposes to laryngeal phthisis. The excessive use of mercury, habitual intemperance, and other debilitating influences, are also sup- posed to render persons more liable to chronic inflammation of the larynx. The disease appears to be most common at the middle period of life. According to Mr. Ryland, it affects women more frequently than men, but this is at variance with the experience of MM. Trousseau and Belloc. Anatomical characters. We have already enumerated the principal lesions which chronic laryngitis induces. They are very various, and have been minutely described by Porter, Lawrence, Stokes, Ryland, and Trousseau and Belloc, to whose work (particularly the last) we refer for details. The simplest effect of the chronic inflammation is, 1. Redness of the mucous membrane in patches; even when not ulcerated, it has often a rough granular appearance, from the irregular enlargement of the mucous follicles. 2. Thickening of the sub-mucous tissue: this is frequently observed in the epiglottis and the lips of the glottis, causing enlarge- ment and diminished mobility of these parts: the ventricles of the larynx are sometimes nearly obliterated from the same cause. 3. Contraction of the liga- ments, wasting, induration, and fibrous degeneration of the muscles which move the cartilages of the larynx: this is a common result of chronic inflammation on fibrous and muscular textures, and must in this case impair or destroy the me- chanism of the voice. Contraction, together with partial thickening affecting the epiglottis, renders it curved or corrugated, so as to defend the glottis very imper- fectly. 4. Ulceration of the mucous and sub-mucous textures: this is a common result of chronic inflammation, and presents itself in great variety as to form and seat, of which the following are the most remarkable: the ulcers are sometimes small and round, but confined to the mucous membrane: in other cases they have been known to penetrate to the cartilages or ligaments; and M. Andral notices a solitary case in which one perforated the thyroid cartilage, just above the inser- tion of the vocal ligaments. In this case the voice was unaffected. When these ligaments are injured, the voice is generally destroyed. When again the ulcers are large and superficial, denuding but not injuring the vocal cords, there is com- monly hoarseness, but not aphonia. It is between the vocal ligaments and the epiglottis that ulcers are most commonly found, but they are often met with in other parts of the larynx and trachea. They are frequently seen on the laryngeal surface of the epiglottis, and sometimes at its margin; it is only in case of syphi- litic disease that the upper or lingual surface is found affected. Considerable parts of the epiglottis, as well as of the arytenoid and cricoid membranes and car- tilages, have in a few instances been found destroyed by ulceration. 5. The ul- ceration, however, does not frequently extend to the cartilages except in young subjects. MM. Trousseau and Belloc do not consider the cartilages of the larynx sufficiently vital to take on the process of ulceration or caries. The common effect of ulceration of the adjoining textures on them is in the first place ossifica- tion, and afterwards necrosis. The cricoid and thyroid cartilages naturally be- come ossified in advanced life; but chronic laryngitis of two years' duration pro- duces the same change in young persons. This is in conformity with a law well developed by Andral, that a certain degree of irritation accelerates in tissues those changes to which time would naturally bring them. The osseous matter is de- posited in irregular places on the surface of the cartilage, and sometimes quite encases it. Instances of necrosis of the cricoid, arytenoid, and even of the thy- roid cartilages, have been recorded by Porter, Lawrence, Cruveilhier, Ryland, and Trousseau and Belloc. The last authors state that they have found this lesion in more than half of the fatal cases of laryngeal phthisis which they have examined. In this state the cartilages are denuded of their perichondrium, and are of a dirty dull hue without their natural lustre. The sequestrum of dead 244 LARYNGITIS—chronic. cartilage is not readily thrown off; but there is often fetid pus in the cellular tex- ture near it. These abscesses may open and-discharge their offensive contents, and even the dead portions of the cartilage, either into the larynx, or outwardly through the integuments of the neck, or into the oesophagus. It can readily be conceived how much local and constitutional irritation these dead matters may produce before they are discharged, and how in the very act of separation, acting as foreign bodies, they may produce suffocation. Diagnosis. The most characteristic signs of chronic laryngitis are the perma- nent change of the voice and the peculiar cough before described, with hissing breathing and pain or tenderness in the larynx when these happen to be present. Except in syphilitic cases where the fauces are also diseased, little is to be learnt from examination of the throat; for it is impossible to see or reach farther than the epiglottis, and to get a view of this is a matter of difficulty. Neither is cre- pitation felt on pressing the larynx to be depended on; for, according to Trous- seau and Belloc, this may be produced in a healthy larynx. Dr. Stokes de- scribes, as a stethoscopic sign of chronic laryngitis, a harshness in the sound of the air passing through the larynx, giving the idea of a roughness of surface, per- ceptible even when the breathing is not distinctly stridulous. In a few cases he observed above the thyroid cartilage a rhonchus, like the sound of a valve in rapid action, combined with a deep humming. We much question that the latter sound was seated in the larynx, for such a sound is often produced in the jugular veins. When the laryngeal constriction is considerable, the peculiar sound of the pas- sage of air through it will sufficiently distinguish it; and where it is slight or altogether absent, laryngeal disease may yet be known as the cause of the cough and other symptoms, by the negative indications of the thoracic organs, the sound of percussion and of respiration being good throughout the chest. But pulmo- nary tubercle is very commonly conjoined with laryngeal disease, and the two affections are apt to disguise each other. The noisy laryngeal respiration, and the absence of the voice may destroy the chief distinctive signs of phthisis in its early stages; but as the disease advances, the dulness on percussion and perhaps cavernous rhonchus in some part of the chest, particularly under a clavicle or scapular ridge, with a more copious purulent expectoration, night sweats, and more rapid emaciation, sufficiently announce this most destructive complication. When the breath and sputa in laryngeal disease are very fetid, it may be sus- pected that some part of the cartilages is dead. This is generally the case where a chronic abscess opens outwardly about the thyroid cartilage. Prognosis. The milder and simple forms of chronic laryngitis are by no means incurable; in fact they generally yield to judicious treatment; and were it not for their liability to exacerbations from acute cedematous inflammation and to com- plications with pulmonary disease, they could hardly be called dangerous. Both these destructive complications may be apprehended when the disease hrs con- tinued long, with increasing severity of symptoms of the voice and respiration, with a change of the cough from dry and ringing to loose and undivided, with increasing purulent expectoration, and particularly if the disease has resisted treatment. If from the history of the individual there be any suspicion of a scro- fulous tendency, and particularly if symptoms of pulmonary disease, such as slight cough, shortness of breath, pains in the chest or shoulders, quickened pulse, »vj?, voice.) This modification of the voice is heard most dis- tinctly in the space between the third and sixth ribs, which corresponds to the middle-sized bronchial tubes: but near the spine it is generally mixed with a louder and more uniform resonance, which is common bronchophony, from the larger tubes at the root of the lung. Two circumstances are remarkable in aegophony: first, that the voice is more audible at the very spot where the lung is pushed away by the liquid, in consequence of the liquid by compressing the po- rous tissue of the lung enabling it to transmit better the sound of the voice from its interior. The second point is, that the voice is altered in character: this may be supposed to be caused by the nature of the matter which it has to pass through, a thin layer of liquid, which, being thrown by it into irregular vibrations, trem- bles and dances, now checking the sound, now transmitting it with increased force, so that the voice comes through tremulous and wiry. The high tones of the voice are best transmitted in this way, for the bass tones do not enter the small tubes, but if strong pervade the whole tissue with a diffused fremitus. Hence aegophony is best heard in women, children, and others, who have high voices. In persons with a bass voice it is more commonly limited to the lower angle of the scapula or near the spine, and from being seated in larger tubes takes more the character of buzzing bronchophony. As the liquid increases, the aego- phony becomes weaker, more distinct, and loses much of its flutter or tremor, having rather the sound of a very slender deep-seated voice, or a silvery echo of pleurisy, (Physical Signs.) 307 the original. This is owing to the lung being pushed so far away from the walls of the chest, and its tubes so much compressed; and as these conditions increase, the sound ceases altogether. It is not easy to determine what quantity of the ef- fusion is enough to do this; but we are inclined to think that much sound of the voice is not transmitted when the layer of serum exceeds an inch in thickness, except over large tubes. If the aegophony remain stationary for several days, it is a proof that the effusion is moderate, and does not increase rapidly, which is a favourable sign: but it is often very transient, and many cases of pleuritic effusion are discovered after they have passed the degree which causes aegophony. Old adhesions will however modify this, as well as the other physical signs. When aegophony is most distinct, it is often coupled with bronchial respiration, espe- cially between the scapulae, where also there is a good deal of common broncho- phony mixed with it. M. Reynaud has lately confirmed the original opinion of Laennec, that aegophony is a kind of bronchial voice modified by its transmission through a layer of liquid. He observed in a pleuritic case, that the aegophony heard at the lower angle of the scapula when the patient was sitting, became changed to simple or louder bronchophony when the patient stooped much for- ward or lay prostrate, this change of posture permitting the liquid to gravitate to the anterior part of the chest, and floating the lung into contact with the parietes. Mgophony and bronchophony are different enough when their characters are well marked; but they often present mixed and doubtful varieties, that do not ad- mit of any such easy distinction. As far as description will go, we would repre- sent the true character of aegophony to be a certain tremulousness in the voice when it is superficial, and an echo-like slenderness when it is deep-seated; whilst bronchophony may present many other varieties. ^Egophony is by no means a certain sign: when present it is of great value, but it is often wanting throughout a large part of the disease: and in practice is, therefore, of comparatively little value. G. 6. An early and very characteristic effect of the accumulation of liquid in the pleural sac, is its intercepting the diffused vibration of the voice, which is usually felt by the hand applied to the chest. A layer of liquid muffles and destroys this vibration; and it may do this even when aegophony is audible at the same spot, the vibrations of the latter being too fine to be felt by the hand. This affords a distinction between a liquid effusion and a consolidation of the lung, for the latter transmits the vocal vibrations with unusual force from the tubes. This diag- nostic sign we owe to M. Reynaud ; and it is more valuable because it is easily obtained, even by a person who does not practice auscultation. It must not, however, be always considered as quite conclusive, for there are some exceptions to it, both positive and negative. For example, in case of partial adhesions of the lung to the chest, even more vibration than usual may be felt at the adhering parts, where the lung and its tubes are pressed into close contact with the walls of the chest: it may happen, on the other hand, in consolidation of the lung, that liquid or other obstruction in the bronchial tubes may prevent the voice from be- ing transmitted through them. 7. As the liquid effusion increases, the aegophony and all sound of the voice cease throughout the affected side, except within two or three inches of the spine, and in spots where the lung may have been adherent, which frequently happens at the upper parts of the chest. The sound of respiration is also aboUshed in most parts, but never in the interscapular region, and rarely under the clavicle and in the axiUa: it is, however, much weaker in these parts than on the sound side, and may probably be only transmitted from that side. 8. Enlargement of the affected side is another sign to be noticed. The effusion must be pretty copious to render this enlargement perceptible; but a differ- ence between the two sides of the chest may sometimes be seen on inspection 308 pleurisy, (Physical Signs.) of the chest in different periods of respiration when the quantity of liquid is not very great. The affected side is first seen to be larger at the end of expiration, when it does not diminish equally with the other side, especiaUy at its lower por- tions. So, on encircling the chest with a piece of tape, fixing it at the sternum and at the spine, it will be observed to tighten and slacken with inspiration and expiration more obviously on the sound than on the diseased side, which remains more fixed in a state of partial distention. As the effusion increases, the dif- ference is perceptible through the whole respiratory act, and the eye can easily detect the want of symmetry, whether the inspection be made in front, behind, or from above, looking down on the patient's shoulders. To be more exact, how- ever, the chest should be measured with a tape or riband passed horizontally around the chest, and made to meet at the centre of the lower end of the ster- num ; then taking it off by the point where it crosses the spinous processes of the vertebral column, the length of the two sides may be compared. In making this comparison it must be recollected that the right side in the healthy state is from a quarter to half an inch larger than the left. Laennec remarked that the en- largement of the side is sometimes discoverable by the eye as well as by mea- surement, two or three days after the first attack of pleurisy: but it does not generally proceed afterwards in proportion to the effusion until this becomes ex- cessive, and has displaced the adjoining parts to a great extent. 9. A very important class of signs arises from the displacement of certain of the walls and organs bounding the effusion. Laennec remarked that the inter- costal spaces on the affected side do not present their usual depressions, and are sometimes, especially in chronic cases, even prominent beyond the surface of the ribs. This had been noticed by surgical writers in empyema. It is scarcely perceptible, however, in acute pleurisy, unless the subject be thin. In such cases we have seen the intercostal spaces not only prominent, but presenting also an evident fluctuation. In looking for this sign, the patient should be placed ob- liquely with regard to the light; and it may be more readily seen by surveying the chest from a little distance, than by a closer inspection. But we may generally learn more from the displacement of the organs adjoin- ing the effusion, especially the heart and the liver. Laennec barely noticed these displacements. To Drs. Stokes and Townsend we chiefly owe their appUcation to the diagnosis of liquid effusions in the chest. The displacement of the heart by an effusion in the left pleura, is the most valuable and easily recognised of these. In this case the pulsations of the heart are felt and heard most distinctly under or to the right of the sternum, or in the epigastrium, instead of, as usual, between the cartilages of the fourth and sixth left ribs. On the other hand, a veiy abundant effusion on the right side will push the heart so far to the left, that it may be felt beating below the left axilla. But in this case the more re- markable displacement is that of the liver, which by feeling and percussion will often be found far below the margin of the ribs. Sometimes it forms a distinct tumour in the abdomen; and we have known more than one case of latent pleu- risy, in which this tumour was long supposed to be the chief disease, the patient not complaining at all of the chest. Dr. Stokes has published some interesting observations with the view to prove that the displacement of the diaphragm and intercostal muscles in great measure depends on paralysis of their muscular fibres, the result of the inflammation of the pleura which covers them. The dis- placement of the mediastinum is to be discovered only by percussion; situated as this is naturally in the mesial plane, it divides the two cavities of the pleura at a line down the middle of the sternum, which bone sounds weU on percussion from the margins of both lungs which lie under it. But a copious effusion will push the mediastinum towards the opposite side, and, by occupying the whole space behind the sternum, will give this bone a dull sound on percussion, and this may even extend half an inch or an inch beyond it All these displacements may also be produced by an accumulation of air in the pleural sac, but the tym- panitic sound on percussion would at once distinguish this case. pleurisy, (Symptoms and Death.) 309 10. In all cases of physical examination, the two sides must be examined with the view to comparison; and in case of pleuritic effusion it will be found, that the sound side will give not only the negative proofs of the absence of disease in it, which may well be compared with the positive signs of disease on the opposite side, but it will even show an exaggeration of the signs of healthy action, in con- sequence of its work being really increased. Thus, whilst the diseased side is almost fixed, the healthy side will be seen to move more fully and quickly than usual, and the sound of respiration will be increased in a remarkable degree, so as to resemble the loud respiration of children; hence it is called puerile. We have before noticed that the physical signs of pleurisy are liable to be much modified by old adhesions, which bind the lung to the walls of the chest. When the adhesions are loose, they only form bands or cells distended with fluid; and, keeping the lung at a moderate distance from the walls of the chest, they may render the continuance of asgophony much longer than it would be without them. When an adhesion is so close and strong that the accumulating fluid cannot sepa- rate it, the lung is there compressed against it; or if there are several adhering points, the attachments to these are preserved by so many pillars of compressed lung at these adhering parts; if they be at the upper or middle regions of the chest, instead of a total abolition of the voice and respiration, there may be loud bronchophony and bronchial respiration, transmitted from the large tubes by the adhering dense column of lung. Sometimes the adhesion is to the diaphragm or mediastinum; and it may then prevent or modify the displacement of these parts by the fluid. Not uncommonly the adhesions are more extensive and close, espe- cially to the upper parts of the chest, and then the lung is pressed by the effusion from below against the whole of the upper walls of the chest. In this condition it may still admit air, and be quite resonant on percussion; but as much of its vesicular structure is compressed, the sound of respiration there will be tubular or bron- chial, and a noisy bronchophony will be transmitted by it to the whole upper re- gion of that side. We have often heard the voice and respiration quite tracheal from this cause. The displacement of the heart and liver, the prominence of the intercostal spaces, and the dulness on percussion of the whole lower portion of the sternum, together with the immobility and enlargement of the lower part of the af- fected side, will generally distinguish the true nature of these cases. Much more rarely the lung adheres closely to the whole of the lower part of the chest, and the effusion occupies the upper. In such cases there may be pulmonary reso- sance in the lower parts, with obscure sound of respiration. The upper may be dull in the situation of the effusion; but sometimes, from the top of the ster- num to the middle of the clavicle and below it, there is a remarkable ampho- ric or tracheal resonance, with some respiration of the same character, yielded by the large tubes through the effused fluid. The character and production of this sound may be illustrated by filliping on a finger pressed against the trachea when the mouth is open. The windpipe passes under the sternum, and divides into the two great bronchi, which spread between one and two inches below the clavicles. Here in health the porous lung lies over these tubes, and intercepts their reso- nance on percussion; but if this be perfectly condensed by liquid effusion, or per- fectly consolidated by hepatisation, the hollow note of the tubes will be pro- duced on percussion, just as it is over the windpipe, where no lung intervenes. I Symptoms and signs of the decline of Acute Pleurisy. The general symp- toms seldom maintain their acute character for many days. The stitch in the side ceases, or is felt only in a long breath, or in coughing; sometimes, but not always, accompanied with soreness. The cough, if there be any, generally con- tinues, and becomes bronchitic. The pulse sometimes loses its hardness, and is reduced in frequency; in other cases, particularly when the effusion is very co- pious, it remains as quick as ever, although it may be weaker. The difficulty of breathing is perhaps less apparent, but the frequency is often not diminished, whilst the effusion is unabated, although the patient is scarcely sensible of it. In other cases again, in the course of a few days, the breathing returns nearly to the 310 chronic pleurisy, (General Symptoms.) natural state, although one side of the chest is full of fluid. In almost all cases, lying on the healthy side embarrasses the breathing, both by restraining its move- ments and by causing the fluid to press against the heart, and the sound lung. For the same reason, pressure on the abdomen may cause little uneasiness on the diseased side; but on the sound side, by impeding the descent of the dia- phragm, it produces a feeling of dyspnoea, even when none may be otherwise pre- sent Not uncommonly after the first few days of the disease, when the acute symptoms have in great measure subsided, the patient complains of nothmg but weakness, and calls loudly for an improved diet. It is especially in such cases that we must be in great degree guided by the physical signs: if these indicate that the effusion is undiminished, or even increasing, we may be sure that the inflamma- tion is not subdued, but only latent. But if, from an improved resonance on per- cussion, and returning movement and sound of respiration, first in the upper parts of the chest, as well as a diminution in the volume of the affected side, we find that the liquid effusion is on the decrease, we may judge that the inflammation is subdued, and that its products will gradually be removed. The reabsorption of the fluid sometimes takes place in the course of two or three weeks; and in that case sego- phony returns when the layer of fluid is thin enough to permit the vocal resonance to pass through it, but more commonly the fluid is not dispersed for a much longer time. Laennec remarks that an effusion which has been formed in the course of a few days is sometimes not entirely removed at the end of six months; and we can add our testimony to the truth of this observation. In such cases the return of aegophony is very uncertain: in fact the signs are rarely watched during so long a period, and the patient may cease to be the subject of medical treatment before the effusion is sufficiently reduced to give transmission to the voice. In very mo- derate cases the liquid is absorbed before the lymph or albuminous matter is removed; and when the pleural surfaces covered with this come together, a sound of rustling or rubbing is sometimes heard with the movements of respiration: but this soon ceases, as the lymph is converted into adherent bands of false membrane. Now if these false membranes are formed after the liquid has been removed, and the lung has recovered its full extent of expansibility, they are adapted to its free motions, and do not to any material extent interfere with them. Hence in dead bodies we often find adhesions which are lengthened in the lower parts of the chest, where, from the action of the diaphragm, the lungs descend as the ribs rise, whilst in the upper parts the adhesions are short, because the lungs there follow more exactly the movements of the walls of the chest. But in more severe or obstinate cases, which are not uncommon, the inflamma- tion continues after the Uquid has been abundantly poured out, and not only in- creases and perpetuates this liquid effusion, but also throws out albuminous matter in various conditions, which by its present qualities, or future changes, may produce a variety of prejudicial effects, all tending more or less to interfere with the perfect restoration of the organs to a healthy state. These, and the signs and symptoms which they produce, may be better considered under the head of chronic pleurisy; for although inflammation in which they originate may often be acute at the first, yet the course and character of these changes are quite of a chronic description. Chronic Pleurisy. General symptoms. There is less reason for distinguishing formally between acute and chronic inflammations of the pleura, because the transition of the one to the other is really not defined; and the symptoms of the recent disease sometimes have so little of an acute character, whilst that of a long duration occasionally manifest such an intensity of irritation, that the terms acute and chronic are less applicable to pleuritic affections than to inflammations of most other organs. We can see some reason for this in the fact, that the pleura, being a short sac, is liable to have its acute inflammation converted into chronic by the retention of its pro- pleurisy, (Pathology.) 311 ductjand chronic pleurisy is liable to be excited into an acute state by the distending or irritating influence of the effusion. StiU differences are very apparent in many cases, in the prevalence of high inflammatory fever in some, and in there being no fever, or one of a hectic kind, in others; in the sthenic condition of the circulation in some, and its weak depressed state in others, whatever be the degree of pain or nervous irritation accompanying them. Thus it may happen that an acute in- flammation with all its prominent symptoms has been apparently subdued; but the effusion remaining undiminished, the disease goes on in a latent form, until, from some imprudence on the part of the patient, who supposes himself cured, an attack of dyspncea, or a stitch in the side, again lays him on his bed; and although these symptoms may generally be mitigated, they then leave those more peculiar to chronic disease. Of these a remittent or hectic fever, with permanently quick pulse; gradual emaciation; shortness of breath, particularly on exertion; inability to Ue on the healthy side,—may be mentioned as the most common: occasionally there is cough, and there may be purulent expectoration from a concomitant chronic bronchitis, and various degrees of pain in the affected side; but these symptoms are very uncertain. A chronic form of pleurisy is sometimes developed gradually without being preceded by a distinct acute attack; but it is probable that many of these cases are at first acute in a latent form, the patient having been supposed to suffer merely from a cold, or a slight feverish attack, during the acute stage of the disease, and the local symptoms not attracting attention until they have become more developed in the chronic form. Pathology. In tracing the signs and compUcations of the more chronic forms of pleurisy, we shall be enabled to exhibit them more concisely and intelligibly through a rational view of their pathology, as we have studied it in the signs and anatomical effects. Besides serum and coagulable lymph in their simplest forms, which may be speedily removed and organized, inflammation, particularly the more chronic kind, may generate the foUowing products, which are less readily removed, and which tend more or less to interfere with the restoration of the organs to a healthy state. 1. Healthy and highly organizable lymph, when deposited in a thick layer, must in some degree restrain the expansion of the lung, and thereby retard the absorption of the fluid. This lymph may be diminished by absorption; and the membranes formed of it may ultimately adapt themselves to the full expansion of the lung: but there will be less chance of this in proportion as the liquid effused is copious, and its removal slow. 2. In cases similar to that just mentioned, but with a lymph less organizable, the product of a less active inflammation, or in which there is much of the colour- ing matter of the blood (but not in this case only, as Laennec supposed,) its organiza- tion is more tardy, and the membrane resulting is of a more rigid and less yielding nature; consequently the lung is more permanently confined in its compressed state. The membranes which are formed on the pleura in these cases are some- times quite cartilaginous in density, and of considerable thickness; and occasion- ally they are found, in process of time, partially ossified- If these acquire their density before the liquid is removed, it is clear that they must for ever bind down the lung: but we have seen cases in which there have been signs of farther contraction after the absorption of the liquid, which may be ascribed to the ten- dency which some newly-formed tissues have to contract for some time after their production. This is exemplified in the contraction of the cicatrices of burns of the skin, and of the false membranes, lining cavities of the lung; and in other cases, where false membranes have been slowly formed, and tend to assume a fibrous or fibro-cartilaginous rather than a serous or cellular structure. 3. But the inflamed pleura may effuse lymph of still lower vitality, susceptible of but imperfect organization, and whoUy incapable of throwing out more of an organizable character: hence, when the pleura is coated with it, if the inflamma- 312 pleurisy, (Pathology.) tion continue, the overflow of the nutritive secretion wiU be in the form of a curdy matter, or of mere loose shreds of solid albumen. 4. The solid matter may be thrown out in a disintegrated state, utterly insus- ceptible of organization, and diffused through the fluid in flakes or particles form- ing a mixture more or less resembling pus, which is the fluid of empyema. Although in many instances this is the result of a more chronic form of pleurisy than that which forms lymph, and owes its persistence and tendency to increase to the want of vitality in its solid matter, yet we do meet with cases of empyema which arise from very acute forms of inflammation. In these instances the fluid is more strictly purulent, the solid matter being in the form of globules, like those of pus; and seems to be the result of what may be called a suppurating diathesis; in con- sequence of which, all the albuminous products of inflammation tend to assume a purulent character. In such a case we have seen pus within a fibrinous clot in the heart; and it is difficult to avoid the supposition that it is something in the condition of the blood that determines this less usual product from the acute inflammation of a serous membrane. It is weU known that the continued access of air will cause the inflamed pleura, as weU as other internal textures, to secrete pus instead of lymph; hence whenever pleurisy is excited by the perforation of the lung, the liquid poured out is more or less purulent. 5. Lastly, as the solid accretions on the inflamed pleura, we may find the various morbid productions called tuberculous, scirrhous, encephaloid, and melano- tic; these being cammonly the result of some constitutional taint developed by the local inflammation ; but in the case of the first and last, probably sometimes the product of peculiar modifications of the inflammation itself. It is not to be supposed that the products of pleurisy in every case belong ex- clusively to one of the kinds now described, or that they are so simple as to be rigidly divisible by any such classification. We rarely examine a case of protracted pleurisy after death, without finding traces of several forms of the products of in- flammation ; and a comparison of many discovers that these pass by insensible gradations into one another; so that, although we may meet with some that are clearly referrible to one class of products, there are others of a mixed or interme- diate character. If we reflect on the consequences of aU these products of pro- longed inflammation of the pleura, we must perceive that they all tend to keep down the lung in that compressed state to which it was reduced by the first effu- sion ; and they do this by the rigid false membranes which are formed when the solid effusion is susceptible of organization; and by the persistence of the Uquid effusion when the solid matter is destitute of organization, and acts as an extra- neous irritant. We must suppose, too, that the absorbing properties of the pleura must be altered by the long continuance of disease; and that various lesions are propagated to the adjoining tissues, which, however they may have escaped the immediate effects of inflammation in its acute form, can scarcely fail to be affected by the slow and less limited influence of chronic inflammation. Hence the paren- chyma of the lung, the bronchi, the pericardium, the bones and cartilages of the chest, occasionally become the seat of various changes; thus, the lung becomes at first consolidated, and afterwards atrophied; the tubes secrete pus, and become dUated; the pericardium forms adhesions to the heart, and becomes thickened; and in cases of empyema, the ribs, vertebrae, and their cartilages, may become carious. Nor must we forget the unfavourable operation of the disease on other functions, the obstruction to the circulation by pressure on the pulmonary and adjoining vessels, the abridgment of the function of the lungs themselves, and the irritating or depressing influence occasionally extended from the seat of lesion to the various organs of the abdomen. In fact, besides the injury done to the respi- ratory organs, an imperfectly cured pleurisy may in an insidious manner oppress the whole system, and bring it into an anomalous cachectic state, in which morbid conditions of various kinds may be produced or brought into activity. Thus we have met with several instances in which tuberculous disease was first pleurisy, (Signs of Absorption.) S13 developed after pleuritic attacks, and in two instances we have found the tubercles confined to the uncompressed lung, indicating that their development was poste- rior to the compression of the other lung, in which their deposition was mechani- cally prevented. For practical purposes it will be convenient to divide the preceding results of pleurisy into two classes:—1. Those in which absorption ultimately predominates over effusion, and the liquid is gradually removed; and 2. Those in which the effusion predominates, and the liquid can only be removed throngh a perforation of the pleura. Signs of absorption of the effusion. In the first of these, as the absorption of the fluid proceeds, what is it that supplies its place ? The lung, as we have seen, may be either so bound down by rigid false membranes, or so condensed and obUterated by long-continued pressure and inflammation, that it is not susceptible of its former expansion to effect this purpose. In the great majority of cases, as the liquid is absorbed, the walls of the chest are contracted or collapsed, so that the diseased side, which at the height of the effusion measured perhaps an inch or two more than the healthy side, now gradually becomes considerably smaUer, sometimes to the extent of two or three inches. The contraction is first percepti- ble in the upper part of the chest, and with the depression and more fixed condi- tion of the shoulder contrasts remarkably, on inspection, with the fuU development and active motions of the sound side. On examining the contracted side more narrowly, we see, in detaU, that the ribs are lower at the sides and closer together, the scapula more prominent and nearer to the spine; and sometimes the sternum, and occasionaUy even the spinal column also, are curved concave towards this side. In aU this we see the results of the atmospheric pressure, together with un- antagonized muscular efforts, acting on the walls of the chest. The same pressure tends to fill the cavity from the abdomen: thus the diaphragm is pressed perma- nently upwards, carrying with it the mass of the liver on the right side, and the resonant stomach on the left; and on watching the abdomen, it is not seen to swell on that side, as on the other, at each inspiration. In some cases, too, the same pressure is exerted within the chest from the sound side, causing displacements the very reverse of those which had been occasioned by the pressure of the pre- vious effusion. We have seen many cases in which the healthy lung had displaced the mediastinum towards the contracted side, not only under the whole sternum, but even under the cartilages of the ribs to the extent of an inch beyond it; so that these parts sounded well on percussion, and the intercostal spaces there showed movements of respiration which scarcely affected any other part of that side. Dr. Stokes has recorded a case in which, after the absorption of an effusion on the right side, the heart was drawn over to that side, so that its pulsations were felt to the right and not to the left of the sternum. We have met with three examples of this kind, in which the heart became permanently displaced to the right. We have also seen, after the removal of pleuritic effusion on the left side, the heart drawn upwards to the left, so that its pulsations were distinct from the fifth to the third rib, near the axilla. Dr. Stokes describes a case in which, after an acute effusion on the left side, which displaced the heart to the right of the sternum after the removal of the effusion, the heart remained loose, falling from one side of the sternum to the other, according to the position of the body. We proceed to describe the signs obtained by auscultation of a side contracting after chronic pleurisy. In many cases where the effusion has been copious and of long standing, the sounds of respiration and percussion continue permanently imperfect, although the liquid be completely removed; and in almost every case they are more or less impaired for months after the attack; in fact they correspond pretty weU with the appearance and diminished motion of the affected side, and are to be referred to the same causes. The improvement is generally to be found first in the upper part of the chest, and near the spine. With the return of a weak respiratory murmur, and slight resonance on percussion, some degree of vocal re- sonance may also accompany the removal of the liquid in the upper parts of the Vol. II.—10 n ^ 314 pleurisy, (Signs of Absorption.) chest, amounting to loud bronchophony, often accompanied by a remarkable buzz, in other parts being merely the diffused vocal fremitus, according to the size of the bronchial tubes and the degree and permanency of their compression. This is one of the instances in which some physical signs may deceive us, unless atten- tion be paid to all, and to the general history of the case; for if, for the first time, we see a patient with the above signs, and he happen to have bronchitis, we may be led to believe that the resonance of the voice and the dulness are caused by consolidation from recent inflammation of the lung, or from tubercle; but this error may be avoided by attending to the history of the case, and the signs of con- traction that characterize it. The dulness on percussion in the contracted chest is less owing to the absence of air, than to the compressed, drawn-in condition of the walls, which are no longer free to vibrate; and although there be air in consi- derable quantity in the lung underneath, this air gives no spring to counterbalance the atmospheric pressure, which is continually acting as a dead weight on the con- tracted side. Sometimes more sound may be obtained by pressing the fingers strongly on the side, and then striking on them; this pressure brings the waUs be- yond the unequal atmospheric weight, so that they may then vibrate more freely, as we have formerly explained. We find, then, that in these cases of pleurisy the condition of the side of the chest was, at the period of the copious effusion, the reverse of what it becomes when that effusion is removed; then it was dilated, and the adjoining parts pushed from it; now it is contracted, and the adjoining parts drawn into it. Is there not, then, an intermediate stage, in which neither of these conditions is presented, and the side has the usual shape and dimensions? Our experience leads to the con- clusion that there is not; but that the transition from one condition to the other is not generally uniform, but partial. The common case is that the contraction begins in the upper part of the chest before the dilatations and displacements have ceased in the lower; and it seldom happens that there is not, during the diminution of a pleuritic effusion, an irregularity in the shape of the chest, a com- parative bulging of the lower portion, which may serve to distinguish it from consolidation of the lung. In the cases hitherto considered, the effusion has been supposed to be general and to fill the cavity of one side of the chest; and the contraction after its removal, although irregular, to be also general. In case of partial effusions limited by rigid adhesions to transverse portions of the chest, it is plain that the thoracic walls cannot contract enough in those parts to obliterate them. In the few cases of this kind which we have seen, there had been partial contraction; but the space occupied by the effusion was chiefly filled either with air, or by the adjoin- ing viscera pushed in, or with a semi-solid curdy fluid, probably the inspissated remains of the effusion. It might be supposed that individuals, whose lunsrs are reduced, by contraction of the chest after pleurisy, to little more than half their natural size, would be reduced to a very frail state of health and a low scale of bodily strength; yet it is curious enough, that some such individuals have continued to enjoy good health, and to be actively engaged in the pursuits of life. Laennec mentions the case of a distinguished surgeon of Paris, who, although he had one side contracted, in a very marked degree, from an attack of pleurisy in his youth, yet enjoyed excellent health, and was in the habit of lecturing twice a-day with- out inconvenience. We have met with a few instances of the same kind, but they were in young subjects in whom the walls and organs of the chest are capa- ble of more extensive adaptation than in after life, and in no such case have we found the contraction excessive, nor the respiratory murmur nearly abolished. In other cases (and they are, we believe, the most common) extensive contraction of the chest causes such an habitual shortness of breath and tendency to palpitation, as to incapacitate the subject from active exertion, so that even slio-ht bronchial attacks, or febrile excitement, cause severe and distressing dyspnoea. We have farther had occasion to observe, that before the system becomes accommodated to pleurisy, (Empyema.) 315 the abridgment of respiration which this lesion produces, and even afterwards, under unfavourable circumstances, there is an enfeebled or cachectic state of the whole frame, in which various trains of disorder may arise; and unless care be taken to counteract them by remedies and circumstances most favourable to the general health, scrofulous or dropsical disorders may be engendered, and develope new mischief in the respiratory organs or elsewhere. Although, therefore, we may look on contraction of the chest as a mode of curative termination of pleu- risy, it is one of the least favourable kind, and liable to many detracting circum- stances. Empyema. The other class of cases in which effusion preponderates over absorption, and the liquid can only be removed through a perforation of the pleura, comes next to be considered. This character is to be traced in some instances to the condi- tion of the membrane, which, either from its continued inflammation, or from change of its structure, secretes more than it can absorb: sometimes the accumu- lative tendency of the effusion may arise from some obstruction in the circulation, dependent on disease of the heart or great vessels, on tuberculous or other conso- lidation of the lungs, or even on the partial pressure of the effusion itself. But the more common cause of increasing effusion is in the nature of the matter effused, which when of a purulent character is not readily absorbed, and constitutes the Empyema of authors. The symptoms und signs of empyema are generally those already described as indicating extensive liquid effusion, but they may be modified by the length of time that effusion continues: thus, although the feeling of dyspncea, and per- haps the fever, may have abated, even with the effusion on the increase, yet the general disorder of the system, and the signs of enlargement of the side, and dis- placement of its usual boundaries, commonly become more marked. It is by no means constantly observed that the effusion of pus is peculiarly marked by the occurrence of rigours, hectic fever, or more constitutional disturbance than that which attends the effusion of mere serum and lymph; but when such symptoms do occur, there is a probability in favour of the effusion being truly purulent. The long-continued pressure, perhaps joined, as Dr. Stokes has suggested, with the paralyzing influence of prolonged inflammation, causes the muscular portions of the walls to yield to an increased extent; hence the intercostal spaces become more prominent, the diaphragm farther pressed into the abdomen, carrying with it the adominal viscera. Thus on the right side the liver may be pressed down to the umbilicus and ilium, causing a protuberance there, which has not unfre- quently been mistaken for the chief disease. On the left side, the stomach is not generally so much displaced, but the diaphragm is pushed down more behind, carrying with it the spleen and the colon, the pressure on which sometimes seems to cause flatulent distention of the abdomen. In a case of this kind which we have recently witnessed, the enlargement of the chest was entirely behind, the left infra-mammary region not being at all full, and giving the resonance of the stomach, although the heart was displaced to the right of the sternum. When the effusion is purulent, there is not uncommonly associated with it an ulcerative process, which may permit the matter to escape through the lungs, the walls of the chest, or the diaphragm, and which, in cases of long continuance, often involves other parts besides that through which the matter is evacuated. Thus, after death we often find small excavations in the layer of semi-organized lymph coating the walls of the chest, and in some instances this ulceration per- forates the pleura and a layer of intercostal muscles, without proceeding farther. In other cases the ribs, vertebrae, or sternum, become partially carious from the same cause. When this ulcerative process proceeds so far as to cause the mat- ter to point externally, a soft fluctuating swelling is felt at some part of the chest; and it may generally be known to communicate with the interior of the chest by 316 PLKtRISV, (C'uuses.) its becoming tense during expiration, and softer during inspiration. Not uncom- monly the matter burrows under and between the muscles and integuments of the chest, and points at several places, and at a distance from the perforation of the pleura. We have seen abscesses connected with empyema point in three instances under the pectoral muscle, once in the right hypochondriac region, and once close to the spine: that in the hypochondriac region had been mistaken for an abscess of the liver; in this case it was found after death that there were per- forations of both intercostal muscles and diaphragm; and between the layers of the latter, the matter passed to the margin of the ribs, and there spread under the integuments, communicating with the other perforation between the ribs. The superficial abscesses are sometimes accompanied by much local pain and tender- ness; but in some cases these are scarcely complained of. These abscesses are generally slow in opening spontaneously: they generally first spread between the muscles and integuments, causing a puffy state of the parts. When the opening does take place, theie is a discharge of matter, more or less copious; and this recurs from time to time, especially during any strong efforts of expiration, as in coughing. Sometimes air is drawn at the orifice during strong inspirations, and the next jets of matter issue with greater force, occasionally mixed with bubbles of air. After the air has gained access to the empyema, the pus, which was at first inodorous, generally in a few days becomes fetid, exhaling the odour of sul- phuretted hydrogen: and with this change in the discharge, there is increased con- stitutional disturbance, sometimes manifesting itself in form of irritative fever, with bounding pulse and heat of skin, alternated with colliquative sweats; some- times producing typhoid symptoms, and a state of general depression. When the matter of empyema is discharged by ulceration through the lungs or bronchi, there is a violent fit of coughing almost like vomiting, ending in the expectoration of large quantities of matter. These efforts sometimes threaten suffocation: but the discharge is followed by considerable abatement of the symp- toms. Laennec considered this a more common event than perforation of the walls of the chest: our own experience would indicate the contrary; but there are on record many cases of both results. The ulceration through the substance of the lung or air-tubes is described by Dr. Townsend to be accompanied by the formation of a gangrenous eschar, which is detached, and the fistulous passage is lined with a false membrane, which prevents the matter from spreading through the lung, and conducts it to the air-tubes. The evacuation of the matter by fistulous openings may go on continually, or recur from time to time, with more or less temporary relief, for weeks, months, or even years: the patient in some instances recovering, in others sinking from the continued effects of the disease. In the former case, the discharge soon becomes less, and entirely loses its fetid character; the wound heals, and the chest gra- dually becomes contracted in the manner before described, there being a partial return of respiration in some portions of the chest. Causes of pleurisy. We are not aware that any circumstances predispose to pleurisy farther than those which render the body liable to other inflammations, such as a relaxed or debilitated state of the system after fevers or other severe disorders, the puerperal state, &c. Of the exciting causes of pleurisy, cold is by far the most common, especially exposure to cold winds; hence it is observed to prevail especially in the month of March. It may, however, be excited by external injuries, such as wounds and contusions of the chest, fractured ribs, &c: in these cases the disease is not un- commonly latent, and becomes chronic. It is an occasional complication of con- tinued and exanthematous fevers, particularly in some epidemics, constituting one of their dangerous complications. Less frequently it is excited by gout or rheu- matism; and on the sudden removal of a cutaneous eruption, or healing of an old ulcer or other habitual drain. It sometimes occurs from the extension of inflam- mation from the lung, the peritoneum, or the walls of the chest. From the lat- ter cause, it not unfrequently forms the closing scene in cancer of the breast. It pleurisy, (Diagnosis—Prognosis.) 317 is occasionally associated with erysipelas, diffuse inflammation of the cellular tissue, inflammation of the veins and puerperal fever; in such cases it is usually latent, and accompanied by the typhoid symptoms common in those formidable diseases. It is not uncommonly excited by tubercles in the lung, both in their solid state, and after they have been softened. In the latter case, when the pleura is perforated, there is generally, also, the admission of air into the pleura, pro- ducing the complex lesion, pleuritic pneumo-thorax, to be afterwards noticed. Diagnosis. In its very earliest stage, at the first attack of pain, pleurisy may be mistaken for pleurodyne and nervous pains of the chest and upper part of the abdomen; and as there are rarely any distinctive physical signs at this period, we must seek for the character of pleurisy in the general symptoms of fever, heat of skin, and sharp hard pulse, and sometimes in the short dry cough which accompanies it. In a short time, however, the physical signs become the most characteristic marks of the disease. It is unnecessary here to repeat the descrip- tion, and it only remains to point out the signs which distinguish pleurisy from some other lesions that most resemble it. Consolidation of the lung differs from pleurisy in its not causing any displacement of the contents or walls of the thorax, and generally, also, in its increasing the vocal resonance of the affected side, whether heard, or felt by the hand; and by its leaving some sound of respiration which is generally of a bronchial character. Partial pleurisies confined by adhe- sions are less easily distinguished, because, where the lung is adherent, there may be as much bronchophony and respiration as in cases of consolidation; but on examination these will be found to be more circumscribed than in the latter case, all sound being absent in other parts, which farther present the signs of enlargement or displacement of the heart, liver, or mediastinum, with fulness of the intercostal spaces, generally more remarkably than usual. A similar irregu- larity in the shape of the chest will serve to distinguish pleurisy in the progress of cure, by contraction of the chest, from the case of a consolidated lung. The diagnosis of intra-thoracic tumours will be described under their head. Chronic pleurisy is liable to be confounded with tuberculous phthisis, for their general symptoms are often very similar; and in truth they sometimes co-exist, or run into one another. But their physical signs sufficiently separate the two kinds of lesion; there never being in phthisis that general dulness and absence of respiration, with enlargement of the side and displacement of parts, which occur with empyema. The expectoration in chronic pleurisy is sometimes purulent without any communication with the pleura, or disease in the substance of the lung; it is in fact the product of a bronchitis which generally accompanies the last stages of most diseases of the chest. From simple bronchitis, dilated air- cells and tubes, and other chronic affections of the chest, the distinction of pleu- risy through its physical signs is sufficiently evident. Its diagnosis from hydro- thorax will be afterwards pointed out. Prognosis. Simple acute pleurisy, although a serious disease, and full of danger when neglected, generally yields to remedies promptly employed before the effusion is copious. But if active measures have been delayed or insuffi- ciently used, or if the effusion be purulent, or if there be other diseases in the chest, such as organic lesions of the heart, liver, or kidneys, or tuberculous or other deposites in the lungs, pleurisy often becomes an intractable and even fatal disease. It does not commonly prove fatal in its acute stage from the quantity of the effusion, except when the disease attacks both pleurae at once, or in cases in which empyema, or some previously existing disease in the other lung, pre- vents its free expansion to supply the defect of that which is compressed. The very rapid accumulation of the effused fluid is generally an unfavourable sign; for experience has proved that in such a case its dispersion is more difficult When the acute symptoms have subsided, and the extreme oppression resulting from the first effusion has abated, the probable issue of the case will depend much on the condition of the general health and strength. If this continue pretty good, there is reason to hope that the effusion will be gradually removed; 318 pleurisy, (Treatment.) and this hope becomes more sure as soon as the sounds of percussion and respi- ration are heard returning to any part, however small, in which they had been previously absent. But if the weakness of the body increase, and some of the functions be more or less disordered, the urine scanty and high-coloured, the legs or surface cedematous, or the expectoration purulent, with night sweats and increasing emaciation, there is much reason to fear an unfavourable issue, either from the nature of the effusion or the want of power to effect its absorption be- fore it fatally oppresses the vital functions. In case of empyema, where the purulent matter makes its way into the bronchi, or through the walls of the chest, although its discharge may give considerable relief for the time, yet the improvement may be but temporary; and here also the ultimate result will much depend on the general health and strength, as indicated by the rational symptoms, as well as on the condition of the lungs and other organs. Where these circum- stances are favourable, a permanent cure may follow; or the spontaneous dis- charge continuing to a greater or smaller extent, a tolerable share of health may continue for months and even years. But not uncommonly, before the matter finds its way externally, it has produced serious mischief in other parts, and by totally destroying the irritability of the intercostal muscles, by causing caries of the ribs, sternum, or spine, extensive fistulous abscesses in the walls of the chest and abdomen, or tuberculous deposites in the lungs, and at the same time in- juring the constitution generally, it leaves the body in a condition most unfavour- able to the restoration of health. These circumstances suggest the propriety of anticipating the process of nature, by artificially evacuating the matter before these serious consequences ensue. Treatment. The leading indications in the treatment of pleurisy are, 1. To subdue the inflammation; 2. To promote the removal of its more injurious product; 3. In chronic cases to improve the state of the general health, and to counteract the injurious effects of the persisting disease. The most desirable object is to destroy the inflammation at its very onset, before the signs show that the effusion is considerable. For this purpose, the most effec- tual remedy in severe cases is a full general bleeding, carried, if possible, to such an amount as to remove all pain on full inspiration; or, if there be little or no pain, until all hardness of the pulse ceases. This should be followed by free leeching or cupping of the affected side. We think leeches generally preferable: but they should not be applied sparingly, and they should be immediately followed by a large warm poultice covered with flannel, or by a succession of warm dry nap- kins. These depletory measures must be repeated if within a few hours the pain return, or the pulse resume its hardness. Of internal remedies, those are the most useful, in the first instance, which assist the blood-letting in producing an impres- sion on the circulation, especially brisk purgatives containing mercury and anti- mony, which act fully on all the secretions. Calomel and James's powder, followed by an active draught consisting of salts and senna, generally answer best Tar- tarized antimony is less effectual in this than in other inflammations of the chest; it may do harm if it excite vomiting; but in doses short of that effect it may prove useful. It commonly happens that such measures take off the edge of the disease with- out destroying it entirely, or, at least, without removing its products, which must be a work of time ; and although the pain, dyspnoea, and cough be much relieved, they are not removed, and the physical signs show that the effusion has taken place to a greater or less extent Under these circumstances the proper means are those which promise to fulfil both indications, to reduce the remaining inflam- mation, and to promote the absorption of the matter already effused. The most powerful of these is mercury, which may be combined with ipecacuanha and opium, to lull the pain and to prevent the calomel from passing off too freely by the bowels. These remedies should be given in pills every three or four hours; and to them may be added digitalis or colchicum in a saline mixture, with an ex- cess of alkali, to keep down the action of the heart and arteries, to determine to pleurisy, (Treatment.) 319 the kidneys and skin, and to lower the inflammatory condition of the blood. The beneficial influence of mercury is sometimes apparent when it does not affect the gums, especially in young subjects; its operation being only manifest on the he- patic and alvine secretion, which is green, dark, or high-coloured, from different conditions of the biUous matter in it: but in most cases the gums exhibit the effect of mercury before these secretions are produced. Venesection can seldom be repeated with much advantage after the first few days, unless on the occasion of a fresh access of pain, or other symptoms which denote the renewal of acute inflammation. Occasional leechings continue to be useful; but after the inflammatory fever has been reduced, the most effectual ex- ternal remedies are blisters, which should be used large, and not left on too long; from six to eight hours is generally time enough to make them vesicate without inflaming the tissues too deeply, or irritating the system by the absorption of their serous discharge. Where the effusion is abundant, a succession of blisters will be necessary; or they may be varied by a suppurating counter-irritant, such as the tartar-emetic ointment or solution. The diet must be of the most spare kind in the early stage of acute pleurisy; and the patient should remain as quiet as possible in bed. But when the inflammation is subdued, sitting up, and, if the strength will permit it, using a little exercise about the room, will be beneficial in promoting the absorption of the fluid. In limited varieties of pleurisy, such as those of a mild or partial kind, those ex- cited by tubercles, and in those which occur in combination with typhoid or as- thenic symptoms, the antiphlogistic measures above described must be reduced to suit the nature of the case, and the amount of the general strength. Circum- scribed pleurisies may sometimes be removed by cupping or leeching only; and in conditions of the system depressed by febrile or other morbid poisons, or re- duced as in phthisis, blisters, or sinapisms may be the only antiphlogistic means which can be borne. In continued fever, besides these external means and the usual salines, mercury in combination with opium is, according to our experience, the most appropriate remedy. If, in severe cases, from insufficiency or delay of treatment, or in spite of it, the signs of effusion continue beyond two or three weeks, little or not at all diminished, with more or less constitutional disturbance, it is to be apprehended that the dis- ease will take a chronic form, in which the character of the treatment must be to a certain extent changed. If the strength continue to diminish, the pulse be weak, and the fever (if present) of a remittent or hectic kind, a more nutritious and tonic plan must be cautiously pursued to the extent that the patient can bear; the heat of skin, pulse, cough, and condition of the breathing being referred to as tests of the suitableness of the change. But external counter-irritation should still be con- tinued, especially by blisters, which may perhaps be useful not only in reducing internal inflammation and in promoting the removal of the effusion, but also, as Dr. Stokes supposes, in restoring energy to the inactive external muscles of respi- ration, as they sometimes do to the muscles of a paralyzed limb. The secretions must be kept free by medicines of a milder class than those used in the acute stage; and, except with this object, we have not found much benefit from mercury in the advanced asthenic stages of simple pleurisy. In fact, when the effusion is purulent, the constitutional effect of mercury seems to be injurious. In these stages we have seen the most salutary effects result from the employment of the hydrio- date of potass, which seem to act both as an alterative and as a diuretic. Dr. Stokes highly recommends iodine, both internally and externally, in the form of a pint of Lugol's mineral water daily, and from a quarter to 'half an ounce of the ointment rubbed into the side. We prefer the hydriodate simply, in the dose of two or three grains, three or four times a-day; and in the more asthenic cases, the iodide of iron in rather smaller doses. As there is apt to be in both these medicines some free iodine, which we believe to be the chief cause of the unpleasant symp- toms which they are sometimes said to produce, it is well to direct the patient to eat a bit of bread or biscuit after each dose; the starch of this, combining with the 320 pleurisy, (Treatment.) free iodine, removes its injurious property; and with this simple precaution we have administered both these remedies in numerous instances, for a great length of time, without ever inducing the gastric irritation and nervous symptoms which are com- monly ascribed to iodine, and which we have seen produced even by Lugol's di- luted solution. These medicines seem especiaUy calculated to promote absorption; and, combined with blisters, we have found none so efficacious in hastening the removal of a pleuritic effusion. Various other medicines are occasionally useful. As diuretics, Laennec recom- mended acetate and nitrate of potash in very large doses, such as from 3ss to 3ij of the former, and 3es to 3iv of the latter, occasionally combining with them hy- drochlorate of ammonia and squills. Where a dropsical diathesis prevails we have occasionally found the tartrate of iron a good diuretic. But in some such cases, a coagulable state of the urine sometimes indicates a state of the kidneys in which diuretics prove injurious. Under such circumstances, powerful purga- tives and diaphoretics alternated are sometimes useful in reducing the effusion. But such remedies can seldom be used for any length of time without causing se- rious weakness and disorder, and are, we apprehend, more hazardous than the simple operation of mechanically drawing off the fluid. Gentle exercise and friction are commonly serviceable in promoting the expan- sion of the chest and lungs, and the absorption of the fluid. In the more chronic cases, it is of the utmost importance to promote the general health by free expo- sure to a pure, mild, and suitable air; and in cases disposed to scrofula, this will be best found at the sea-side. The removal of the fluid effused by pleurisy through an artificial opening in the chest (paracentesis thoracis,) the utility of this operation, and its mode of per- formance, have long been, and are still, subjects of much question among both medical and surgical writers. We must refer to other works for the different opinions on these points: we shall endeavour to state in the simplest terms the general results of our reading, observation, and reflection on the subject. There are two kinds of cases in which it becomes proper to give exit to the liquid accumulated in the pleural sac. One includes the examples of the recent disease, in which the effusion takes place so quickly and abundantly as to endan- ger life by the pressure which it causes on the lungs and blood-vessels. A sud- den effusion may have this effect, where its quantity is not sufficient to compress the lung totally, or to displace the viscera to a great extent, especially if the lungs be previously disabled, as by emphysema, catarrh, &c; there is, however, alwavs some enlargement of the side, which, with dulness and absence of respiration and vocal vibration, will sufficiently indicate the nature of the case. Here the liquid is generally serum, with more or less lymph, and it commonly deposites a farther clot of gelatinous fibrin after it has been drawn from the chest: the same liquid is however sometimes yielded by pleurisies of long standing. The other class comprehends those cases in which the pleurisy has existed for a lono- time; and the effusion instead of showing a disposition to disperse under the influence of remedies, either increases or remains stationary; and whether it cause a dangerous degree of dyspnoea or not, its longer continuance must do mischief by perpetuating the compressed state of the lung, as well as by the various other structural and functional affections which we have before alluded to. The cases of true em- pyema are generally included in this number, and are considered the more legi- timate subjects for operation, because there is less chance of purulent matter being removed by absorption; but we must add that the operation has not been so often successful in these cases as where the effusion is not purulent. Now the object of the operation is to remove the fluid, which either from its quantity oppresses the functions, or by its quality extends and perpetuates the structural lesions of the chest and its organs. With this view, an outlet is given to it, any number of times, until its quantity is so far diminished and its quality improved, that it shall not prevent the re-expansion of the lung as far as that is possible; the contraction of the chest filling up the deficiency as the remaining pleurisy, (Treatment.) 321 fluid is afterwards gradually absorbed. It is easy to perceive that after the disten- tion is relieved by the flow through the opening, the remaining fluid cannot be drawn out of the chest without something to occupy its place; and, unless proper precautions be taken, that something will be air, drawn by inspiration, not into the lung, but through the orifice into the cavity of the chest. Air thus introduced often seems to have the effect of causing an unfavourable change in the nature of the remaining liquid, rendering that which was serous decidedly purulent, and giving to pus a fetid character. Farther, when air gets access, it tends to do mis- chief, whether the orifice remain open or be closed: in the former case, the air passing in and out prevents the lung from expanding, and constantly irritates the serous membrane, which is not fitted for contact with it; and if it be closed, the air admitted tends to engender more air by the decomposition which it causes in the remaining fluid, so that the pleura soon becomes as much distended as before the operation. Hence, although the operation generally gives temporary relief, it has often been followed by symptoms of irritation, or of increased oppression, which have ultimately led to a fatal result. It is true that in some cases the cause of failure is irremediable disease in the walls or viscera of the chest, or perhaps in the constitution, which may be either the cause or the effect of a long continu- ance of the pleuritic effusion; but even in these oases, the operation may prove the means, either of great temporary relief, and considerable prolongation of life, or of just the contrary, according as it is, or is not, performed with due reference to sound physiological and pathological principles. The operation has, we admit, sometimes succeeded where these principles do not appear to have been much at- tended to; but this has been for the most part in young subjects, where the repa- ratory powers are active, and sufficient to countervail very unfavourable circum- stances; and we are confident that it would succeed in many more instances, were it resorted to at the time in the way pointed out by our improved knowledge of the subject. One great error has been to delay the operation too long, until some of the bad consequences of the disease, such as obliteration of the tissue of the lung or deposites in it, surfaces secreting inorganizable matter, and incapable of adhesion, ulceration and even sloughing of the soft parts, caries of the bones, morbid deposites in other parts, and depression of the vital powers generally, prevent the possibility of recovery. Another great error we consider to have been in the neglect of all means to promote the re-expansion of the lung, which is the only natural mode of supplying the place of the fluid drawn off, and is an obvious step towards a resto- ration of the healthy condition of the parts. The operation of paracentesis thoracis has been in use since the time of Hip- pocrates, and has been held in different degrees of estimation by the very nu- merous authors who have described it in its various modifications, but a great preponderance of opinion is in favour of its utility and safety when properly per- formed. It is very remarkable that many of the more important precautions in the operation were attended to by Hippocrates and his followers more than by the greater number of writers down to the present century; and we find from the " aphorisms," that the operation was considered to be the only means of cure, and when these precautions were attended to, and the fluid white and of good qua- lity, the patients recovered. The chief of these precautions were, not to delay the operation after the existence of the empyema is known, and to draw off the liquid gradually, at successive periods, closing the wound in the interval. We must refer to works on surgery for details of the different modes of operating; and we would remark that from the time of Hippocrates to that of Laennec, al- though many new plans were proposed, little improvement had been made, and the credit of the operation had rather declined than otherwise; but the greater precision conferred by the latter author on the diagnosis and pathology of effusions in the chest, has furnished the means of rendering this operation more successful than it has hitherto been. Formerly the signs of the very existence of empyema and hydrothorax were so uncertain, that many patients have been tapped when there was no effusion: in many, the existence of empyema was not suspected VoL II.—41 322 pleurisy, (Treatment.) • until it had proved fatal, or produced changes which prevented recovery; and In many instances the almost hopeless lesion of tuberculous perforation of the lung and pneumothorax has been joined with liquid effusion, and its incurable cha- racter has thrown additional discredit on the operation. But now we have sure means not only of detecting the presence of liquid in the chest, but in a great measure also of discovering the complicated lesions, and of distinguishing the cases which give the operation the best chance of success. The same means also enable us to simplify the operation; for, whereas, formerly it was expedient to make a long incision with a knife or lancet through the integuments, and then cautiously to divide the intercostal muscles and pleura with a bistoury, for fear of wounding the lungs or heart, now the surgeon, guided by the physical signs and the exploring needle, may without fear plunge a trocar at once into the chest, thus much diminishing the pain of the operation, and the risk of haemorrhage. Before describing the mode of operation which we would recommend, it is necessary to advert to some disputed points in regard to it. One respects the place for making the puncture. In case of the matter forming an abscess in the walls of the chest, there is no choice: this must be opened; but in the absence of such pointing, it is of importance to determine what is called the place of election. The majority of the older surgeons preferred the inferior parts of the chest, under the notion that the fluid would ponderate there. But as the fluid occupies the whole pleural sac, and by change of posture may be made to ponderate in any direction, this notion is of no weight in opposition to the risk of wounding the dia- phragm and abdominal viscera in these regions. Accidents of this kind have re- peatedly occurred. Laennec gives an instance in which a trocar passed between the fifth and sixth ribs on the right side, perforated the diaphragm and entered the abdomen; the diaphragm having been pushed up by an enlarged Uver. In other cases, the Uver, the kidney, and the lung have been wounded, the latter in conse- quence of its adhering to the diaphragm. On the other hand, the objection against puncturing the upper parts of the chest is chiefly on account of the greater fre- quency of adhesions of the lung there. The middle portions of the chest are therefore generally considered the most eligible, between the third and seventh ribs: and as the intercostal spaces are widest, and there is less thickness of the walls at the side, this part is generally selected as the place of puncture. Another debated point is, whether as much of the liquid as possible shaU be evacuated at once, the aperture left open, and a canula inserted, or a little only at a time and the orifice closed. In regard to the quantity to be drawn off, we are fully per- suaded, by the study of recorded cases, and by personal observation, as well as by reflection on the pathology of the case, that the Hippocratic method of evacu- ating the fluid gradually at successive times, closing the orifice in the intervals, is the best; both because it give the lungs time to expand, and the vessels to adapt themselves to the diminished pressure, and also because it affords the best means of preventing the admission of air through the orifice. For the same reasons we decidedly disapprove of the practice of leaving the orifice open, and particularly of leaving a canula in it. In proportion as the air has free access to the pleural sac, it will irritate it, perpetuate its inflammation, and prevent the lung from expanding, even in cases where it does not cause decomposition of the remaining fluid. But in many instances the foetor, which in the course of two or three days is perceived in the air and discharge which proceed from the orifice, becomes evidence of the latter mischievous effect of the introduction of air; and not a few patients have obviously sunk under the pernicious influence of the putrid matter thus generated. This result has ensued in some cases even where air has been admitted only in a very small quantity; and we therefore hold it to be highly desirable to prevent the entrance of any air. We are surprised that Dr. Townsend, who otherwise advo- cates the plan of the gradual discharge of the fluid, and the closure of the orifice, expresses a doubt whether the admission of air be really hurtful, and supports the doubt by the experiments of Nysten and Speiss, who found that air introduced into the healthy pleura was invariably removed by absorption in the course of a few pleurisy, (Treatment.) 323 days. These are obviously not parallel cases, and it is highly Improbable that air admitted to a serous cavity whose absorbing properties are manifestly impaired, the membrane being covered with products highly disposed to decomposition, will be absorbed without farther mischief To prevent the admission of air, it has been lately proposed to puncture the chest under water, the patient being in a warm bath; and this expedient is weU worthy of attention, particularly in cases where, from the long continuance of the disease, and consequent loss of expansibility of the lung, and elasticity of the walls of the chest, the method to be described after- wards may be insufficient. Several writers have recommended liquid injections with the view both to expel the air and to facUitate the discharge of the matter. The ancients in some cases injected oU and wine to promote the healing of the cavity; and it has repeatedly been tried, and sometimes with good results, to attain this by aromatic and tonic vegetable infusions. Sir P. Crampton used with suc- cess an injection of a weak solution of chloride of lime. However useful these in- jections may be for these purposes, they must in some degree prevent, rather than favour, the re-expansion of the lung. To attain this point, as weU as to increase the discharge of the liquid, it has been attempted to suck the latter through the orifice, by means of different kinds of syringes. Laennec proposed using a cup- ping-glass with an exhausting syringe after the puncture: this contrivance would probably draw off the fluid and promote the expansion of the lung very effectually; but unless the operation be conducted with great care and gentleness, there may be danger of rupturing the lung by the forcible entry of the air into it, or it would be almost impossible in the mode proposed by Laennec to prevent air from entering through the puncture on removal of the cupping-glass. StiU we think that the ex- pedient might be useful and safe by means of a little management, by which the canula should be slipped out, and the integuments drawn over the puncture, so as to make it valvular before the cupping-glass is removed, when the orifice might be farther secured by means of a compress confined by strips of adhesive plaster. But we apprehend that the exclusion of air as well as the expansion of the lung, as far as that can be safely attempted, may be effected by applying manual pres- sure to the wafts containing the effusion, and by closing the orifice before that pressure is removed. The following is the manner in which we recommend the operation generally to be conducted. The spot for the introduction of the trocar must be determined with due reference to the physical signs; carefully avoiding every part where or near which there is sound of respiration, voice, or not perfect dulness on percussion. A projec- tion and fluctuation of an intercostal space give greater eligibility to a spot; and these circumstances present themselves most frequently at the inferior lateral parts of the chest from the third to the seventh rib, where also the soft walls of the chest are as thin as any where. In all cases it is a proper precaution to pass a grooved needle first, as recommended by the late Dr. Thomas Davies; for this at once determines the presence of the liquid, its quality, and the thickness of the walls which contain it at that spot. Of course it is proper to avoid the imme- diate vicinity of the heart or of any of the known arteries or nerves. The upper margin of the fifth or sixth rib most commonly presents a favourable spot, but whe- ther more or less at the side must be determined by the position of the heart and other circumstances. The patient should be lying on his back, inclining to the affected side, and not more raised than is necessary for the state of his breathing. The skin should be drawn aside, so that the puncture through it may not, after the trocar is withdrawn, correspond with that of the costal pleura, but form a valvular orifice. The trocar should not be pushed in farther than is necessary to clear the parietes; but the canula may be pushed in farther after the stilette is withdrawn, and its sides should have several holes in them. As soon as the sti- lette is withdrawn, steady pressure should be applied by a bandage or by the hands of assistants, to depress the shoulder and ribs, and to push up the dia- phragm on the affected side, to promote the flow of liquid and to prevent the in- troduction of air through the orifice during any sudden or forcible act of inspira- 324 pleurisy, (Treatment.) tion. For the same reason, during a fit of coughing, if there appear any tendency to intermission in the stream of liquid, the orifice should be closed by the finger. The pressure should be steadily increased as the liquid flows; and if the stream should stop, a probe may be passed through the canula to clear it of clots of lymph or any other obstructing matter; but if still no more flows, a compress, or if the liquid is purulent, a large poultice should be placed on the orifice; and then, but not till then, the pressure on the walls of the chest may be discontinued; The result will be, that the walls of the chest, expanding by their own elasticity on the removal of the pressure, will draw air into the compressed lung, which, being thus inflated, will begin to resume its part in the function of respiration and cir- culation, and will thus promote the absorption of the rest of the fluid, and im- prove the condition of the whole system. Even if the fluid should accumulate again, the temporary expansion of the lung will have served to restore its natural properties, so that when another quantity of fluid is again withdrawn its tissue will be better prepared for a restoration of its function. Performed in the manner as directed the operation is almost free from risk, and will seldom fail to give relief. If the liquid be purulent it will generally be necessary to repeat the operation several times; but if it be serous, one tapping, which will partially expand the lung, will often be sufficient to give a turn to the disease, its complete removal being effected by nature aided by appropriate re- medies. When the fluid is purulent, we should strongly recommend the injection of warm water with the view to displace it; but instead of doing this, as it is usually practised, with a single tube, it should be done through a double-tubed canula, the tube for injection being cautiously carried two or three inches into the chest, whilst the evacuating tube is merely long enough to pass through the walls. If warm water previously boiled be then thrown in through the long tube by Read's syringe, it will drive the matter through the short tube; and in this way the greater bulk of the secretion will be displaced by water, which is very likely to be absorbed. If after repeated evacuations there be no apparent disposition to the ex- pansion of the lung or contraction of the chest, and matter continues to be secreted, it may be useful to use medicated injection, such as a very weak solution of nitrate of silver, or chloride of soda. The pleural sac may be treated as an abscess, and if the discharge be unhealthy it is quite proper to correct it and to promote the healing of the diseased parts by such means as are known to pro- mote granulation and desiccation of suppurating wounds. When the dis- charge is fetid, it is more decidedly necessary to correct it by injections of chlori- nated solutions, mixtures of creasote, or other antiseptic liquids. The same practice may be advantageously pursued when the matter has pointed and open spontaneously, leaving a fistula which may remain open for months and even years. Dr. Townsend mentions the remarkable case of Dr. Wendelstadt, who had been tapped thirteen years before, since which time the wound had remained open and discharged daily to an amount varying from half a drachm to four ounces. The diseased side was much contracted, and did not move in breathing, yet he could blow the flute, walk fast, and actively perform his professional duties. Pleurisy when free from complications is not of muc'i danger except in those cases in which a very large purulent effusion or empyema takes place; in this case, as the absorption is dif- ficult, death not unfrequently ensues from the continued irritation and dyspnoea. But pleurisy, although in itself of little comparative importance, becomes a very serious affection from its connexion with tuberculous diseases of the lungs and of the membrane itself. In some cases it is a causo of the tuberculous disorder, in others, a mere sign of its presence* We regard the pleuritic inflammation as the cause of tubercles, when it occurs in a person who was previously in good health or nearly so, and is followed immediately by pulmonary phthisis, or when the symptoms of the pleurisy are gradually replaced by Ihbse of the tuberculous dis- ease. In these cases the pleurisy acts as a cause in two ways: 1st, by the long continued irritation, which at last favours the development of tubercles either in the lung or pleura pleurisy. 325 and 2d, by a peculiar modification of inflammation giving rise, in the first instance, simulta- neously with the ordinary products of inflamed serous membranes, to a tuberculous secretion. In both cases there is probably a tuberculous predisposition, or cachexia; but the individual is often robust and in apparent good health, and the evidence of a tuberculous disease is rather a matter of inference than of positive demonstration. In many instances it is probable that there was no previous predisposition, but that some peculiarity in the mode of invasion of the disorder, or of local circumstances in which the patient was placed, caused the tubercles to be developed in this sudden way. When the tuberculous disease has been gradually forming before the pleurisy, the serous inflammation is a mere consequence, and has little influence upon the course of the disorder. It is, therefore, of little interest to the physician except as a sign of the tuberculous disorder; for as we shall afterwards see, repeated attacks of pleurisy, if combined with some of the general symptoms of the tuberculous affection, are very good indications of pulmonary phthisis. The same rule holds good in a still stronger dogree if the pleurisy first attacks one side and then rapidly passes to the other. The signs of pleurisy connected with a tuberculous disease differ but little from those of the same inflammation when it is perfectly uncomplicated. The physical condition is the same, and the signs which depend upon it are, of course, perfectly similar. The diagnosis of the tuberculous variety, or of the pleurisy which is about to pass into phthisis, depends upon the symptoms of constitutional irritation. If these are permanent, the disorder is apt to terminate in phthisis; that is, there are at the time tubercles in the lungs or pleura? which may probably become more completely developed, and general phthisis will then follow. I« many cases the tuberculous disease seems to abate, and the inflammation of the pleura passes through its stages and presents towards its close the symptoms of tuberculous deposite. But the morbid secretion is not abundant enough to pass into phthisis, which is nothing but a more advanced stage of the disease. The fever of empyema, and even of the early stages of simple plurisy, resembles very closely, it is true, that of incipient tubercular disease, which signs show that the constitutional irritation is in both cases nearly the same, and is often accom- panied with the double secretion of lymph and tuberculous matter. The practical importance of attending to the relation between pleurisy and phthisis is suffi- ciently obvious, The pleurisy should be watched after the decline of the urgent symptoms, and the patient should not be neglected until conducted to a full convalescence. The remains of the inflammation may be most effectually removed by the repeated application of small blisters to different parts of the chest, not larger than two or three inches square. These create but little irritation, but at the same time are sufficiently powerful in their action. The mercurials and nauseants, with other debilitating remedies, which act so well in the early stages of pleurisy, are not applicable to those cases in which, with a declining strength, symp- toms of tuberculous disease begin to manifest themselves; we are often in such cases obliged to combine with the local counter-irritation a tonic treatment by the wild-cherry bark, and sometimes the addition of the preparations of iron, or of iodine according to the case. The mercurials and other antiphlogistic remedies, are not adapted to those cases in which phthisis has positively declared itself, but they are often the surest means of preventing it by quickly curing the inflammation, and thus relieving the disease before tubercles are formed. After the acute inflammation is entirely removed, a sea-voyage or a journey is often of great benefit, and may complete the cure. As to the propriety of performing the operation of paracentesis, my own views accord entirely with those of the author. The operation is followed by more or less relief of the dyspnoea, but the admission of air into the cavity of the thorax generally increases so much the irritative fever, by the decomposition of the purulent liquid, that the result is almost necessarily fatal. I never advise the operation, therefore, except as a last resource, when other means have failed, and when the pus is evidently tending towards the exterior. The precautions advised in the text should always be kept in mind. G. 326 pneumothorax, (Causes.) PNEUMOTHORAX. Modes in which it may arise.—Physical signs.—Prognosis.—Treatment. Pneumothorax (from ruvftx, air, and, A»p«g the chest) implies the presence of air in the cavity of the chest. The discovery of this disease, or rather of this effect of other pulmonary lesions, is of modern date, though it for a long time re- ceived no distinctive name till the term pneumothorax was proposed by M. Itard, and subsequently adopted by writers on pulmonary diseases. Pneumothorax may be produced in three different ways:—1. It may be the consequence of a partial pleurisy. We have mentioned, that after a pleuritic ef- fusion has long compressed the lung, and the compression has been perpetuated by a rigid false membrane formed over it, the absorption of the liquid leaves a void, which the collapse or contraction of the walls of the chest is in some cases insufficient to obliterate, and this void is sometimes filled with air secreted by the membranes. We have seen two instances of partial pneumothorax produced in this way. They each occupied about half of the pleural sac; in one case the upper, in the other the lower half; and the lung in both cases was strongly bound down by fibro-cartilaginous membrane, and condensed in the part contiguous to the empty space. There was also some contraction of the chest in both cases. This kind of pneumothorax is very rare. 2. Another kind of pneumothorax is that which may be called idiopathic, and arises from an effusion or secretion of air into the sac of the pleura without perfora- tion. This is also of very rare occurrence. It is said to occur sometimes towards the termination of fatal diseases, in the same manner as tympanitis occasionally occupies the peritoneal sac under similar circumstances. We have never met with such a case in which the signs of pneumothorax were observed during life; but we have several times seen a little air in the pleural sac when it is opened after death, without any discoverable perforation of the pleura. It is possible that a little air may have been exhaled from the animal fluids after death, and then increased by exosmosis through the lung: the facility with which gases pervade dead membranes countenances such a notion. Pneumothorax is also said by Drs. Hudson, Graves, and others, to have occurred in a few instances at the commence- ment of pneumonia, and to have soon afterwards disappeared: but as the chief sign in these cases was a remarkable resonance on percussion, we suspect that these were examples of the production of tracheal or amphoric sound, from con- solidation of the upper lobe of the lung, and not cases of pneumothorax. 3. By far the most common kind of pneumothorax is that caused by some unnatural communication between the pleural sac and the external air, and this may be by a perforation either of the external parietes or of the pulmonary pleura. The latter case is now recognised as the usual cause of pneumothorax, and constitutes the great bulk of the examples that are met with. The perfora- tion depends on the progress of the ulceration, generally of tuberculous character, rarely of gangrenous abscess, through the pleura. The circumstance of ulcera- tion reaching and perforating the pleura indicates a low state of the reparative powers, and a want of plasticity in the products of inflammation; for imder ordi- nary circumstances ulceration could not approach the pleura without causing it to inflame and throw out coagulable lymph, which, becoming organized, forms either a protecting thickness of membrane, or close adhesions to the costal pleura. We see this in most cases of chronic phthisis, where the upper lobes are general- ly adherent to the ribs. We have seen ulceration extend from a tuberculous cavern across the two layers of the pleura, thickened and adherent, and completely through the walls of the chest, so that when the patient coughed, air bubbled out of two or three fistulous openings in the front of the chest, but there was no pneu- mothorax. On the other hand, we have met with more than one case in which pneumothorax, (Physical Signs.) 327 the adhesive process seemed quite Incapable of protecting the pleura, which was consequently perforated at several points, wherever in fact the ulceration of the lung reached it, and air freely passed into the pleural sac by all these holes. More commonly however, there is only one perforation; and this is generally near the apex of the lung, in connexion with some of the cavities which first form there. The completion of the perforation is in most instances sudden—a part thinned by ulceration, and imperfectly adherent, giving way during a fit of coughing, or some other unusually forcible act of respiration. We have met with an instance in which external violence produced the rupture. The immediate effect of the perforation is to admit air more or less rapidly into the pleural sac, which by equal- izing the atmospheric pressure outside and inside of the lung, permits it to assume that state of collapse to which its natural elastic contractility would reduce it. Hence dyspncea, sudden and severe in proportion to the extent to which the air enters and the lung becomes collapsed. But the access of air to a serous mem- brane totally unaccustomed to it, with perhaps the discharge of matter from the ulcerous opening, also occasions great irritation and consequent inflammation of the pleura. Hence a sudden sharp pain and dry cough, with spasms of the inter- costal muscles and a weak quick and sometimes irregular pulse. Soon the irrita- tion becomes accompanied with inflammatory reaction, and then follow the symptoms of acute pleurisy with heat of skin and inflammatory pulse; and liquid effusion is added to the air in the pleural sac. Although a perforation of the pleura will not fail to introduce air into its sac, the amount and effect of this introduction of air will vary considerably according to the size and other conditions of the ulcerated opening. If this be very small, or if, as it not unfrequently happens, it be so placed that the walls of the chest close it in expiration, by which it is rendered valvular, or if it be below the level of the liquid, the air introduced by each inspiration will not escape as freely in expiration, and the result will be the progressive accumulation of air in the pleura, and a con- sequently increasing compression of the lung and dyspnoea; and in this way per- foration of the lung has in some cases caused suffocation within a few hours of its occurrence; in others this catastrophe has been delayed by the egress of the air by accidental changes of position, by violent coughing, or by puncturing the chest. If the aperture be of larger size, and no impediment occur to the passage of air through it, it will interfere with respiration only so far as it suffers air to pass outside of, instead of into, the lung. But when the air passes thus freely, the pleura is more irritated by it, and there is a more copious secretion of liquid, which is generally more or less purulent and often fetid. In either of these cases, after the subsidence of the spasm, pain, and dyspnoea, first caused by the entry of the atmospheric air, there are no characteristic general symptoms which can serve to distinguish pneumothorax. The occurrence of perforation may sometimes be suspected from the sudden supervention of acute pain of the side and oppression, which the patient in some instances refers to something having given way during a fit of soughing. But such sudden attacks sometimes take place from pleurisy without perforation, and we have repeatedly known perforation happen without being followed by any remarkable increase of pain or distress. The physical signs of pneumothorax are generally very remarkable and dis- tinctive. The presence of air in the pleura will give to the walls of the chest a freedom of vibration, and therefore a degree of resonance on percussion, even greater than that which the air-filled structure of the lung confers upon them; so that percussion will give more of the drum-like note or tone which is obtained by striking on the region of the stomach or caecum. This is more marked in pro- portion as the quantity of air is considerable. The same circumstance will also impair or destroy the sound of respiration; for the air not only removes to a greater distance the pulmonary structure in which this sound is produced, but also by its pressure diminishes that entrance of air into the cells on which' the sound depends. There will be therefore this remarkable contrast of signs to dis- tinguish pneumothorax—a clear or hollow sound on percussion, with little or no 328 pneumothorax, (Physical Signs.) sound of vesicular respiration, whilst the healthy side gives a duller sound on percussion, but a much more distinct respiratory murmur. There is however produced in air-filled cavities another class of sounds, which often gives decisive evidence of their existence. The character and cause of these sounds may be shown by a simple experiment. If the mouth of a caout- chouc bottle be held to the ear, and its outside struck, each stroke causes a short tinkling note, like the clink of a piece of metal or glass. This note is a kind of echo, produced by the reverberations or repeated reflections of the impulse from the walls of the cavity, and it is shrill and acute because the reflections are short and quick in so small a space. The same kind of note may be heard in other hollow bodies, such as an empty cask; but it is there less shrill, because the space is larger. Any sound proceeding from, or communicated to, the interior of the cask, the caoutchouc bottle, or any cavity in the body with reflective walls, will be accompanied or followed by this sort of tinkling or ringing echo, which will be more prolonged and distinct in proportion as the walls are perfectly and uni- formly reflecting. Sounds of this kind may often be heard on using the stetho- scope over the stomach and large intestines, as their contents move and cause a sound within them. So, too, this tinkling echo may accompany the sounds pro- ceeding from an air-filled cavity in the chest, and it becomes a distinctive sign of the existence of such a cavity. In idiopathic pneumothorax, and in that partial kind resulting from the absorp- tion of a pleuritic effusion confined by adhesions, although the cavity be present, there may be no sound produced in it, or transmitted to it, so as to cause the tinkling echo. Sometimes percussion on the external walls will do this; and we have heard the metallic tinkling accompany both the voice and the cough in a case of partial pneumothorax without liquid effusion or perforation of the pleura, the sound being transmitted to the cavity through the condensed tissue of the lung. But it is where the pleura is perforated and where liquid is present, that the phenomenon of metallic tinkling is commonly heard; not, as Laennec supposed, because these conditions are essential to its production, but because the motions of the liquid or of the air through the orifice make sounds within the cavity which serve to show its echoing properties. So metallic tinkling has often been heard after the operation for empyema, manifesting the presence of air in the pleura. Perforation of the pleura, with its consequence, pneumothorax and liquid effu- sion, is not a very uncommon accident in the course of phthisis; and its signs are so remarkable, that they can scarcely fail to be recognised even by those who are but moderately versed in auscultation. The tinkling echo may present several modifications, which it is useful to notice, as they serve to give a more accurate knowledge of the condition of the parts and of their tendencies. When the per- foration is small, or obstructed by its position against the walls of the chest or below the level of the liquid, the tinkling is seldom heard except on coughing or taking a full breath, which reaches the cavity and may throw the liquid into bubbles. The voice may also sometimes reach the cavity through a consolidated portion of the lung, and then it will be accompanied by a tinkling. When the orifice is large and free, the air will pass in and out in ordinary breathing, and will produce in its vicinity a sound like that of blowing into the mouth of a glass bottle: this kind of respiration is therefore called amphoric. In such cases there is seldom so much oppression of the breathing as in those where the air passes less freely and accumulates in the cavity. In listening for the tinkling phenomena, it must be held in mind that they may be audible only in certain parts of the chest where the lung is not adherent, and where the liquid effusion does not reach. Generally, in the sitting posture they are heard best about the mamnwe and the lower part of the scapula and axilla; but we have heard them in some cases in every part of the affected side, and in others only in one spot. In fact, there must be a certain degree of tension in the walls of the cavity to make them good reflecting surfaces, and if this be deficient at the spot of the cavity opposite to pneumothorax, (Prognosis.) 329 that on which the stethoscope is applied, the sound may be absorbed and not re- flected. The addition of the liquid to the air in the chest makes the diagnosis still more easy. By percussion we can find the exact level to which the liquid rises, and that this level moves with change of posture; this is much more distinctly per- ceptible than with simple liquid effusion. The motions of the liquid may far- ther give very decisive evidence of its presence with air in the cavity. On change of posture and on coughing, the liquid will sometimes drop from the parts which have just been immersed; and the sound of this will exhibit the metallic ringing in so distinct a manner, that it resembles the note which a glass or porcelain ves- sel yields when struck. If the liquid be agitated more forcibly, as by the patient giving his trunk an abrupt jerking turn, or being violently shaken, it may be heard to splash most distinctly against the walls of the chest: this is the sign of succussion described by Hippocrates. It may be best heard by applying the ear to the chest at the time of the movement, and then the tinkling is heard to accompany it, and sometimes to follow it as the liquid drops from the sides, or . the bubbles break on its surface. The splashing is not easily produced, unless there be a good deal of air in the pleural cavity with a moderate quantity of liquid. The proportions of these are however better ascertained by percussion. The prognosis of pneumothorax from perforation must be generally unfavoura- ble, because, besides its own formidable character, in the vast majority of cases it arises from tuberculous disease of the lungs. Provided however the tubercu- lous disease be very limited, it does not seem unreasonable to think with Laen- nec that the case may not be entirely hopeless. Laennec mentions an instance in which pneumothorax lasted for six years. Dr. Houghton describes another in which the individual suivived the perforation eighteen months, and probably would have lived longer if he had not imprudently exposed himself in his work as a bricklayer; for the signs of the cavity had disappeared, the side had con- tracted, and the general health had been much improved. In a case related by Dr. Stokes, the patient lived for many months, during which he rode much on horse- back, and could hear a splashing in his chest when he trotted or cantered. We have known two patients with pneumothorax leave the hospital with the impres- sion that they were nearly well, having gained flesh, and lost the worst phthisical symptoms after the first severe consequences of the perforation had subsided. In such cases which are to be considered exceptions to the general rule the pro- duction of the new disease in the pleura seems to act favourably in retarding the tuberculous affection of the lung; and if this be of limited extent, it is pos- sible that it may be removed, the wound on the lung cicatrised, and the cavity of the pleura obliterated by contraction and adhesion. I have seen a case in which the patient lived for a year and made two long voyages, doing full duty as a seaman, going aloft, &c., yet the purulent effusion continued in his chest. On his return to the hospital about one year after his discharge, the gas had wholly disappeared, and the whole pleura was enormously distended with a purulent liquid, which was on the point of perforating the walls of the chest. It was not judged advisable in the circumstances of the patient to perform the operation for empyema. In another case, the patient, a stout mulatto, lived a still longer period, about eighteen or twenty months; he returned to the hos- pital after he had left it, and remained in the enjoyment of tolerable health, although too short- breathed to be capable of any laborious occupation. This case at last proved fatal. In neither of these cases did the tuberculous disease apparently advance: a few scattered tubercles only were found in the lungs, and the consumption had scarcely formed itself when a single tubercle softened near the pleura, and gave rise to the pneumothorax. In another case which I witnessed, death took place in less than half an hour. The lung which was perforated contained but few tubercles, but the other lung was filled with them and offered numerous cavities at its summit. The respiration therefore was cut off, as the only lung which was capable of performing this act was suddenly rendered unfit for its function. Vol. II— 42 330 pleurodynia, (Nature.) On examination after death the injection of the pleura had already commenced, and there was a very slight deposite of lymph around the perforation. I am not, however, sure that I have seen any case of absolute recovery. CJ. Treatment. The measures calculated to relieve the symptoms of pneumotho- rax with perforation vary considerably according to the period of the lesion, and the condition of the system. In the first instance the perforation and access of air and matter to the pleural sac is often attended by considerable prostration of the system with rapid feeble pulse and faintness, together with the pain and cough, which are then the result of irritation rather than inflammation. Consi- derable doses of opium or morphia are necessary to allay this irritation; they may be advantageously combined with calomel and antimonials; and sinapisms or warm fomentations may be applied to the affected side. More active antiphlo- gistic measures cannot be used until the reaction takes place, which generally be- gins in a few hours, bringing with it heat of the skin, strength and hardness of the pulse, and great soreness as well as pain of the whole affected side; then blood-letting, chiefly local, must be used, with aperients, and salines, according to the strength of the patient, and the degree of fever present. These may be fol- lowed by blistering or tartar-emetic counter-irritation in proportion to the continu- ance of the inflammatory symptoms. But it is not to be forgotten that perforation of the pleura and its consequences are almost always added to a previously ex- isting disease, tuberculous phthisis: and the degree of advancement that this may have reached must much limit the propriety and efficacy of the measures for this accidental inflammation that has been excited. The same considerations are to be kept in view when, in consequence of the smallness of the perforation, or its valvular condition, air accumulates in the chest, and becomes the cause of op- pressive dyspncea. The immediate indication in this case is, doubtless, to give exit to the air by puncturing the chest; and this has been done in several instances with great temporary relief. But before this operation is prescribed, it should be considered whether, as the relief from it will be but temporary, the condition of the patient be such as to make this likely to outweigh the pain and risks of the operation. These certainly are not great; but when added to the dubious view in which the friends of the patient may regard an operation which proves but imperfectly successful, they are sufficient to deter us in many cases from recom- mending it. The case is different when the accident occurs before the consump- tive disease has advanced far, when there is much flesh and strength, and when the physical signs have shown that there is a large proportion of sound lung. The operation may be repeated if the air accumulate again. As it is impossible to avoid the continued introduction of air into the chest, the mode of performing the operation is a matter of much less consequence than in empyema. It is more desirable to puncture below the level of the liquid, to allow this as well as the air to escape. ' PLEURODYNIA. Nature and characteristic symptoms of the various kinds of pain in the chest, and tiitir treatment. The affection usually called Pleurodynia is generally considered to be of a rheumatic character, either in the intercostal muscles, or in the fibrous fascice lining the chest. If it occur singly, it may be of little consequence; but if con- nected with constitutional rheumatic disease in other parts, whether attended bv pleurodynia, (Treatment.) 331 much fever or not, it is not to be lightly thought of, for it may readily be con- verted into a pleural or pericardial inflammation. It not unfrequently happens in sensititive frames, particularly those of females, that an acute pain suddenly seizes some part of the chest, causing shortness of breath and perhaps cough, very like the stitch of pleurisy: but there is no heat of skin, and the pulse, although often quickened, is not hard. The respiratory motions and sounds may be diminished by the restraining influence of the pain; but the other physical signs of pleurisy are wanting. There is no friction sound, or dulness on percussion; but there is sometimes a continued dull rumbling sound produced by the vibrating contraction of the muscles, which is kept up by the sensation of pain. These affections appear to be neuralgic, and are often con- nected with a condition of the system the very opposite of inflammatory, such as that which comes on after considerable losses of blood, or when the blood is in an impoverished state, as in chlorotic females. Sometimes they occur in con- nexion with the periodic plethora of irregular menstruation, and are relieved when the catamenia flows. In such cases blood-letting relieves the pain, but often at the expense of the natural function. There are other kinds of pain in the chest which may be called nervous, such as those associated with indigestion and a disordered stomach: they are generally referred to the sternum, and in the case of gastrodynia are so severe, as to cause great apparent dyspncea. Pains are also felt in the chest and shoulders, from a congested state of the liver. The treatment of nervous pains of the chest must be directed more to the con- dition of the system inducing them, than to the part which seems to be most affected; for it may be at one time the chest, at another the abdomen, or a limb that is the seat of these pains. Sinapisms, hot fomentations and stimulants, or anodyne liniments or plasters, will generally relieve the pain. Where the ner- vous irritation seems to arise from an undue depression or depraved state of the vascular functions, as in chlorosis, the careful administration of tonics, especially steel medicines, with due attention to the state of the excretions, will be most bene- ficial. When the pain seem3 to be the result of misdirected rather than of exces- sive nervous influence, as in amenorrhoea without chlorosis, those remedies are indicated which tend to draw blood and nervous irritation towards the uterus, such as small doses of aloes, the hip-bath, and for a more continued effect, wear- ing flannel over the hips and thighs, and riding on horseback. If blood is to be drawn at all for temporary relief, it should be by leeches to the inside of the thighs. The application of three or four every night for four or five successive days, sometimes brings on the natural relief when all other means have failed. If there be much tenderness at any part of the spine, all the symptoms may sometimes be relieved by leeches applied to that part. Nervous pains unconnected with menstruation maybe treated with narcotics both externally and internally. Pleurodynia of a rheumatic kind will require the treatment commonly useful in the form of rheumatism, with which it happens to be associated. It is not necessary here to enter into farther details on these sub- jects. 332 pneumonia, (Symptoms.) PNEUMONIA. General symptoms of acute pneumonia.—Anatomical characters.—Sanguineous congestion.— Red hepatisation.—Suppuration, or yellow hepatisation.—Gangrene.—Physical signs.—In- dicalions by physical signs of the situation, extent, and stage of pneumonia.—Varieties and complications.—Typhoid pneumonia.—Complication witli bronchitis—with pleurisy, con- stituting pleuro-pneumonia—with phthisis—with the various forms of fever.—Pneumonia and purulent deposites in the lungs after injuries and surgical operations.—Diagnosis.—Prog- nosis.—Causes.—Treatment of the first stage—of the second stage—of the third stage.— Application of the treatment to particular cases.—Of chronic pneumonia—its anatomical characters, symptoms, and ^treatment. Pneumonia, Gr. frvev^oviu, peripneumonia, mptwcupon*, pneumonitis, pulmoni- tis, (from ■nnvy.ai, pulmo, a lung, or the lungs,) are names given to inflammation of the parenchyma of the lung. These terms were applied by Hippocrates and other ancient writers to most of the acute diseases of the chest unattended with severe pain, those connected with this symptom being by them termed pleurisy. Although this ground of distinction by no means holds good with our improved knowledge of the subject, yet we shall find, in opposition to the opinion of Cullen and some modern writers, that between pneumonia, pleurisy, and bronchitis, there is a distinction founded in pathology, and most important in practice. The characteristic symptoms of pneumonia may be given as follows:—fever, with more or less pain in some part of the chest; accelerated and sometimes op- pressed breathing; cough with viscid and rusty-coloured expectoration; at first the crepitant rhonchus, afterwards bronchial respiration, and voice with dulness on percussion in some part of the chest. We shall find, however, that many of these symptoms are not essentially connected with pneumonia, which, with more precision, may be defined pathologically, as inflammation and its product in the par- enchyma of the lung. Symptoms. Acute inflammation of the lungs is, like other phlegmasia?, accom- panied by fever, which often commences with rigors prior to any other symptoms, but sometimes preceded by the local symptoms. The fever is generally very in- tense, and in plethoric individuals accompanied by flushing of the face, injection of the eyes, headach, and other signs of local determination of blood. The pain in the chest, which when present usually appears early, varies much in degree, being sometimes intense, and sometimes diffused and dull; frequently it is a deep- seated feeling of heat and weight rather than of pain. It generally seems to be deep-seated in the chest, under the sternum, the breast, or the scapula; when more at the side, it is often more acute, and this is frequently, but not always, caused by the extension of the inflammation to the pleura. There is commonly more or less cough, which aggravates the pain: it is short and dry at first, or accompanied with scanty mucous expectoration, 'and is by no means proportioned to the intensity of the inflammation, being in some cases so slight as to escape notice. The shortness or quickness of breathing is also an early symptom, and a better index of the extent of the disease: but it is to be judged by the number and forced character of the respirations, rather than by the feelings of the patient which are often deceptive. The number of respirations in a minute (which in the healthy adult is about twenty) may rise to thirty and upwards. In some cases, particularly where the attack has been sudden, or has supervened on previous disease of the lungs or heart, the dyspnoea is more urgent, obliging the patient to assume a particular attitude, which is commonly on the back with the shoulders elevated. Muscular efforts, and particularly speaking, bring on or increase the pneumonia, (Symptoms.) 333 oppression. The pulse is quick, and in most instances sharp; sometimes but less commonly it is hard, and it generally loses this character as the disease advances. There are, moreover, the other symptoms of fever, such as thirst, furred tongue, loss of appetite, scanty and high-coloured urine, pain in the head and limbs, and weakness. If blood be drawn it exhibits the buff coat. The febrile irritation varies greatly in character, sometimes affecting particular organs, as the brain, causing delirium; the stomach, inducing sickness; the liver, giving rise to jaundice, and other bilious symptoms; and in many cases the fever, instead of being inflam- matory is typhoid, producing a variety of the disease which will be afterwards noticed. In the course of a day or two, the cough becomes accompanied by the ex- pectoration of a rusty-coloured sputum of various shades, semi-transparent, tena- cious, and coherent: at first it does not differ from that of acute bronchitis except in colour, which is light reddish or rusty, sometimes passing into an orange-yellow or even a greenish tint: as the disease proceeds, the tint becomes more pronounced, and the viscidity greater. When the characteristic sputa appear, the dyspncea is often increased; and if the pulmonary inflammation be extensive, the oppression is urgent. The pain on the other hand is often diminished, though sometimes it continues and prevents the patient from lying on the affected side. In favourable cases the disease may decline on the third or fourth day, with a general alleviation of the symptoms. This is generally first evinced by the skin becoming more cool and moist, and the expectoration less tinged and viscid, and more abundant and opaque, like that of declining bronchitis. Sometimes the im- provement is rapid, the patient being restored to convalescence in six or eight days; but it tis often more protracted, slight exacerbations recurring every eve- ning, and prolonging the disease for a fortnight or more. The quickness of pulse, cough, and slight dyspnoea are the symptoms which are most apt to linger, with the temporary recurrence of the sanguinolent tinge in the sputa: these are to be re- garded as signs of a lurking disease, which a slight cause may aggravate and bring to a relapse. In more formidable cases, the increase of the disease is appa- rent on the third or fourth day, by the quickened respirations (sometimes amount- ing to forty or sixty in a minute,) occasionally obliging the patient to sit up ; some- times by more frequent cough, though this is by no means constant; by the greater viscidity and deeper tinge of the sputa; the more weak and rapid pulse; more de- pressed state of the bodily powers; the loaded or dry tongue; the hot skin, or its feeling cold and partially perspiring. Sometimes there is delirium or coma, which are dangerous symptoms, especially in old persons, and often disguise the nature of the disease. Laennec justly describes comatose symptoms as of more unfavour- able import than fierce delirium. The progress of fatal cases is marked by increasing failure of the strength and more hurried breathing, but the feeling of dyspnoea is not always increased in pro- portion, sometimes it is even diminished. The cough is less effectual in discharging the sputa, which sometimes retain their viscidity and sanguinolent hue. In most instances there is a total suppression of the expectoration for some hours before death; in others, it is still voided, but in an altered state, being a thin transparent or dirty mucus, or an opaque dirty brown or greenish fluid, consisting of a mix- ture of mucus and pus, with a little blood. In some cases it has a very fetid odour; in others the thinner reddish-brown fluid, noticed by Andral, like prune juice or liquorice-water, is that last expectorated. With these changes in the ex- pectoration, the pulse becomes thready, very frequent, and often irregular; the countenance pallid and cadaverous; the lips livid; the skin cold and,bedewed with cold sweats; the breathing gasping, with an increasing rattle in the throat; the sen- sorial functions give way, and the patient dies asphyxiated. When the disease terminates favourably, the amendment is often accompanied by some critical evacuation, such as perspiration, aiateritous deposite in the urine, expectoration, diarrhoea, epistaxis, haematuria or some other haemorrhage, or the menstrual discharge: of these the first four are by far the most common, and the 334 pneumonia, (Anatomical Characters.) first two are often conjoined ; but the critical evacuation varies with the cause of the disease and the nature of the prevailing epidemic. The observations of Andral have in some degree confirmed the opinions of Hippocrates and other authors, an- cient and modern, that on certain days the symptoms show a tendency to abate. These are especially the seventh, eleventh, fourteenth, and twentieth days. In ninety-three cases observed by Andral, the recoveries on critical days averaged fourteen, on non-critical little more than three. In these favourable cases, after continuing with greater or less intensity for the various periods just mentioned, the symptoms become evidently ameliorated; the dyspnoea subsides; the cough be- comes less constant and more easy; the expectoration less viscid and tinged, and more opaque and free ; and the pulse less frequent, often with an increased fulness The fever also abates; the skin becomes cool, soft, and moist; the tongue cleaner, and the thirst abates. Some quickness of breathing and of pulse generally linger after the other symptoms, and often cough with bronchitic expectoration, which may remain for some time, and pass through the changes observed in acute bronchitis. In recovery from pneumonia, relapses are by no means uncommon: they are marked by a recurrence of the chief symptoms, pain, shortness of breath, cough, and viscid sanguinolent expectoration. The fever is less acute than at the first attack; hence a relapse, if serious, may be less tractable. We shall have occasion to revert to the character and variety of the general symptoms, when treating of the pathology of the disease and the physical signs. Anatomical characters. The first condition produced in the lung by inflam- mation is sanguineous congestion or engorgement, in which the vessels are then so much distended, that the whole tissue appears red, of different shades, and is much heavier than usual, but still crepitates. In some cases a frothy serum ex- udes when a section of the lung is made; this is probably the effect of the coagu- lation of the blood after death, for it is not observed in those cases in which the blood remains fluid. It is a common notion that the blood in an inflamed lung is effused into the air-cells, but for several reasons we are inclined to believe that it is contained chiefly in the distended vessels and in the tissue, although it may be occasionally extravasated. Andral examined an inflamed lung after drying and slicing it, and the only difference which he could perceive in its structure was, that the membranes between the cells were somewhat thicker and redder than natural; but there-was not that obliteration of the cells that might have been expected if they had been filled with blood. In typhoid pneumonia, and that from asphyxiating gases of the sedative kind (such as those generated in sewers,) the inflammation often docs not go beyond this stage, and when it does, it passes at once into a half gangrenous, half purulent destruction of the lung, there being apparently in these cases some change in the vital properties of the tissues, or in the condition of the blood, which incapacitates it from supplying coagulable lymph, the deposition of which constitutes the next stage. The second stage of pneumonia, red hepatisation as it is called, brings the lung to a state of solidity more or less approaching that of the liver. But the transition from the first stage is not sudden but gradual, being the result of the same over- flow of the nutritive function, which causes the effusion of lymph in the inflamed pleura. The tissue of the lung, thus consolidated, is so heavy that it generally sinks in water; but. it is also more fragile than usual, so that, on being pressed, it breaks down under the finger. This softening seems to be chiefly the consequence of the interstitial deposite of soft fresh lymph, which diminishes the molecular cohesion of the tissues; and the more acute and recent the inflammation is, the greater generally is the softening. The colour of. a hepatised lung varies much according to the quantity of blood left in it: if this be much, it is red; if little, pink- ish-brown; or reddish-gray, if mixed with the black pulmonary matter. The de- position of lymph seems to supersede the red particles, or possibly it may be formed at their expense. When a hepatised lung is cut into or torn, numerous little granulated points, of the si^e of pin-heads, and of a lighter colour than the rest, pneumonia, (Anatomical Characters.) 335 are often observed. These granules Andral first represented to be the single air- cells or terminations of the bronchi, and he conceived that they were distended with the same viscid mucus secreted by their mucous linings, which is seen in the sputa. Laennec considers these little bodies, the air-cells, converted into solid grains, by the thickening of their parietes and the obliteration of their cavities by a concrete fluid. From many minute examinations which we have made, wre have been long convinced that the granulations of hepatised lungs contain no ap- preciable quantity of viscid mucus, but that they are probably portions of vesicles and minute tubes, with their tissues distended with an interstitial deposite of lymph, and occasionally having the same matter in their interior. In his wrork on Patho- logical Anatomy, Andral has expressed a similar opinion. But hepatised lungs do not always present this granulated appearance; sometimes there is a uniform condensation of a deeper red than usual. This condition Andral refers to a more complete obliteration of the cells, a farther degree of solid effusion; but this would not agree with its redder colour. We are disposed to view this non-granular kind of hepatisation as the result of inflammation confined more to the plexus of vessels and intervesicular tissues, and less affecting the membranes forming the cells: hence the consolidation partakes more of the character of the vessels and the blood which they convey, and less of the lighter coloured deposite which the membranes of the cells secrete. The recent researches of MM. Hourmann and Dechambre, on the pneumonia of the aged, confirm this view: they have been led to distinguish the granular hepatisation from that of a more uniform aspect; and they designate the first as the result of vesicular pneumonia, the other of interlo- bular. Having been the first to describe the latter as a separate form of pneumo- nia, we prefer the term intervesicular. When the blood remains fluid, the conso- lidation is imperfect, and the portion of lung thus affected, although it may sink in water, is quite soft and resembles the substance of the spleen rather than that of the liver; hence it has been called splenisation. The third stage to which inflammation brings the lung, is that of suppuration, or yellow hepatisation. This consists in the conversion of the semi-solid particles of lymph or blood, which constitute the solid or red hepatisation, into an opaque, light-yellowish, soft, friable matter, and finally into a liquid pus. This suppuration is commonly diffused in the form of purulent infiltration; and it is rare to find it assume the character of a distinct abscess. We see a sufficient reason for this in the very porous structure of the lung, which renders the circumscription of the matter by the effusion of lymph, such as that which takes place in abscesses in general, a very unlikely result; and the life of the patient, or the vitality of such a delicate and porous structure as that of the lung, is generally destroyed before the process of suppuration can be completed. Hence, even where the suppuration has advanced farthest, there is generally much of the tissue of the lung remaining, and a gangrenous condition is often added to the suppuration, giving the matter a very offensive odour. Nevertheless, circumscribed abscesses in the lung are now and then met with, and this is generally when the inflammation is limited, or more intense in one part, so as to tend to the early formation of pus, whilst the adjoin- ing parts are still capable of throwing out a circumscribing lymph. In this way we have seen abscesses arising from pneumonia, affecting separate lobules: thus, too, abscesses are formed around foreign bodies within the lung, such as a musket- ball, and around calcareous and scrofulous tubercles, which may act as foreign bodies. In all these cases the inflammation of the most imtated parts reaches the stage of suppuration long before that of those around -them.;, and the latter thus forms a separating wall of effused lymph, which may afterwards constitute a kind of cyst. The purulent deposites that are sometimes met with in the lungs of individuals who have died after surgical operations, wounds, or other injuries, generally pre- sent this circumscribed character. Gangrene unconnected with suppuration is a very rare sequel of pneumonia. It may, however, be caused by the inhalation of noxious gases, which seem directly to destroy the vitality of the lung. The lungs of those who have died 336 pneumonia, (Physical Signs.) some days after being nearly asphyxiated in sewers, have been found reduced in parts to a dark brown, greenish, or livid softening, having a very fetid odour, and being probably the result of the poisonous influence of the gas on a congested lung. The state of the tissues adjoining the vascular plexus, which is the proper seat of pneumonia, is worthy of notice. The interlobular cellular texture some- times partakes of the general redness, and sometimes it is singularly free from it, or has it so much less, that a section of the lung is quite marbled by its lines, which are of a lighter colour. So, also, in the hepatised stage the interlobular septa retain their cohesion, and in more chronic cases sometimes become more thick and hard than usual. The mucous membrane of the large and middle-sized bronchi is almost always more or less inflamed, and presents the striated aspect that is also seen in the more acute forms of bronchitis. That of the smaller bronchi is often of a deeper red than in bronchitis; but from its bluish tint this would appear to arise rather from the blood under it than in it. The bronchi in the inflamed part, generally but not always, partake of the softening of the parenchyma. We have in a few instances found some of them plugged with coagulated lymph, as described by M. Reynaud and Dr. Stokes; but this by no means occurs so frequently as to strengthen the opinion of these writers, that pneumonia is generally a plastic inflammation of the minute air-tubes and cells. When this albuminous exudation does take place, M. Reynaud has shown that it may cause the obliteration of some tubes, which would lead to the dilatation of others. More commonly the air-tubes, as far as they can be traced, contain more or less of the slimy rusty mucus, like that which has been expectorated. The pleura is generally, but by no means constantly, inflamed: we have seen it free from redness, lymph, and liquid effusion, even where covering a hepatised por- tion of lung. The cases of pleuro-pneumonia in which the inflammation of the pleura is so considerable as to modify the course of the parenchymatous inflammation, will be considered hereafter. Physical signs. On applying the ear or a stethoscope to the chest of a per- son with incipient inflammation of the lungs, a fine crackling sound accompany- ing the respiratory murmur is heard generally in the inferior and posterior region of one side. In its slighter degrees it is scarcely more than an unusual loudness and roughness in the vesicular murmur, as if the air met with slight short resis- tances in its passage, which destroy the smoothness of the sound; but in its more pronounced degree there is a distinct crepitation, like that heard when common salt is thrown on a hot iron, or like that caused by rubbing between the finger and thumb a lock of hair near one's ear. This, which is the crepitant rhonchus, is first heard at the commencement of inspiration and at the end of expiration; but it soon accompanies the whole respiratory act, and in advanced degrees of the first stage it is heard only at the end of inspiration and the beginning of ex- piration. The physical cause of the crepitation of pneumonia has been the subject of some difference of opinion. M. Andral considers it to be produced by the pas- sage of air in minute bubbles through, serum effused in the smallest air-tubes and vesicles, and that the fine and even character of the crepitation depends on the fineness of the bubbles in these tubes. Thus, he supposes that this crepitation differed from the mucous rhonchus only in the size of the tubes in which it is produced, and the consequent size of the bubbles in them. This opinion has been adopted by several writers, who reduce the liquid rhonchi of catarrh and the crepitant rhonchus of pneumonia to two heads, large and small crepitation. From a consideration of the pathology of pneumonia, and of the course exhibited by its physical signs, we have long been led to consider the crepitation which attends the first stage as distinct in nature from the other rhonchi. We have before had occasion to notice, that the structure and motions of the lungs tend to bring all liquids secreted in the minute tubes into those of larger size, whence pneumonia, (Physical Signs.) 337 they are ultimately collected in the trachea, and expelled by expectoration. Were the crepitation of pneumonia dependent on serum in the smallest tubes and cells, we ought to have proof of the presence of this serum in the other tubes by a bubbling rhonchus, if not in the expectoration also. But in most cases of the first stage of pneumonia, the chest is remarkably free from bubbling sounds in the large tubes, the rhonchi, if any, are dry, sonorous, or sibilant, and the ex- pectoration is not serous but viscid. In fact, there is good reason to suppose that the serum which exudes from an engorged lung after death, and which An- dral assumed to be the cause of the crepitation, is chiefly the result of a cadaveric change, the coagulation of the blood in the distended vessels, which does not take place during life. But what is the condition of the extreme air-tubes and cells in the first stage of peripneumony? They are narrowed and partially ob- structed by the enlarged vessels which are distributed between and around them; and as the smallest tubes are narrower than the cells in which they terminate, it is easy to conceive that they are so far obstructed that the air can pass through the viscid mucus lining them only in successive minute bubbles, the bursting of which constitutes the crepitation in question. This appears to be the true view of the crepitant rhonchus; and we can thus understand that at first the crepitation must be slight and confined to the period of the respiratory movements in which the tissue is most collapsed; that as the narrowing increases, it extends to the whole movements; that subsequently the obstruction is such that it permits the crepitating passage of the air only when the lungs are most expanded, as at the end of inspiration and at the beginning of expiration; and finally, that the ob- struction becomes complete, and the crepitation ceases, except perhaps still on a forced respiration. Dr. Stokes has made the important observation, that a peurile or unusually loud sound of respiration precedes the occurrence of crepitation in pneumonia, and he considers this to denote the first stage of the inflammation. We question the pro- priety of calling this another stage, which probably is only a degree of the same condition which causes crepitation, the partial narrowing of the tubes, which ren- ders the sound rougher and louder, before the crepitation begins. The sound of respiration becomes weaker as the crepitation comes on, and extends to more of the minute tubes: and it ceases when the abnormal sound occupies them all. If the disease be extensive, and the function of the lung much infringed on, the en- ergy and frequency of the respiratory movements will be increased, and conse- quently the respiratory murmur on the sound side will be louder than usual, having the character of puerile respiration. The loud or, to use another term, the harsh respiration, depends in part upon the rapidity of passage of the air through the portions of lung which are not congested, and in part upon a commencing resistance presented by the inflamed cells. The crepitant rhonchus itself depends partly upon the tough liquid contained in the cells and finer bronchial tubes, and partly upon the same resistance of an inflamed and indurated tissue. G. The increased matter of the congested lung will have farther effects on its pro- perties with regard to sound. It will deaden the sound on percussion, so that the affected side will give a sound rather duller than the opposite side, and different degrees of force in percussion will not materially affect this variation. But the first stage of inflammation, without liquid effusion, is insufficient to make the sound on percussion quite dull; for even in its most advanced degree, there is still enough air in the lung to give some elastic resistance to the walls of the chest, and to leave their vibrations pretty free. The motion of the affected side will be diminished in proportion as the air fails to get admission to the inflamed lung; and instead of being fixed in a state of permanent distention as in pleurisy, or in a state of contraction, as in spasmodic asthma, the side holds an intermediate size, measuring on full inspiration less, and on the completion of expiration more, than on the sound side. The increased density of the congested lung also makes it Vol. II.—43 338 pneumonia, (Physical Signs.) conduct sound better than the light spongy condition of the healthy organ; so that in extensive inflammation, even during the first stage, and whilst the crepitation still continues, there may be heard some degree of the bronchial respiration and vocal resonance that are fully developed only in the stage of hepatisation. The deposition of lymph which constitutes hepatisation of the lung, completes the obstruction of the minute tubes and cells: hence all crepitation and vesicular respiration cease, and the only sounds which reach the ear are those of the air and voice in the larger tubes, and these are transmitted by the consolidated lung with unusual loudness. The respiration is no longer heard with its prolonged murmur; but in the neighbourhood of the bronchial tubes there is a short whif- fing, confined to parts only of the respiratory act, and often ending abruptly with a click. This bronchial whiffing is not to be heard in every case, but only when the hepatisation involves bronchial tubes of some size, and is most commonly found in the middle regions of the chest. Here, too, both may be heard and felt various degrees of morbid bronchophony, or vocal resonance. When the conso- lidation of the lung is very complete, and involves especially the central parts of the lung, the voice may be heard to sound over a space of considerable extent in the mammary, scapular, or axillary region, and-so loudly, that it resembles pecto- riloquy, for which it is sometimes mistaken. The bronchophony of a consoli- dated lung may generally be distinguished by its being extended over a conside- rable space, and by its being much diminished by using the stethoscope with the stopper, Avhich is not the case with the pectoriloquy of a cavity. The vocal re- sonance of the tubes is also transmitted to the walls t»f the chest, as a vibration or fremitus which may be distinctly felt by the hand placed on the affected side, and which is much stronger than that on the healthy side. This sign, the discovery of which is due to M. Reynaud, affords an easy mode of distinction between a hepatised lung and a pleuritic effusion, for the latter generally abolishes pretty completely the vocal vibration. The dulness on percussion is now pretty com- plete, but it is seldom so uniform and general in the lower and middle portions of the chest as the dulness from liquid effusion. We see a reason for this on ex- amining a hepatised lung: there are generally some lobules or portions retaining enough of air to prevent them from sinking in water: this is also sufficient to pre- vent the stroke sound from being uniformly and perfectly dull; and when the consolidation is perfect, it transmits the stroke of percussion to deeper-seated parts, which then yield their resonance. Thus on the left side a hepatised lung some- times gives the tympanitic resonance of the stomach; and near the sternum, or in the mammary, axillary, or scapular regions, we may occasionally have the tubu- lar resonance, or bottle note of the large air-tubes. It is not difficult to distinguish these sounds from that of healthy percussion; and when once we understand the cause, their presence and properties will serve rather to instruct than to confuse us. In the stage of hepatisation the lung being nearly inexpansible, the corres- ponding walls of the chest are nearly motionless; and they are so in a state, neither of distention nor of contraction, without fulness of the intercostal spaces, or displacement of the viscera; and thus we have farther distinctions between this case and that of pleuritic effusion. When the left lung is solidified, it transmits the sounds and impulse of the heart to an unusually wide extent of surface, instead of diminishing or displacing them as a pericardial or a pleuritic effusion does. In the third or suppurative stage there is no change in the condition of the luiii.', which can modify the physical signs until the effused matter begins to liquefy; and then there is a mucous or bubbling rhonchus from the secretion into the air-tubes. There may be a change in the expectoration, either to pus or to the liquorice-water-like liquid, described by Andral, and which seems to be a sero- mucous fluid, coloured by hoematine in an altered state: this kind of sputum, however, we have found to succeed to pulmonary haemorrhage more commonly than to pneumonia. More generally there is no expectoration, or such only as proceeds from the upper tubes, and therefore gives no evidence of the state of pneumonia, (Physical Signs.) 339 the lung. In fact, we are to infer the supervention of the third stage from the duration of the disease and the general symptoms, rather than from the physical signs. The inflammatory symptoms and fever give way to great prostration, rigors, cold sweats, a quick, weak, thready pulse, whilst the breathing is as short as ever, and the countenance exhibits the pallid, waxy, anxious, drawn, tremulous features of ebbing vitality. The formation of abscess is less unfavourable, because it implies less extent of suppuration, and a power in the structure to circumscribe it. There are several cases recorded of recovery from pneumonia after the signs of abscess had mani- fested themselves. Dr. Stokes describes a case in which the cavity became obli- terated by a cartilaginous septum, during a complete recovery and enjoyment of health in the pursuit of a laborious occupation for twelve months, at the end of which time the individual was again attacked with pneumonia, which proved fatal, and its effects were found to have been curiously limited by the cicatrix of the former abscess. The signs of abscess are those of a cavity communicating with the bronchial tubes, first containing liquid and air, and producing a course bub- bling or gurgling sound on coughing or deep breathing, and, after the expectora- tion of pus, a cavernous or hollow respiration with pectoriloquy, or loud reso- nance of the voice, in some part of the chest corresponding with the affected spot. These abscesses are not uncommonly of a gangrenous character; and then there is added to the signs a putrid fetor in the matter expectorated as well as in the breath of the patient. As our limits do not permit us to enter into minute details, it may suffice to point out how the physical signs of pneumonia indicate the situation and extent of the inflammation; and, as far as relates to the dis- eased organ, they may guide us in the prognosis and treatment. Thus a cre- pitant rhonchus heard throughout a whole lung, or a considerable part of both lungs, implies extensive disease: if heard at the root of the lung, or at its apex, that is, at the scapulae or under the clavicles, it indicates a more severe form of the disease than if heard only at the lower parts of the lung in the back. The extension of this crepitation, or its presence in new parts, is a proof of the increase of the inflammation. Its cessation, and the substitution of bronchial respiration and perfect dulness on percussion, are proofs of its advancement to the second stage. On the other hand, the return of the crepitation and resonance, where it had been replaced by bronchial respiration and dulness, announces a progress towards cure by the absorption of the obstructing lymph, and by the air again getting a straitened admission into the cells. As this process proceeds, the act of respiration accompanied by crepitation becomes longer in duration, until it equals in length that on the healthy side; but the sound is still for a time somewhat whiffing where it has been bronchial; and a crepitation of a looser, less even character, also remains after apparent cure: this is the sub-crepitant rhonchus, and probably depends on the presence hi the smallest bronchi of a little thin serous mucus, such as that which is seen in the expectoration, and the secretion of which seems, as in bronchitis, to assist in removing the depositions left by the in- flammation. If the inflammation have proceeded to the stage of hepatisation, and particularly if it have verged on that of suppuration, in which the albuminous de- posite, becoming opaque and lower in vitality, is less susceptible of absorption, the restoration of the texture of the lung to its natural light condition requires a con- siderable period of time, even after the apparent cure of the disease; and during this period there remain more or less of the physical signs just noticed, as well as some dulness on percussion, and perhaps also not a full power to expand that portion of the chest We suppose here the cure to become perfect eventually, but to require a long time; though there are other cases in which inflammation of long duration produces permanent changes in the lung, as the obliteration of some portions of the tissue and the dilatation of others: these changes happen most frequently when the inflammation is modified by a cotemporaneous effu- sion in the pleura, which will be noticed hereafter. 340 pneumonia, (Typhoid.) Varieties and Complications. The form termed typhoid pneumonia, whether it be secondary to continued fever or primary, and originally attended by low adynamic fever in consequence of the constitution having been lowered by excesses or extreme privation, or by the depressing influence of foul air, or of an unhealthy season, differs remarkably from common pneumonia in many of its phenomena. The local symptoms are by no means prominent; and although there may be pain, cough, and very dis- ordered breathing, the obtuse state of the mental faculties prevents attention from beino- drawn to these symptoms. The general functions are however greatly disordered; the pulse is very quick, small, and weak; the skin harsh, dry, and partially hot, or covered with a clammy sweat, and sometimes covered with petechiae, or suffused with a dusky rash; the tongue is furred, brown, and dry, the alvine excretion dark and unusually offensive; and the urine is scanty, turbid, and ammoniacal. The lungs in such cases are sometimes found after death so engorged, particularly but not exclusively their posterior portions, that they sink in water: the texture is very soft and fragile, and when broken exudes a dark grumous blood: there is only an imperfect approach to hepatisation; but the tex- ture in some parts occasionally shows a softening of a lighter colour, which seems to be an imperfect suppuration. Sometimes partial hepatisations are found, and slight films of lymph on the pleura; and in such cases it is not uncommon to find similar marks of slight recent inflammation also in the pericardium and peri- toneum. We have observed this particularly in cases of external erysipelas. The physical signs in such cases are, in the posterior parts of the chest, dulness on percussion and absence of the respiratory murmur, with an occasional short whiffing and sibilant rhonchus; but, as Dr. Stokes has remarked, there is often no crepitation, or, if it be present, it soon ceases, the obstruction becoming com- plete. In the anterior parts of the chest, the breathing sometimes remains quite distinct, although accompanied by sonorous and sibilant rhonchi. The signs of obstruction remain for a very long time, and the sound of respiration and percus- sion is much slower to return than in acute peripneumonia. Dr. Stokes has ob- served, that recovery in these cases is very slow, and sometimes attended by contraction of the affected side. We are disposed to consider this affection as partaking of a congestive more than of an inflammatory character; and Dr. Hudson, in an able paper on typhoid pneumonia published in the Dublin Medical Journal, has taken a similar view. By some unknown cause, whether in the condition of the blood in the affected capillaries, or in both, the blood stagnates in particular viscera, generally to some degree under the influence of gravitation; and the functions of the organs are pro- portionately impeded or disturbed. There is at the same time more or less irrita- tion, which may give to the congestion the semblance of an inflammation; but its products are imperfect and irregular; and neither by the free effusion of plastic lymph, nor by the formation of pus, is a true inflammatory orgasm manifested. We can see why this condition in the lung may be unaccompanied by the usual signs of the gradual formation of a crepitating obstruction, because the engorge- ment is at once produced, and renders a greater part of the tissue impervious to air. But this degree of congestion, if it occupy the middle parts of the lung, may give bronchophony and bronchial respiration. The complication of pneumonia with bronchitis is very common: in fact, in almost every case of pneumonia the bronchi are also inflamed; but sometimes the bronchial affection is primary and extensive, and inflammation of the parenchyma is superadded. In such cases, if the bronchial secretion be considerable, the noisy rhonchi which it occasions mask the physical signs of peripneumony; and in consequence of the depressing influence of the same cause on the respiratory function, the general symptoms also are more than usually obscure. But on listening particularly at the end of inspiration on the posterior and inferior regions pneumonia, (Pleuro.) 341 of the chest, which correspond with the lower margins of the lobes, the fine cre- pitation may generally be heard if pneumonia is present. The rusty tinge of parts of the sputa, and, as the disease proceeds, the greater dulness on percus- sion, will also become apparent when the inflammation has extended to the pul- monary plexus of vessels. Of the forms of bronchitis that occasionally pass into pneumonia, those of epidemic influenza, hooping-cough, and those accompanying fevers and diseases of the heart, may be mentioned as presenting this combi- nation. Pleuro-pneumonia. The effects of a concomitant pleurisy on the pathology and signs of pneumonia are highly deserving of notice. Whenever the inflam- mation extends from the lung to the pleura, it may be supposed to increase the serous secretion, and perhaps lead to the effusion of lymph; but when the pul- monary inflammation has existed first, and become extensive, these pleuritic pro- ducts are commonly of small amount. When the inflammation has attacked the parenchyma and the investing membrane nearly to an equal degree, constituting the disease called by Laennec pleuro-pneumonia, the effusion in the pleura by its pressure modifies the effects of the inflammation in the lung. The lung is found after death consolidated, but more tough and red than in the state of ordinary hepatisation, and totally destitute of the granular aspect. It much resembles the substance of some muscles; hence Laennec termed this condition carnificalion. It seems to exhibit the more essential part of inflammation of the lung; the sequel or effect, effusion into the coats of the air-cells, which constitutes granulation, having been prevented by the pressure of the external liquid effusion. This combination is therefore also slower in progress than simple pneumonia: the de- gree of the inflammation as well as the quantity of its product is restrained by the external pressure, and it scarcely, if ever, proceeds beyond the second stage. But this slower rate of progress tends to make its effects also more permanent. If false membranes are formed on the pleura, they have time to become firmly organized, and to bind down the lung in its compressed state; and the lymph effused in the tissue itself, scanty though it be in comparison with that of a hepa- tised lung, may become the means of adhesion and permanent contraction of the compressed cells and finer tubes, and of consequent obliteration of more or less of the proper tissue of the lung. There is an ulterior result which has hitherto escaped the attention of pathological writers. When the liquid effusion is re- moved by absorption, and the chest becomes again capable of expansion, what will supply the place of the obliterated cells? The chest remains to a certain degree contracted as after pleurisy; but the atmospheric pressure will also at each inspiration be brought to act on the larger air-tubes that are yet unobstructed; the air can no longer reach the smaller branches or cells of these tubes, so it must dilate the tubes, and make their increased size in some degree compensate for their defective terminations. Pleuro-pneumonia is then, as we have before had occasion to remark, a cause of dilatation of the bronchi. We have met with seve- ral examples of this kind; and on referring to the records of other cases of ex- tensive dilatation of the bronchi, we have found several in which the symptoms are described to have originated in an inflammatory attack like pleuro-pneumonia; and probably all those cases in which the dilatation affects one side only, and in which there is much consolidation of the lung with some contraction of the chest, originate in this way. The general symptoms of pleuro-pneumonia are not materially different from those of the more simple inflammations, but they are often less severe, and some- times very obscure. The physical signs are a combination of those of pneumo- nia, and of liquid effusion in the pleura. At first there is crepitation; but this becomes indistinct, as the lung is pushed aside by the liquid; whilst the dulness on percussion is much more marked than in pneumonia, at least in the lower parts of the affected side. In the central regions of the chest, bronchial respira- tion and bronchophony are soon produced by the condensed lung being pushed against the walls; and if a thin layer of liquid intervene, the bronchophony ac- 342 pneumonia, (Diagnosis.) quires a loud buzzing accompaniment, like the voice in the performance of Punch: % in fact, the sound seems to consist of two voices, which probably arises from some of the vibrations being modified into a buzzing or bleating, by passing through the thin layer of liquid, whilst other vibrations pass unchanged. The vocal resonance is generally louder in pleuro-pneumonia than in either pleurisy or simple pneumonia; w hich probably arises from the chief tubes being pressed more closely against the walls of the chest, with complete condensation ofthe vesi- cular structure. The same circumstance sometimes gives the amphoric or tra- cheal sound on percussion in the mammary region, which forms a singular con- trast to the dulness of other parts. We have also found the respiration quite tracheal in this spot, and the resonance of the voice quite as loud as that of ca- verns. These phenomena become more remarkable in cases which from ineffi- cient early treatment become chronic, the consolidation of the lung remaining permanent;, for, as the liquid is absorbed, the bronchi become dilated, and exhibit the phenomena of pectoriloquy, cavernous breathing, &c, as described under Dilatation of the Bronchi. Pneumonia frequently attacks patients in both the early and advanced stages of tuberculous disease. Sometimes it is partial and readily yields to treatment: but not a few fall victims to it when it is more general, and this sometimes in the ab- sence of symptoms sufficient to distinguish it from the pre-existing disease. Again, it is not unusual to find miliary tubercles in the lungs of those in whom the ordinary treatment of pneumonia had proved unavailing. The pneumonia which sometimes supervenes in continued fevers, small-pox, erysipelas, scarlatina, and in various chronic diseases during the prevalence of epidemic peripneumonia, is generally of a congestive or typhoid kind, and often appears to be the immediate cause of death. In many such cases the symptoms of the pulmonary affection are often very obscure. The bronchial affection of measles sometimes passes into pneumonia, espe- cially when the eruption disappears suddenly wkh continuance of fever; here the symptoms are generally pretty evident. A congestive and latent inflammation of the lungs is sometimes a complication of endemic and periodic fevers; and the re- action of the collapsed stage of malignant cholera and asphyxia is peculiarly apt to fall on the lungs. Several surgical writers have noticed the occurrence of pneumonia after severe injuries and surgical operations. It is often latent, and may declare itself only a short time before death, by the oppressed breathing and rattle in the tubes. In some instances of this sort the lungs are found only in the first stage of inflam- mation; in others there are circumscribed hepatisations; and not a few present the singular lesion of purulent deposites in the pulmonary tissue. These deposites are always well-circumscribed, the tissue around being sometimes inflamed, some- times healthy; they are at first of a red colour with a brighter margin, and inter- spersed with pink, drab, or yellow spots, the latter appear to be sections of the vessels, and on being pressed exude pus. In a more advanced state more of this lighter colour is seen and gives the appearance of purulent infiltration, whilst on the margin of the deposite a distinct coat of lymph can be traced, circumscribing the diseased part In a few cases, the process of suppuration has been found completed in the formation* of an abscess. These fatal sequels of injuries are to be considered as the result of a diseased state of the blood rather than of true pneu- monia. Pus is probably formed in the blood or elsewhere, and deposited in the lungs on account of their great vascularity, where it is circumscribed by second- ary inflammation; sometimes it is deposited in other organs. Diagnosis. Under this head we need only pass in review some of the more distinctive signs of pneumonia, and the chief points by which it may be distinguished from the diseases which most resemble it. The general symptoms, when all grouped together, often sufficiently characterize the disease, but their occurrence and degree are very uncertain, and by no means constantly announce its amount or even its presence. Of the single symptoms the expectoration is certainly the pneumonia, (Prognosis.) 343 most characteristic. The rusty tinge is considered by Andral and others to be quite pathognomonic of pneumonia; but we have seen it in various degrees communi- cated to the bronehial mucus by congestions which are not inflammatory, as in bronchitis supervening on organic diseases of the heart, causing great pulmonary congestion, and also after pulmonary haemorrhage. It somtimes happens, too, that there is no expectoration, especially at the onset of the disease, and in the case of young children it is seldom brought to view. The crepitant rhonchus, in conjunc- tion with the general symptoms, may be more safely depended on, for its presence is more constant, and its extent and progress well represent the amount and state of the disease. Increasing dulness with bronchial respiration and sound of the voice equally mark the transition of pneumonia to the second stage. From pleu- risy, pneumonia may be distinguished in the first stage chiefly by the crepitation and expectoration; in the second, by the bronchophony and vocal vibration sensi- ble to the hand, and by the absence of signs of displacement of the walls or organs bounding the lungs, and of any change by posture in the sound of per- cussion. From bronchitis, pneumonia may commonly be distinguished by the crepitation, which is finer and more equal than that of bronchitis, by the rusty tinge of the sputa, and, as the disease advances, by the dulness on percussion, bronchophony, and bronchial respiration. The skin is hotter and less livid than in severe bronchitis; neither is the cough or the dyspnoea generally so urgent. From, pulmonary apoplexy, or haemorrhagic congestion, it may be known by its febrile commencement and course, by the absence of any real haemoptysis, and by the crepitation and dulness on percussion being progressive, and rarely so circumscribed as in pulmonary apoplexy. Inflammation is, however very com- monly engrafted on pulmonary apoplexy. OSdema of the lungs and tuberculous disease in their physical signs may resemble pneumonia, but their history and general symptoms will in most instances sufficiently distinguish them. Prognosis. Pneumonia must at all times be viewed as a serious disease, and the prognosis even in favourable cases should be given with caution, as cases which are at first slight may take an unfavourable turn, and in progress towards recovery, as long as the disease lasts, there is a chance of relapse, which may throw the patient into new danger. The circumstances which chiefly affect the prog- nosis are the stage of the inflammation, its seat, its extent, its complication with other affections, and the state of the general health and strength. As this disease in its progress tends to the disorganization of the lung, so its continuance increases its danger; hence the prognosis is more unfavourable if hepatisation has taken place; and still more so, if the signs seem to indicate the supervention of the third stage! The duration of the stages varies very much in different cases, according to the violence of the inflammation, the age of the subject, and the effects of the remedies. Laennec states the average duration of the first stage (engorgement,) at from twelve hours two three days; the second (hepatisation,) from one to three days; the suppurative from two to six: remedies which retard the progress of the disease prolong the period of the first two stages. We think even these state- ments more precise than the subject will admit of, for the duration of the first two stages presents a remarkable variety in different cases. In children, and in some epidemics, also in adults, the first stage may last for more than a week, without the production of hepatisation. On the other hand, in aged and debilitated subjects, the inflammation may speedily reach the stage of suppuration. Laennec de- scribes this to have taken place in some instances within twenty-four hours. Recovery may take place from every degree of pneumonia; but the chances of this are very small, when it is probable that suppuration has taken place. Even simply hepatisation requires time and favourable circumstances to effect the absorption of the effusion. Until there is evidence of the advancement of this pro- cess of absorption, as well as improvement in the general symptoms, the prognosis must remain doubtful; for inflammation may readily return in the lung around the hepatised portions. The supervention of a gangrenous odour in the expecto- 344 pneumonia, (Causes.) ration is a formidable event; but not a hopeless one, for a few cases in our own experience, and several on record, have occurred in which recovery took place The extent of the inflammation greatly affects the danger of he case. A double pneumonia affecting both lungs at the same time is frequently fatal even in the first stage; and whenever the whole of one lung is involved, there is great peril of an unfavourable issue. Inflammations attacking the upper lobes and root of the lungs are more fatal than those confined to the lower lobes: a result which may be the consequence of the former containing blood-vesses of larger size The complication of pneumonia with other diseases generally increases its dan- ger It is often fatal when supervening on the different forms of fevers, on gastro- enteric bronchial, pericardial or peritoneal, inflammations, and in these cases it is very apt to be latent. Pleurisy on the same side may diminish the intensity of the pulmonary inflammation, but if it attack the opposite side, it adds to the oppression and danger. Pneumonia is more than usually fatal during pregnancy and m the puerperal state, and at the extremes of age, especially in weakly infants in cachec- tic old people, and in those exhausted by habitual excesses. The fatality is much greater among the lower classes than among those well and regularly fed and clothed Besides the preceding circumstances, the general health and vigour of the subject the severity of the chief symptoms which indicate the state of the vital functions, especially the dyspncea, the pulse, the expectoration, and the mental fa- culties and the influence of the remedial measures which have been employed, all must be taken into account in estimating the prognosis in particular cases. Causes It is well worthy of remark, that bronchitis and pleurisy affect vessels which freely communicate with those of the parenchyma; but although they do occasionally extend to the latter vessels, and thus excite peripneumonic inflamma- tion yet they are generally quite distinct from it both in their present course and in their ulterior effects, and require a distinction in treatment which should be borne in mind. We find an explanation of this difference in the peculiar charac- ter and importance of the pulmonary blood-vessels; in their great number and capacity; in the large proportion which they bear to the other solids of the lung; and in their great liability to congestive distention. This extensive and important plexus of vessels, through which the whole blood of the body passes, is, as we have before seen, peculiarly liable to distention from any cause which may disorder the function of the heart or lungs. Thus all those causes which tend to induce as- phyxia, produce also that congestion of the pulmonary vessels which, added to irritative reaction, may constitute inflammation. Thus we see that various causes which disturb greatly the balance of the circulation, particularly by deranging the passage of the blood through the lungs, may become causes of pneumonic inflam- mation. Of these the most remarkable are, long-continued exposure to cold, as- phyxiating poisons, congestive fevers, violent exertion, diseases of the heart, bron- chitis, asthma, wounds, tubercles, and foreign bodies in the lungs, and the mori- bund'state. Pneumonia is so frequently complicated with hooping-cough, measles, and small-pox in children, that it forms one of the chief sources of the danger in these diseases. The same remark applies to many forms of continued fever in adults. In common with other inflammations, it may be occasioned by the sup- pression of habitual discharges. The inflammations of gout, rheumatism, and cu- taneous diseases, are rarely transferred to the lungs. Cold is unquestionably the most common cause: this is especially shown by its prevailing almost exclusively in the cold season, and chiefly in March and April, during the continuance of cold winds. The epidemic occurrence of the disease has been repeatedly noticed. Laennec conjectures that the epidemic cause is often not merely change of tem- perature but deleterious miasms in the air, which exert a specific operation on the lung, as the poisons of the rattlesnake and of some fungi are said to do. Huxham observed that, during an epidemic, bronchitis prevailed in low damp places, and pneumonia and pleurisy on more elevated situations. Although met with chiefly in cold countries, milder climates are not free; it occurs to a great extent in the south of France and Italy; where however the winds cause great and sudden pneumonia, (Treatment.) 345 changes of temperature. Its frequent occurrence in the neighbourhood of Vesu- vius may perhaps be attributed to the noxious exhalations which prevail there. Treatment. The indications of treatment in pneumonia vaiy according to its stages. In the first stage, the chief object is to remove the inflammatory irritation and congestion from the pulmonary vessels; in the second there is another indi- cation, to promote the removal of the interstitial effusion, the product of the inflam- mation ; even in this stage, when the strength fails, and more particularly in the third stage, it is necessary as far as possible to support the functions which are oppressed by the extent of the organic lesion induced. Particular symptoms may also give occasion to other indications in every stage. We shall shortly notice the principles which may guide us in the use of remedies to fulfil these several indica- tions, and then advert to the application of the treatment in the different forms and complications of the disease. Treatment of the first stage. Distention of the great pulmonary plexus of blood-vessels being the first condition of pneumonia, from whatever course it may proceed, we may hope in the early stage of the disease to relieve it by blood-letting, as well as to prevent the process of reaction which renders it essentially inflam- matory; and in some instances, where the local signs announce the presence of the disease in its first stage, and the general symptoms prove it to be of a sthenic character, the free loss of blood by one venesection will arrest the progress of the disease. But when the vessels have been so long distended and become the seat of fixed irritation so much, that the mere removal of pressure from the sanguife- rous system at large will not enable them to recover their usual size, a single blood- letting may not be sufficient; it must be repeated as often as the strength will bear it, and other remedies must be used, which also have the power to counteract the inflammatory irritation. Of these the most important are tartarized antimony and mercury. M. Louis has inferred from an application of numerical calculation to certain cases of pneumonia, that early blood-letting never arrests the disease, and that it only shortens its duration by four or five days. It is clear, however, that many of the cases classed by Louis as pneumonia, were instances of the asthenic or typhoid disease; an affection certainly in treatment, if not in pathology, differ- ing widely from sthenic or acute pneumonia. We suspect also that a great pre- valence of similar cases, and the absence of the fully sthenic character among the pneumonic patients of the Meath Hospital, have led Dr. Stokes to conclude that one, or at most two, bleedings will be sufficient, and that local blood-letting is the principal remedy. The utility of tartarized antimony in emetic and nauseating doses in pectoral inflammations had long been recognised, but its power of subduing acute inflam- mation, independent of its emetic, nauseating, or diaphoretic effects, was first pointed out by Dr. Marryatt of Bristol, and farther developed by Rasori of Genoa. Its peculiar efficacy in pneumonia was especially shown by Laennec, who consi- dered its value to be above that of blood-letting. Chiefly to the efficacy of this remedy he ascribes the uncommonly small mortality of only two in fifty-seven cases which he states to have been the result of his practice of late years. He gave the medicine in doses of from one to two and a-half grains in three ounces of sweetened weak infusion of orange-leaf, withholding the medicine after the sixth dose, or preserving it according to the severity of the symptoms. This remedy has now been successfully employed by many practitioners at home and abroad, and its efficacy seems pretty well established, but not to the degree claimed by Laennec. In this country it is considered as subsidiary to blood-letting; and it has not been found useful to give the large doses which Laennec sometimes employed. From half a grain to two grains in an ounce and a-half of some agree- ably flavoured liquid may be given every second, third, or fourth hour, according to the severity of the case. The first dose commonly causes vomiting, but this generally ceases after the second or third, and if it should not, two or three drops of the diluted hydrocyanic acid will generally stop it. If it causes purging, it may be useful to combine a small quantity of opium with the antimony. The mode in Vol. II.—44 340 pneumonia, (Treatment.) which tartar-emetic acts is not well understood. Its antiphlogistic power does not essentially depend on its nauseating, emetic, purgative, or diaphoretic effects; for although these are occasionally induced by it, yet it is as often quite as successful where none of these effects has been produced. It appears to be directly anti- phlogistic by a specific action on the inflamed vessels; this, although not an expla- nation, is as intelligible as the specific action of remedies on the vessels of the intes- tinal canal, the liver, or the kidneys. Some pathologists, particularly the followers of Broussais, suppose tartar-emetic to act as a kind of internal blister, mflaming and causing pustules on the gastric mucous membrane; and Andral cites two or three cases in which such a condition was found after death. But these are rare instances; and among very many in which we have seen it used we have never met with any in which, with due discretion in its administration, any symptoms of permanent gas- tric irritation have resulted from its use. In the wards of Laennec we have seen pa- tients taking twenty grains daily, not only without experiencing sickness, pain, or diarrhoea, but even without losing either appetite for food or the power to digest it. Such a quantity is however by no means necessary; we have never found it useful to exceed ten or twelve grains in the day, and a smaller quantity often suffices. After blood-letting judiciously employed, this remedy has appeared to us the best for reducing the inflammation in its first stage, if properly administered: it will often prevent the necessity of farther loss of blood; but as Drs. Graves and Stokes remark, its use must be continued for some time after the apparent amelio- ration of the general symptoms; and it must not supersede farther bleeding should the symptoms indicate the propriety of this measure. The exhibition of mercury and opium as a remedy in inflammations was first practised in this country by Dr. Hamilton of Lyme Regis: it is now very generally employed as an antiphlogistic, after and together with blood-letting. The efficacy of mercury depends in great measure on its being given to such an extent as to affect the gums; but its beneficial operation is often apparent before this effect is produced, and in some instances, as in children, without its occurring at all. But there is seldom that speedy improvement, which is often apparent after the first doses of tartar-emetic: the operation of mercury is more gradual, and as might be expected, when once the system is under its influence, the effect is more perma- nent. It is therefore more adapted to the less active forms of the disease and to the second stage. Calomel is the form of mercury generally preferred in acute inflammations; and as its purgative effect is not an object, it is necessary to com- bine it with opium, except the first dose, with which it may be useful to clear the intestinal canal. With this view, from five to twenty grains of calomel may be given alone after the first bleeding; and subsequent doses of from five to twelve grains with a grain or a grain and a-half of opium, and the same of ipecacuanha three or four times in the day until the gums be affected, will generally be found suitable for the more sthenic cases. Smaller doses more frequently repeated an- swer better in less acute cases, and those with more semblance of continued fever. Where there is a tendency to diarrhoea, the Hydrarg. c. Cret& in larger doses may be substituted for calomel. In apportioning the doses of mercury and opium we must be guided by the features of the individual case. The opium acts as an ano- dyne in allaying the pain and cough, and as a sedative in quieting that nervous irritation which often follows free blood-letting and the use of mercury, whilst the injurious stimulant and astringent effect of opium is counteracted by the mercury and previous blood-letting. But the chief action of the mercury appears to be of that specific kind which enables it to remove the product effused by inflammation, as we see visibly illustrated in the case of iritis. It may be supposed that in an inflammation so deep-seated as pneumonia local blood-letting is but of inferior efficacy, and is useful only as an aid to venesection, when from the local pain there seems to be inflammation of the pleura: or after general bleeding has been carried to a full extent, a decided impression on the symptoms may be kept up by local bleeding together with tartar-emetic or mer- cury. Counter-irritation in the early stage during the prevalence of fever causes pneumonia, (Treatment.) 347 too much excitement, but it becomes of use when the pulse has been reduced; and in typhoid cases blisters may be used from the commencement. They also much promote the dispersion of the congestion, which even the first stage of in- flammation leaves in the lung. Little good is to be anticipated from purgatives, diuretics, diaphoretics, or sedatives until the violence of the inflammation has been reduced by blood-letting; then each of these kinds of remedies may be in- dicated by the symptoms. The same observation will also apply to expectorants in all but the slighter cases, in which there is obviously a natural tendency to re- lief by expectoration: in such instances the decoction of senega with tincture of squills and solution of acetate of ammonia or an alkali may considerably promote this discharge. Treatment of the second stage. When the physical signs announce that the lung has already become extensively consolidated, with little remains of crepita- tion, the treatment must be conducted on a different principle from that of the first stage. Solid matter is already effused, and no amount of blood-letting or other means of depressing the circulation can remove this. Their utility is there- fore much more limited, and is chiefly confined to the removal of any increase of irritation or congestion, or to reduce the bulk of the blood to the capacity of the abridged state of the respiratory organs. The most powerful remedies are those which modify the action of the diseased vessels, and promote the absorption and elimination of the effused matter. Mercury is the most efficacious of these, and calomel the most convenient form. Its combination with opium assists its effect, and tends to allay the pain and cough which may be present, as well as the nervous irritation which is very apt to occur after depletion has been carried to a full extent. As the consolidated state of the lung often remains for a long time, even after the inflammatory action has been subdued, a great variety of remedies, according to the state of the general symptoms, may become necessary in this stage. Thus, besides the antiphlogistic means before mentioned, some of which must be used as long as crepitation is heard in any part of the lung, more aid may now be de- rived from external counter-irritation by blisters of tartar-emetic, and from expec- torant mixtures containing an alkali. According to the state of the pulse, heat of skin, cough, pain, &c, these mixtures may be saline, with digitalis, squill, and liquor potassae, or in a less sthenic state decoction of senega, camphor, squill, &c, with acetate, muriate, or even carbonate of ammonia. We have found these alkaline salines exert considerable influence in promoting expectoration and in dispersing the solid recent product of inflammation in the lung. If such mea- sures with external counter-irritation be neglected because the general symptoms are relieved, there is great risk that the hepatised portions of lung may become the seat of chronic disease or that acute inflammation may be re-excited around it, and there is more danger of these evil consequences in scrofulous constitutions and where the inflammation has been of less acute character. When the fever has entirely subsided, and the symptoms of local irritation are inconsiderable, although the physical signs show that a portion of the lung remains consolidated, a combination of liquor potassae and hydriodate of potash with decoction of senega or sarsaparilla will sometimes assist to restore the healthy state of the lung. Treatment of the third stage. When from the supervention of rigors, cold sweats, feeble, very rapid, or irregular pulse or other signs of prostration, it is probable that suppuration has commenced in the lung, the utility of antiphlogis- tics wholly ceases, and if any thing may be yet done by medicine, which can rarely be hoped, it is by remedies of a stimulant kind, especially those which may lend to assist the respiratory forces to expectorate the matter which accumu- lates in the tubes; such as carbonate of ammonia, tincture of lobelia, ether, and camphor, in decoction of senega, or wine, or hot spirits and water. Nor are such remedies to be restricted to the third stage; they may be indicated when- ever the vital powers fail, and when the sthenic character of inflammation has 348 pneumonia, (Treatment.) entirely ceded to its ulterior and opposite result—depression from incapacity of the disabled organ. Under all such circumstances, the general symptoms are better guides to practice than the physical signs, for the whole frame then suffers as well as the function of the lung, and requires more immediate attention. When from the fetid odour of the breath and expectoration, it is probable that a portion of the lung has lost its vitality, the treatment must still be guided by the general symptoms. If these betoken the persistance of active inflammation, the grangrene is probably circumscribed, and antiphlogistic remedies must still be used; but if they have given way to the adynamic symptoms, the use of sti- mulants is indicated even more imperatively than in the suppurated stage. Dr. Stokes gave the chloride of lime combined with opium in a case of gangrene of the lung, with a temporary effect of removing the foetor of the breath and sputa, and of greatly improving the constitional symptoms. We have used the nitro- muriatic acid with the same view, to counteract the septic influence of the putre- scent matter in the system, and apparently with good effect. In one instance the patient recovered, although the physical signs had showed the existence of a large cavity in the posterior lobe of the right lung with great foetor of the breath and expectoration. Laennec recommends bark or sulphate of quinine in large doses in gangrene of the lung, even when accompanied by extensive hepatisation. We now proceed to point out the application of the treatment to particular cases. Where the disease is at all severe, the treatment with tartar-emetic or with calo- mel and opium should be commenced immediately after the first bleeding, and continued uninterruptedly until an impression is produced on the disease. It is not safe however with either of these remedies to lay aside blood-letting: if ob- vious relief do not ensue in the course of five or six hours after the first full bleed- ing this measure must be repeated either generally or locally, as the strength may bear it, and again on the next day if necessary, In the more acute cases, uncomplicated with gastric disease, we have found advantage from combining the mercurial with the antimonial treatment, by giving a pill containing from 5 to 10 grs. of calomel with from £ to 1| gr. of opium every four, six, or eight hours, and in the intervals the tartar-emetic draught, and where the tolerance is soon established the effect of this combination is very pow- erful. If the bowels be too much acted on, the Hydr. c. Creti in double quan- tity may be substituted for the calomel. When an improvement takes place in the symptoms, the mercury may be given at night only, or omitted altogether, and the case left to tartar-emetic and whatever depletion or counter-irritation may be required. If the attack of pneumonia be very recent, and accompanied bv a pleuritic stitch in the side, or catch in the breathing, a full dose of opium after a large bleeding, as recommended by the late Dr. Armstrong, will sometimes succeed in cutting short the disease. This plan can be adopted only where the bleeding has been so copious as to produce a great impression on the heart's action, almost if not quite amounting to syncope. The dose of opium should be large; two or three grains of the aqueous extract, or, if the pain and tendency to reaction be urgent, from thirty to sixty minims of the liquor opii sedativus, or of Squire's tincture of bi-meconate of morphia, will generally succeed best. Even in this case we think it advisable to give from six to twelve grains of calomel soon after the opium: it does not interfere with the sedative operation of the latter, and by preserving the balance of the secretions it prevents those functional derangements which sometimes follow the use of opium even in this way. If the disease have to any extent passed into the second stage, and even if the first have lasted twenty-four hours, there can be little hope of subduing it by opium; and we must then trust to the other remedies. Blisters can seldom be used with advantage until all fulness and hardness of the pulse and heat of skin have subsided; and either these symptoms or the continuance of a fixed pain would counter-indicate the use of senega and other mild tonics and expectorants, which are otherwise useful in the decline of the inflammation. pneumonia, (Treatment.) 349 The great fatality of pneumonia among children renders it necessary that its treatment should be directed with the greatest promptitude and care. This fata- lity does not arise so much from the course of the inflammation, as this is less rapid than in adults, but from the latency of the local symptoms, and the tendency of the disease in a disguised form to pass the period in which remedies are most effectual. Hence many infantile cases of pneumonia, particularly among the lower classes, are in an asthenic state before we are summoned to treat them; the depressing influence of the injured function of the lungs having already removed the sthenic character of the disease. This shows the importance of physical ex- amination of the chest in all the febrile affections of children, in order that if any crepitant rhonchus be discovered, the fit remedies may be promptly used. In this early stage, blood-letting is very efficacious; but when used after the dis- ease has lasted for several days, it sometimes produces convulsions and sinking without relieving the breathing. The same observation applies to tartar-emetic, which, if used together with blood-letting soon after the commencement, will seldom fail to subdue infantile pneumonia uncomplicated with tubercle. Mercury acts in children more on the bowels than on the gums, causing green feculent evacuations: it is of great efficacy, and our chief remedy when blood-letting is no longer borne. In children there is little risk of arresting the expectoration by purgatives: it would seem that as it is a less natural process in early life, expec- toration is of less consequence than in the adult. Counter-irritation with mild tartar-emetic ointment or solution is of great benefit in the after stages of pulmo- nary inflammation in children, and should especially be persevered in when there is any sign of a phthisical tendency. In aged persons the disease being generally of an adynamic or typhoid type, is often intractable in consequence of the great debility which accompanies it. Advanced age alone, however, should not restrain us from blood-letting where the state of the breathing, heat of skin, and the pulse seem to require it. Frank bled an octogenarian with pneumonia nine times with a good result. Such cases are however exceptions; for the period in which blood-letting is useful in old people is short, and often restricted by a complication with humid bronchitis. Expectoration is here an important process, and may sometimes be aided by some of the remedies just mentioned, with the mercurial or tartar-emetic treatment and blisters at an earlier period than usual. The typhoid form of pneumonia requires a treatment considerably modified. Blood-letting not only is very ill borne, but it appears to have very little influence on the disease. There seems to be in the pulmonary vessels a loss of tension or tonicity, and we might empty the great blood-vessels, and stop the heart's action before the congestion of the lungs would be relieved and their vessels enabled to contract. Besides, the depressing influence of typhoid diseases renders any loss of blood hazardous, and local depletion is the utmost that can be attempted. Considerable advantage may under these circumstances be derived from dry cup- ping on the chest; which for the time tends more effectually than even blood- letting to draw the fluids from the congested organs whilst it does not drain the blood from the system. Blisters and sinapisms also may give relief in slight cases, but their effect is limited, where, as it commonly happens, the. whole pos- terior part of both lungs are congested with blood which is itself probably in a morbid state. The principal remedy in this form of pneumonia (if pneumonia it can properly be called) is mercury, which may be combined with opium and saline medicines, and, in case of great prevalence of the adynamic symptoms, with stimulants and tonics, such as wine, ammonia, and bark. Medicine has often very little power in these cases; but as far as our experience goes, stimu- lants judiciously given when the heart's action, as examined by the stethoscope, is feeble, and diminished or withdrawn as soon as it becomes increased, and the pulse sharp or hard, have appeared to relieve the pulmonary affection as well as to support the strength. Musk is highly recommended by M. Recamier in 350 pneumonia, (Diet and Regimen.) typhoid pneumonia: he gives it in doses of from twenty-four to thirty grains, with an effect which he almost considers specific. * It may be questioned whether the affection called intermittent peripneumony, and said to have been cured by bark, is really an inflammation; it is more probable that it consists of a simple congestion of the lung, just as similar congestions are more familiarly known to take place in the spleen and liver, and which, when recent, give way to bark or arsenic, not to blood-letting. We have stated that typhoid pneumonia, and that attending continued fevers, are more properly to be viewed as congestive than inflammatory; at the same time it must not be forgot- ten that congestion may by a process of reaction be converted into acute inflam- mation with all its products, and otherwise, unless soon removed, frequently tends to produce some chronic change of structure. The complication of pneumonia with bronchitis is generally best treated by moderate blood-letting followed by the antimonial treatment. Blisters and expec- torant mixtures are of more avail than in simple pneumonia, the disease often terminating by free expectoration. In pleuro-pneumonia local as well as general blood-letting should be practised freely; and after the more acute stage has subsided under the influence of these and of antimony, if the buzzing bronchophony and dulness on percussion still continue, the side should be blistered repeatedly, and a mild course of mercury prescribed to promote the removal of the fluid and the interstitial lymph which might lead to partial obliteration of the tissue of the lung. In pneumonia supervening on hooping-cough and influenza, it is sometimes a chief indication to give sedatives to allay the cough, which appears often to have a considerable share in producing the parenchymatous inflammation; with this view the sedatives recommended for hooping-cough should be combined with the usual treatment. Where an inflammatory state of the mucous or serous membranes of the ali- mentary canal accompanies pneumonia, it is of great moment that in the treat- ment these complications should be considered, as they may render some of the ordinary remedies injurious. Leeches followed by poultices should be applied to the abdomen, and the milder forms of mercury with Dover's powder exhibited, assisted by laxative enemata or very gentle aperients. Diet and regimen. In ordinary cases of pneumonia the diet should be strictly antiphlogistic, and during the early stages confined to thin mucilaginous or fari- naceous liquids. Even these should not be used in excess, for in large quantity any liquid may first distend the stomach and then increase the mass of the blood, and in both ways augment the dyspnoea. In those addicted to a very free use of fermented or spirituous liquors, as well as in typhoid pneumonia in general, it is sometimes necessary to continue a certain quantity of these stimuli. M. Chomel found a considerable diminution in the great mortality of such cases on adopting this plan. In gangrene or extensive suppuration indicated by foetor and copious purulent expectoration with great prostration of strength, it also becomes neces- sary to give beef tea, animal jellies, and wine; but great circumspection must be used to withdraw them in case of fresh excitement. It is equally necessarv to be very cautious with regard to the improvement of the patient's diet during con- valescence, by adopting gradual transitions, and by properly regulating the alvine function. Pneumonia patients should be kept in an airy room without draught, of mode- rate temperature (about 60°.) It is of considerable importance in the more severe cases to raise the chest above the level of the body by a bed chair: this facilitates breathing and expectoration, and prevents the too free gravitation of the blood to the lungs. In prolonged cases, especially those of a typhoid kind, it is also proper to vary the posture from side to side, and to lying on the face when the patient cannot sit, several times in the day, to prevent the hypostatic congestion. This is recommended by M. Gerdy and Dr. Stokes. pneumonia, (Signs.) 351 Chronic Pneumonia. As we have seen with regard to pleurisy, so also in pneumonia, the inflamma- tory action may not entirely cease with the effusion of lymph, although it do not lead to the third- or suppurative stage. When acute inflammation is extensive, and the effusion of lymph is not removed by absorption, the disease generally proves fatal before there is time for farther change; but in circumscribed peripneu- monies, or in small parts of more extensive hepatisation, a chronic inflammation sometimes goes on, and produces that kind of tough induration which is the gene- ral result of chronic inflammation in a parenchymatous structure. Thus in the lungs of those who have suffered from long and repeated attacks of inflammation of the chest, even where there are no tubercles, we not unfrequently meet with portions of the tissue that are dense, almost destitute of air and of liquid, tough, and sometimes almost cartilaginous. Their colour varies from a dark dingy-red to different lighter shades of reddish-brown and buff, sometimes rendered gray by a mixture of the black pulmonary matter. Their aspect also is varied, like that of acute hepatisation, by the tissues that are chiefly affected being sometimes granular or oolitic (as Laennec has stated) from the especial thickening of individual vesicles; in other cases streaked or veined, from the hypertrophy of the interlobular septa and cellular tissue around the large vessels; in others more uniform and of a darker colour, from the pulmonary plexus of vessels being the chief seat of the alteration, and the colouring matter of the blood entering largely into the deposi- tion. In this last variety the cellular tissue between the lobules is sometimes thick- ened to the amount of several lines, and is of a light drab or gray colour, like that of miliary granulations, and like them has almost the density of cartilage. These changes, which thus occur as the sequel of acute pneumonia, are also frequently met with, complicated with those states of the lung which are called tuberculous; and a considerable portion of the consolidation that is met with in phthisical lungs often presents the same anatomical characters as these chronic hepatisations which supervene on acute pneumonia imperfectly subdued. These will be farther no- ticed under Phthisis. We have also several times met with these chronic conso- lidations in the lungs of those who have long suffered from extensive organic dis- ease of the heart, where the circulation of the lungs was perpetually impeded by the structural lesions of that organ; it is probable that the same mechanical con- gestion from this cause which sometimes lead to effusion of blood in the tissue, constituting pulmonary apoplexy, may if long continued terminate in effusion of lymph, and obliteration and consolidation of the pulmonary texture. This condi- tion of the lung is sometimes coupled with an irregular dilatation of the air-cells; and on examination after death the organ presents a knobby surface, and feels nodulated, where the consolidation occupies lobules or parts. There seems to be reason for ascribing also to a minor extent of chronic inflammation of the paren- chyma, that increased density and rigidity of the pulmonary tissue, without entire consolidation, which is often found in the lungs of those who have long suffered from dyspncea, whether from bronchial or cardiac disease. The signs of chronic pneumonia are those of circumscribed consolidation and obstruction of the pulmonary tissue, which continue long after the urgent symp- toms of the acute disease have subsided. The dyspncea has become less oppres- sive, but it is still felt on exertion; the fever has been reduced, but there is still some quickness of pulse and heat of skin towards night; there is still some cough; and although there may be improvement in the appearance and strength, it is not pro- gressive, the patient remaining with his organs and functions abridged: there is still partial dulness on percussion, with some bronchial respiration and vocal re- sonance in the seat of the late inflammation. If in this state the patient neglect the means which may most conduce to the restoration of his general health, as well as to the removal of these remains of local disease, the indurated portions of lung may either prove centres of fresh inflammation, or they may themselves 352 PNEUMONIA OF CHILDREN. spread, ulcerate, and commence the career of phthisical disease, which will sooner or later destroy life. We have met with several cases of consumption that have appeared to originate in this way, independently of any distinct tuberculous dis- ease or diathesis; the individuals having been in excellent health, and quite free from all chest complaints before the attack of acute inflammation, which afterwards degenerating into this chronic form laid the foundation of a consumption, and ulti- mately proved fatal. It is however slower and less intractable in its progress than the true tuberculous consumption, for the disease is more local than consti- tutional ; and if circumstances do not occasion its extension, and injure the consti- tution by a constant and increasing inroad on the functions of respiration and cir- culation, it may be in the power of nature, aided by art, to effect its removal. The subject of the treatment of chronic pneumonia will be resumed in con- nexion with that of phthisis. It may suffice for the present to add that for those cases which succeed to acute disease, the most effectual treatment consists in a mild course of mercury in the first instance, combined with external counter-irrita- tion, followed by a course of hydriodate of potash and sarsaparilla or some simi- lar alterative, with a mild sea-air, regular gentle exercise, and a well-regulated diet. PNEUMONIA OF CHILDREN. The pneumonia of children differs in some respects from that of adults. The disease ap- pears in them under two distinct forms, which are almost peculiar to children of certain ages. That is, one form attacks children from birth to the period of the second dentition, while the other does not differ from the ordinary frank pneumonia of adults; and docs not, therefore require a separate examination. The two forms are not strictly confined to one or the other age of life, but that which is most frequent in young children is rarely found in those more advanced, while the ordinary form of the disease is extremely uncommon in young subjects. The lobular pneumonia, which is almost the only form met with in young children, derives its peculiar features in part, from the peculiarities of organization of this age, and in part, from the causes which give rise to the disease. These are generally very prolonged bronchitis, previous disorders of the digestive tubes, or the exanthemata; in short, discs; s which de- press the powers of life or alter the constitution of the blood, which then gravitates towards the inferior parts of the lungs. In adults, the action of analogous causes is occasionally fol- lowed by the same affection, which then produces similar symptoms ; and the inflammation of the lung then differs very slightly from the lobular pneumonia in young children The peculiar anatomical character of the disorder is, that the inflammation is diffused through several scattered points which are attacked at the same time, or nearly at the vinie time. These points are single lobules, or parts of lobules, divided by the cellular tissue. The tissue is first congested, and afterwards inflammation sets in, and as t!ic disease extends from point to point it passes along the posterior portion of the lung according to the ordinary laws of pneumonia, but, as it were, in a scattering way, attacking several lobules at the same time. This form of the disease sometimes even passes into suppuration; when it proves fatal it is in most cases rather by depriving a large portion of the lung of air, than by the true in- fiammutory action and its direct consequences. The signs of lobular pneumonia are less evident than those of pneumonia of the ordinary form. The respiration is at first rough, and almost always there is more or less mucous and sub-crepitant rhonchus which depend upon the accompanying bronchitis, but there is rarely a dry crepitant rhonchus. The respiration becomes bronchial only in a late stage of the dis- ease, and scarcely ever to as great degree as in ordinary pneumonia, for the bronchial tubes are blocked up by the secretions before the hepatisation is perfect. The percussion is dull; but as this dulness exists nearly to the same degree in both sides of the dies!, we lose the advantages of comparison, and can, therefore, with some difficulty detect slight deviations GANGRENE OF THE LUNGS. 353 from the normal standard. In the advanced stages of the disorder there is, of course, no ob- scurity ; but in the earlier stages we must remember that the same dulness is not to be looked for as in ordinary pneumonia, and the evidence of the disease will rest, therefore, on less decided signs. The treatment of lobular pneumonia consists of two distinct parts, the hygienic and thera- peutic. To answer the first indication we direct a mild unirritating diet, and frequent change of position, so that the blood may not gravitate towards the posterior part of the chest: with- out this precaution all other means of treatment are apt to fail. The apartment in which the child is placed should be of a remarkably uniform temperature, and the clothes arranged in Buch a way and made of such materials as to prevent any chilliness of the surface. The therapeutic means are, in the commencement of the disorder, local bleeding by a few leeches or cups proportioned to the age of the child. The advantages of these remedies are, however, limited to but a short period, that is, the earliest stages of the affection; afterwards they debilitate the child without removing the inflammation. Blisters are often of benefit, and are never of mischief if they be applied only for a few hours, and the cuticle then removed by a poultice; but in this disease, as well as in the genuine ordinary pneumonia, they are less certain than many other remedies. The best counter-irritant for most cases is a weak mus- tard poultice; a very good one consists of thick slices of bread dipped in hot vinegar, and sprinkled lightly with mustard. A common poultice made of roasted onions is often of great benefit; or the bruised cloves of garlic, if they can be readily procured, may be used in pre- ference. The revulsive applications should not be confined to the breast, but may be used to various parts of the body, and especially to the lower extremities by means of weak mus- tard poultices and baths. The internal remedies which are most to be depended upon are the preparations of ipeca- cuanha, of which the best for children are the wine and sirup. This medicine should be given frequently in small doses, so as to facilitate expectoration and thus to aid in the natural cure by secretion from the inflamed tubes. Other remedies of a similar kind are called for in many cases of the disorder'; if the child be strong and robust, tartarized antimony is of great benefit; but if the pneumonia follow a disorder of another kind, which has previously debili- tated the patient, the antimony is not well adapted for the case. The stimulating expecto- rants, as senega and the balsam of Tolu, are necessary when the lungs are obstructed with mucus, they may then replace or be given in conjunction with ipecacuanha, according to the strength of the patient. If there should be much bronchitis, and the pneumonia remain in its early stage, free emesis after a dose of ipecacuanha or tartar-emetic, will often relieve the child of the mucus secretions and give such a shock to the circulation of the lungs as will sometimes produce a rapid resolution of the disorder. The main difficulty in the management of the pneumonia of children is not the selection of the remedies, but the perse- vering employment of them in such doses and at such times as cannot materially affect the strength of the patient; but will still have a powerful action on the local inflammation. Many other remedies which are useful in certain stages of ordinary pneumonia are appro- priately adapted for the pneumonia of children; but these are so various, and require such a knowledge of the particular condition of the case, that no general rules for their employment can be given. GANGRENE OF THE LUNGS. In many cases, gangrene of the lungs is not a mere consequence of pneumonia, but depends upon the same causes as idiopathic gangrene of the mouth, or of other parts of the body; that is, it is an immediate result of a vitiated condition of the fluids. In most patients this state follows excessive intemperance, mercurial salivation, or some disease which pos- sesses a powerful influence upon the general health, and brings about that alteration of the Vol. II.—45 354 GANGRENE OF THE LUNGS. fluids upon which gangrene depends; hence gangrene of the lungs sometimes occurs simul- taneously with that of the mouth or other parts, depending upon the same cause. The physical condition of a lung affected with gangrene independent of pneumonia, is very well understood. The tissue at first is infiltrated with serum, which is sometimes of a dark red or almost purple colour, and at other times grayish; it yields readily on pressure and ex- hales a fetid odour. This is the first stage of the disorder, and differs but little from that of the first stage of pneumonia, except in the fetor and colour of the infiltrating liquid. In the second stage, the cohesion of the parenchyma is destroyed, it may be washed away by a small stream of water, and at first the blood-vessels and bronchial tubes remain longer than the in- tervening cellular tissue, the fetor is then decidedly gangrenous, of the peculiar odour of ordi- nary gangrenous matter,or the smell resembles that of putrid oysters: the colour of the lung is blackish like that of other gangrenous parts. In the third stage the gangrenous lung is replaced by a cavity, which follows the softening and discharge by expectoration of the gan- grenous matter. If the gangrene be circumscribed, the cavity is lined by a false membrane, which gradually secretes pus, and finally extends over the whole interior, cutting off the dead fi;om the living tissue. Cicatrization then follows, either by the gradual obliteration of the cavity by cellular substance, or a eyst is formed, which is lined by a smooth mucous mem- brane continuous with that of the bronchial tubes. If the gangrene be more extensive, death may occur during the progress of the second stage or at the commencement of the third. The sputa of gangrene of the lungs vary with the stages of the disorder, at first they are mucous and slightly fetid, afterwards they are blackish and similar to prune-juice, or of a dirty grayish tint. In the third stage the proper gangrenous sputa are intermixed with muco- purulent matter from the walls of the cavity; the latter gradually increases in quantity until it forms the whole of the expectoration. As the disease goes on, the sputa gradually pass into the character of simple mucus. The expectoration presents throughout the disease the fetor characteristic of gangrene, especially in the middle of the second stage when the softening is most rapid. The breath of the patient offers the same character, which is more marked both in it and in the sputa after the paroxysms of cough which come on from time to time, and are followed by a copious discharge of the liquid which has been accumulating in the cavity. The physical signs of gangrene are at first similar to those of bronchitis of the smaller tubes with free secretion, that is, sub-crepitant and mucous rhonchus, they afterwards gradually pass into gurgling and pectoriloquy as the cavity forms. The diagnosis of the disorder is made from the peculiar odour of the sputa and breath, the physical signs serving only to point out the extent of the disease and the stage of the affec- tion. The prostration of strength and complexion of the patient arc similar to what is observed in ordinary gangrene from accidental causes. The treatment of the disease should be of a tonic supporting kind, to keep up the strength of the patient during the time required for casting off the gangrenous mass, and filling up the cavity. The sulphate of quinine, porter, wine, and even milk-punch, with as generous a diet as the stomach of the patient will bear, should be liberally given. The solution of the chlo- ride of soda in the dose of twenty drops every three or four hours will generally be borne by the patient, and I have found it of decided benefit. For the same purpose chlorine should be allowed to disengage itself from several saucers filled with moist chloride of lime and placed about the bed of the patient; the gas rises into the lungs, and is thus directly applied to the diseased part. If pleuretic pain should come on, a blister to the chest is the best mode of relieving it. G. pulmonary cedema, (Treatment.) 355 PULMONARY (EDEMA. Anatomical characters.—Causes.—Symptoms and physical signs.—Treatment. QShema of the lung consists in an effusion of serum into the tissue, probably both between and within the cells and minute tubes. Its anatomical characters are, that the lung is heavier and paler than usual, pits on pressure, crepitates little under the finger, and when cut exudes a frothy serum. It is seldom idio- pathic, but like oedema of other parts results from some loss of balance in the circulation, an obstruction to the return of blood, or in a few instances an excess of exhalation. Thus it may arise from the obstructions occasioned by organic diseases of the heart, lungs, or liver, or from the increased exhalation supervening on exanthematous fevers, particularly scarlatina and rubeola, or on those diseases of the kidneys which interfere with their excretory function, and are accompa- nied by dropsical effusions in various parts. Being thus a sequel of other disease rather than a pathological condition dis- tinct in itself, the symptoms accompanying oedema must vary greatly according to the cause which produces it. When extensive it occasions dyspncea, cough, and thin mucous or serous expectoration. The physical signs are a crepitant or sub-crepitant rhonchus, with the breathing less fine and even than that of pneu- monia, and giving proof of the presence of more liquid by the mucous rhonchus in some of the larger tubes. The natural vesicular murmur is rendered indistinct, especially at the lower and back part of the chest, where also the sound on per- cussion is impaired. These signs are very like those of the first stage of pneu- monia ; and the distinction is chiefly to be found in the general symptoms; the fever, rusty expectoration,.and progressive increase of pneumonia being absent, and there being present oedema of other parts, or other signs of disease that may be supposed to produce it. From our own observation we should say, that the lungs are less liable to oedema than the external cellular tissue; and they are rarely so affected unless there be also anasarca, or oedema of the limbs. Treatment. This must depend on the nature of the cause, and be adapted to the character of the organic lesion which is generally present. The oedema which follows scarlatina and measles generally yields to hydragogue purgatives and digi- talis ; in addition to which general or local bleeding may in some severe cases be required. 356 pulmonary emphysema, (Causes and Nature.) DILATATION OF THE AIR-CELLS; OR PULMONARY EMPHYSEMA. Anatomical characters.—Causes and nature.—Symptoms.—Physical signs.—Prognosis.— Treatment.—Interlobular emphysema.—Nature and supposed physical signs. This lesion, like others essentially affecting the structure, will be best understood through its anatomical characters. Anatomical characters. These present some variety, but they have this in common, that when examined either through the pleura in the recent state, or after this membrane is inflated, dried, and sliced, the air-cells are seen much larger than those of healthy lungs. When the dilatation is general the pleural surface of the lungs may be as smooth as usual, only more convex; but when it is partial, there are seen either several enlarged vesicles or lobules forming irre- gular prominences. Individual vesicles are sometimes seen under the pleura, and especially at the margin of the lobes, dilated to the size of a pea, a hazle-nut, and in some cases to a much larger size. Dilatation may be partial or general: ge- neral dilatation may affect one lung, or the whole, or a considerable part of both lungs ; partial dilatation may affect all the vesicles of a lobule or be confined to distinct vesicles. These different lesions may be accompanied by very opposite conditions of the texture of the lung: sometimes this has acquired an increased rigidity; it does not collapse where the chest is opened, and resists the impres- sion of the fingers more than a healthy lung. There are, notwithstanding, the dilatation of the air-cells and its general lightness, hypertrophy and toughness of some of its textures, and portions near the root are sometimes found considera- bly indurated. With this condition there are commonly associated an altered state of the air-tubes, redness and thickening of the mucous membrane, hypertro- phy of the longitudinal fibres, dilatation or partial contraction. In other cases, there is the opposite condition of the lung. The texture is more flaccid and yielding than usual; and when the margin of a lobe is pressed between the fin- gers, it feels thin, almost like a single membrane. It often does not collapse on opening the chest, and this appears to arise from a loss of elasticity, for it pits on pressure like an cedematous lung, and is commonly much paler than usual. This is the condition which M. Lombard describes as lobar emphysema; and he re- marks that the inter-vesicular texture seems to have been absorbed, and the blood-vessels obliterated, changes which he considers to be the cause, rather than as we view them, the effects of the dilatation. Andral has noticed this condition of the lung, under the name atrophy, and remarks that it occurs most frequently in old people. We have seen it both general and partial; the partial kind of flaccid dilatation being common in the anterior lobules and margins of the lungs in tuberculous phthisis. The fringe of dilated cells like a row of beads, sometimes seen at the margin of the anterior lobes, is also simple dilatation, without the least rigidity. Causes and nature. Laennec explained the origin of this lesion in this man- ner:—In cases of chronic catarrh, particularly of the dry kind, the small bron- chial ramifications become so obstructed by the swelling of their membranes or by the secretion of a viscid mucus that the air can be forced through them into pulmoary emphysema, (Causes and Nature.) 357 the vesicles only by an effort. Now, as in ordinary respiration, the inspiration, a muscular effort, is more forcible than expiration, the former may prove suffi- cient to overcome the obstacle to the introduction of air into the vesicles, while the expiration is inadequate to expel it. Successive portions of the air expand- ing by the increased temperature are thus introduced and incarcerated in the cells, which are thereby kept in a state of continued dilatation. This may be one mode in which the air-cells become dilated, but there are probably other causes more efficient and common in operation. When there is partial or com- plete obstruction in any of the bronchial tubes or cells, the inspired air cannot press with the usual force beyond the obstructions; but it presses with more than the usual force into the adjoining tubes and cells to which its access is quite free, and these latter may thus become distended, and in time permanently dilated. The obstructions may be caused by viscid secretion in the tubes, thickening of the textures, tuberculous deposites, and the like; and it is with diseases in which these occur, that dilatation of the air-cells is most commonly associated. Another cause of dilatation of the air-cells is rigidity or want of extensibility of the longi- tudinal fibres of the bronchi. This change has been already noticed as an effect of chronic bronchitis; and it is easy to perceive, that if the tubes do not lengthen with the expansion of the chest the air will press unduly on their terminating cells, and occasion their dilatation. Thus we find the margins of the lower lobes most dilated, for these are most exposed to the influence of the forces expanding the chest. It is not common to find the marginal vesicles dilated in the lungs of old people with ossified cartilages; which may also be ascribed to the compara- tively immobile state of the ribs and central portions of the lungs, and the in- creased action of the diaphragm, and consequent undue pressure of the air into the texture immediately contiguous to this part of the respiratory apparatus. Such are the chief mechanical causes by which the vesicular texture of the lung becomes distended: but there are others of a more vital nature, which may also be concerned in the production and perpetuation of this lesion. M. Andral conceives that the air-cells sometimes become enlarged by a wasting aAvay and breaking down of some of their walls, so that several are reduced to few of larger size. This has been shown by M. Lombard to be the case when- ever the enlargement of some cells is considerable: but we are induced to con- sider with Dr. Carswell, that this is a consequence rather than a cause of the dilatation. The latter author has well observed that the long-continued pressure of the confined air on the vessels is a sufficient cause of their diminution, and of the atrophy of the tissues. Dr. W. Stokes supposes that paralysis of the circular fibre3 of the' bronchi is a chief cause of dilatation of the air-cells. Following the view which Dr. Aber- crombie holds with regard to the intestinal muscles, he considers inflammation of the tunics investing the tubes, such as that of bronchitis, to be the chief cause of this paralysis. It is, however, doubtful, that this is more than an aiding cause in the production of pulmonary emphysema. The contractile property of the vesicular tissue is not fully proved; but its elasticity is undoubted, and it is very probable that a defect of this may assist in producing the lesion in question. But the chief agents are probably the mechanical causes of irregular distention of the lungs, which have been already noticed. Reverting to the anatomical differences of the tense and the flaccid vesicular emphysema, we may well trace in one the effect of an over-active and irregular nutrition of the textures, the common result of repeated or prolonged inflamma- tion, and in the other the absence of any such process, if not the presence of one of an opposite character, causing a wasting of the same parts. It is obvious that these opposite conditions will lead to very different effects in the signs and course of the lesion. In the one case, the lungs become comparatively fixed in a distended state; and as they resist the power of the expiratory forces to expel the air from them, unusual exertion is required in inspiration to introduce suffi- cient air to serve the purpose of respiration. They are, therefore, perpetually 358 pulmonary emphysema, (Physical Signs.) exposed to a distending force: and as the dilatation proceeds, and the increasing rigidity or obstruction with it, the lungs acquire a permanent volume beyond what is usual even in full inspiration, and they distend the walls of the chest, and press on and even displace the adjoining organs and vessels. Hence may be expected to arise continual oppression of the functions of both respiration and circulation, and, as the sequel, cachectic and dropsical disease of the system. In flaccid vesicular dilatation on the other hand, there is little or no increase of volume of the whole lung, and no pressure on the other contents of the chest. Symptoms. We are now prepared to understand the symptoms and signs of extensive vesicular dilatation. Inasmuch as it is permanent, it will cause a con- stant shortness of breath, or even dyspncea ; and the least additional obstruction, such as that of a cold, bodily exertion, or flatulent distention of the stomach, may increase this symptom to an oppressive degree, so as to resemble an attack of asthma. The permanency of the oppression to the function of respiration in severe cases induces a cachectic state of the body, which is manifested by pallidity and some emaciation, and a depraved condition of all the excretions. In the tense form of emphysema, with increased volume of the lungs, there may be superadded the symptoms of obstructed circulation as well as imperfect oxygenation of the blood, occasional lividity and even blueness of the face and lips, dropsical effusions, palpi- tation and other signs of hypertrophy of the heart. Dr. Stokes has remarked, that these symptoms are always worse in cases where the lower lobes of the lungs are chiefly affected, which he explains by the enlarged lungs of these parts pre- venting the free play of the diaphragm. The expectoration is various; most com- monly it is mixed, a thin dirty, mucous fluid, with portions of tough, pearly clots, or of the opaque sputa of chronic bronchitis. In the attacks of acute bronchitis which frequently occur, it becomes glairy, and often very copious towards their termination, as in bronchorrhcea. Of the Physical signs of pulmonary emphysema, one of the most remarkable is the loud, hollow sound on percussion, which is even greater than that of a healthy chest. This is common to both the tense and flaccid kinds of emphysema; but in the former, when extensive, there is a distinctly raised pitch in the sound, such as in a less degree that which can be produced by striking the chest of a person holding in a very full breath. In fact, as in this case, the walls of the chest are rendered more tense by the increased volume of the lung, and the vibrations which they make are therefore quicker although from the elasticity of the contained material they are still quite free. In advanced cases, the increased volume of the lung is manifest in the shape of the chest, which is unusually convex or rounded. The sides, the front, the back, and even the supra-clavicular spaces, some or all present this rounded projection; and as Dr. Stokes has observed, when the lower lobes are affected, the heart, the liver, and the spleen may be displaced by the emphysematous lung, which then yields its clear resonance on percussion over an extended region. In this tense kind of vesicular dilatation the sound of respi- ration is very imperfect and wheezing, and forms a remarkable contrast to the efforts used to introduce and expel the air. On inspecting the chest it can be seen that, with all the expiratory efforts, it is very little diminished, and retains its large convex shape; whilst every intercostal and every supplementary muscle can be seen at work, endeavouring in vain to depress the ribs. We can scarcely won- der that this force, continually exerted on the thoracic vessels through the stuffed lungs, should obstruct the circulation, and cause lividity, cyanosis, dropsical effu- sions, and diseases of the heart. Inspiration is more easy, but even this requires exertion, for breath is taken as it were on the top of breath, and needs the supple- mentary aid of the cervical and superior dorsal muscles. Sometimes there are heard in the chest some odd sounds, besides the various rhonchi of the tubes, such as a sudden, loud clicking or cracking, as if from the sudden passage of air into or out of a set of tubes and cells which were before closed. Sometimes there is a sound of friction like that of a finger rubbed on a table, perhaps produced by the rubbing of projecting lobules or cells against the costal pleura. pulmonary emphysema, (Prognosis—Treatment.) 359 The signs of the flaccid kind of dilated air-cells may be much modified by the other disease, such as tuberculous deposite, that commonly produces it; but they are essentially distinct from those of tense emphysema, and this difference has not been noticed by authors. There is the clear sound on percussion, but no raising of the pitch of the sound. In old people, where this form of emphysema is uncom- plicated with solid deposite, the sound on percussion is clearer and deeper than in any other case. Neither the shape nor the motion of the chest is materially af- fected ; and the sounds of respiration, instead of being obscure and wheezing, are remarkably loud and even puerile, sometimes with a little whiffing or bronchial character, probably from accompanying dilatation of the tubes. The reason of all this will be apparent when we reflect that, in these cases, air passes freely into and out of the dilated cells; and that their enlarged size, together with the in- creased energy which the feeling of dyspncea gives to the acts of respiration, explains why the sound of respiration should be louder than usual. Prognosis. When dilatation of the air-cells is so extensive as to alter the shape of the chest and to cause constant shortness of breath, there is little probability of its ever being entirely removed, and its general tendency is to increase, especially during the occurrence of any fresh attacks of bronchial inflammation. In some cases the disease, if not congenital, takes its origin in very early life, and the indi- vidual is always very short-breathed, and on the occurrence even of a common cold becomes completely asthmatic. But these are not the most severe cases; such are those which supervene to repeated and obstinate bronchial attacks which in the course of a few months may induce a formidable degree of the disease. Even these cases do not prove speedily fatal, but only after the system has suffered much and long, and disease of the heart and dropsy has supervened. Treatment. The prevention of the disease is more attainable than its cure; and with this view we should endeavour to remove those inflammations which lead to an obstructed state of respiration, and to disperse the obstructions which they pro- duce. The use of counter-irritants and alkaline attenuants and expectorants, and other remedies recommended for chronic bronchitis and dry catarrh, is the most successful mode of effecting these objects. We have seen, in several cases, con- siderable relief with marked improvement of the physical signs, from the use of small doses of hydriodate of potash and liquor potassae, with squills and other ex- pectorant remedies. Where there is already evidence of considerable dilatation, blisters to the chest, or frictions with a strong stimulating liniment, and the inhala- tion of steam impregnated with a little tar, turpentine, creosote, or even iodine, may prove of some benefit. Dr. Stokes mentions strychnia as likely to restore, in some measure, the lost contractility of the circular fibres. The symptoms which arise in inveterate cases of pulmonary emphysema must be treated on general principles, remembering that although we may be unable to remove the cause, we may, in some degree, prevent its increase and diminish its aggravations from temporary circumstances. With this view care should be taken to avoid the renewal of bronchial inflammation and congestion, by guarding against cold, keeping the secretions free, and carefully regulating the diet. If the expectoration be not sufficiently free, and a fit of dyspncea occur during the night in consequence, benefit may often be derived from smoking stramonium in the evening: this excites secretion from the bronchial surface, and prevents the conges- tion which would otherwise ensue during the first sleep. The flaccid form of emphysema is scarcely an object for treatment: we cannot increase the number of the pulmonary cells; but we may, in some degree, so regu- late the body as to diminish the want of breath, and make the small number suf- fice. With this view, a tranquillizing plan of medicine and regimen, avoiding all excitements of the circulation and respiration, at the same time promoting the due activity of the secretions and tone of the system by gentle exercise and alterative tonics, may serve to keep a balance of imperfect health, and prolong existence on a lower scale. 360 pulmonary emphysema. Interlobular Emphysema is an effusion of air into the cellular membrane be- tween the lobules and under the pleura; and, though essentially distinct from the preceding affection, it may be combined with it. It is distinguished anatomically by the air being in the lines of the interlobular septa, and contained in angular cells of various shapes and sizes, and not round ones like those of the lung. Sometimes air is effused under the pulmonary pleura, detaching it from the lung in large bub- bles. This affection is commonly produced by violent efforts, or by wounds of the lung, but sometimes from rupture of the air-cells by excessive or sudden dilata- tion. It may, if extreme, produce sudden and even fatal oppression to the breathing; but in slighter cases it is of no consequence, and is removed sponta- neously. The only sign, supposed by Laennec to mark this affection, is a sound of rub- bing with the motions of respiration, which the projecting emphysematous septa or bubbles make against the walls of the chest This is heard and felt sometimes in successive jerks, so as to resemble the steps of a person mounting and descending a ladder. Atrophy and Hypertrophy op the Lung. We have already adverted to atrophy of the lung as a concomitant of flaccid dilatation of the air-cells. But the same condition not unfrequently presents itself where there is no distinct evidence of enlargement of the cells ; as in the lungs of aged persons, and of those who have died after a prolonged and emaciating illness. In such cases, the textures of the whole lungs are found much thinner, softer, and paler than usual, and when collapsed, they are shrunk into a very small compass. The cavity of the chest seems to be also diminished by the diaphragm occupying a higher position than usual. There are other cases in which partial atrophy of the lung can be traced in connexion with tubercle, obliteration of the bronchial tubes, and as a sequel of pleuro-pneumonia; but, in these cases, there is generally also dilatation of either the neighbouring tubes or cells. It is very reasonable to suppose with Andral and Stokes that, when from a permanent obstruction, a part of the lungs do not receive its supply of air and blood like other parts, whose func- tions are not exercised, it loses its substance; and it is still more interesting to conceive that the same result may effect more generally the lungs of those whose sphere of respiration is contracted by their being bed-ridden, or otherwise long limited in the exercise of the function. Such individuals, should they recover the power of being active, are short-breathed without any other disease; and although weakness of the heart and muscles of respiration may partly cause this, we must suppose that the wasting of the lung through disuse is also concerned in it Hypertrophy op the Lung has been already noticed in connexion with chronic pneumonia and emphysema. But we also meet with the lungs in a denser, heavier state in some other diseasesv particularly those of the heart. This has been de- scribed by Dr. Clendinning, and, from much observation, we can bear testimony to the fact that, after the long continuance of organic disease of the heart, the sub- stance of the lungs, even when not congested, is much more dense and heavy than usual, although the vesicular texture is every where filled with air. The lesion of the heart with which this state of the lung is most commonly associated, is hyper- trophy of the right ventricle, with difficult transmission of blood through the heart; and we can readily conceive how the increased impulsion of blood produced by the one, and the long existing congestion resulting from the other cardiac lesion, may occasion an increased growth of the solid textures of the lung. The indif- ferent sound on percussion which the chest often yields in such cases, may result from this change; and the permanent shortness of breath is, perhaps, also in part due to the same cause. The treatment belongs to the subject of hypertrophy of the heart, and the lesion which it induces. I TUBERCULOUS DISEASE OF THE LUNO. 361 TUBERCULOUS DISEASE OF THE LUNG, OR PULMONARY CONSUMPTION. General characters.—Anatomical characters.—Pathology of pulmonary tubercles.—Symptoms —of the first—second—and third stage.—Physical signs—of the first—second—and third stage.—Complications.—Varieties.—Acute—Chronic.—Origin and causes.—Diagnosis.— Prognosis.—Treatment.—Prevention of tubercular disease. Under this head we propose to include all those forms of disease of the lungs which arise from the formation of tuberculous matter, or of depositions and indu- rations which are allied to it, in the substance of the lung. By the names, phthisis, consumption, and more properly by that of decline, is implied the wasting of the body from the effect of a disorganizing process going on in the lungs. A disease so varied in extent and course as phthisis is can scarcely be comprehended in a definition by symptoms, but its most general character may be stated as follows: cough, with at first little or only transparent expectoration, occasionally haemop- tysis, afterwards opaque, purulent, and copious expectoration; quick pulse and fever, particularly in the evening, and ending with night sweats: dyspncea, or shortness of breath, gradually increasing; progressive emaciation and debility. The chief physical signs are, irregular expansion of the chest, dulness on percus- sion, with imperfect or bronchial sound of respiration in some of the upper parts of the chest; afterwards cavernous rhonchus, respiration, and pectoriloquy; indi- cating partial consolidation of the lung, followed by the formation of cavities com- municating with the air-tubes. But it would be irrational and tedious to enter into any details of the symptoms and history of the disease, without first considering the pathological nature of those changes which it causes in the lung; and as these are chiefly learned by a study of the anatomical characters of the lesions, we shall premise a brief sketch of these; and by tracing out their progress through their stages and complications, we may be enabled better to comprehend the nature of the disease, and the signs and symp- toms which accompany it. Anatomical characters. When we examine the lungs of persons who have died of consumption, we find them greatly changed from their natural condition: they are more or less consolidated in irregular masses; and on cutting into them, they are also generally found excavated into hollows of various sizes and shapes, which are either empty, or contain a thick liquid matter. The morbid conditions may be arranged under the following heads: 1. On pressing the softer parts of the lung between the fingers, there are felt in it a number of hard little bodies; and on cutting into them they are found to be roundish granules, of a light, semi-transparent reddish drab, or skin-colour, some- times more gray or ash-coloured, more rarely devoid of colour and quite transpa- rent ; of sizes varying from a pin's head to a hemp-seed. Their hardness is con- siderable, sometimes almost equalling that of cartilage; these are the miliary granulations and miliary tubercles of Laennec and other writers. They are sometimes found isolated, and studding a tissue otherwise healthy: but more com- monly they are in groups of several together: and then they are either clustered in bunches like little berries, or they form a considerable mass, with the interstitial tissue consolidated and indurated between them. They are most commonly dis- tinct in the inferior lobes; in the upper parts, and near the root of the lung, they are usually conglomerated in masses. In the upper parts, too, it is most common to find in them opaque specks of a yellowish-white colour, which are generally in the centre of the granules, sometimes at their margins. In the distinct granula- Vol. II.—46 362 TUBERCULOUS DISEASE OF THE LUNG, OR tions, the opaque part is little more than a speck; but in those which form a con- glomerated mass, the opacity is often seen extending from granule to granule; and in others it constitutes a mass of considerable size within the indurated cluster of granulations. 2. A consolidation of another kind is also commonly found. It is diffused through some extent of the pulmonary tissue, of no particular shape, except that sometimes it seems to be limited to single lobules: it varies in consistence! it is often as nearly as hard as the miliary granulations, and in parts has somewhat of their semi-transparency and colour; but generally it has a darker hue, from the colour of the blood and the black pulmonary matter in it. The consolidation is pretty complete, and the pulmonary texture cannot be distinguished in it, except here and there the coats of a large blood-vessel, bronchus, or interlobular septum, which are often thickened and partake of the induration. In other cases, the consolidation is less perfect; there being still some air in the tissue, and the ad- joining portion of lung being often emphysematous. In these indurated masses, are often to be seen, here and there, more opaque light-coloured spots, which are sometimes quite distinct, and of a dead yellowish-white, like those seen in the miliary granulations: but they are here less regular in their shape and size: being sometimes in streaks, curves, and angles, and mottling the dark consolidated tex- ture with spots and patches of a lighter and opaque hue. In the lightest and most opaque spots we recognise what must be described as the* next class of morbid appearances to be met with in phthisical lungs, namely,— 3» Opaque yellowish-white masses of various form and size, generallv some- what rounded. Some of these are nearly as solid as the dark or semi-transpa- rent indurations, but they are much less tough; others have more or less of a cheesy consistence; and some are found in parts approaching to a state of emi- mous fluidity, still retaining their light colour and opacity. These opaque masses are commonly found within the indurations from which they appear to be formed, and they are just of the same character as the specks before described as occurring in some of the single or aggregated miliary granulations. In fact, as these specks are seen (in some in greater number and extent, and preceded by an intermediate state of opacity) in parts to pervade the whole mass, it mav be fairly concluded that the clusters and nodules of granulations are also converted into this same opaque friable yellowish-white matter. This matter which is in- disputably entitled to be distinguished as tuberculous, is occasionally found also in other situations, unaccompanied by any induration; such as in the interior of dilated vesicles and bronchial tubes, in masses under the pulmonary pleura, and in the bronchial glands. In these instances, it is commonly of a more friable and cheesy consistence, and has not the hardness which it seems to retain for awhile when it has ongnated in the indurated tissue. But this yellow tuberculous mat- ter, however tough and hard it may be in the first instance, rends to soften, par- tiaffy or wholly; and thus the masses are sometimes found con^ting of loose clots in a punlagmous fluid, or wholly reduced to a curdy or cheesv kind of puriform matter. The tuberculous matter is also not unfrequently found diffused through a considerable extent of the pulmonary texture, constituting the infil- trated tubercle of Laennec. In its earlier condition, the lung in this state closelv resembles the advanced stage of hepatisation, when the opacity which precedes suppuration shows itself. It is very much mottled or marbled"; for, besides the ye lowish-white opacity, which is seen in different decrees, there is the black pulmonary matter, giving it a gray or greenish colour, besides the white coats of vessels and interlobular septa, and red spots of tissue less affected When the lung m this state is cut or torn, which it commonly mav be with facility, its inte- rior presents a granular surface like that of hepatisation;"and except that'its colour is more varied, and it has generally more of the light opacity of tuberculous mat- ter, it resembles a hepatised lung very closely. But in it there are often found what are rarely met with in hepatised lungs-circumscribed abscesses or cavities containing a fluid matter. To this softened and fluid state, then all the condi- pulmonary consumptiox, (Anatomical Characters.) 363 tions which we have been describing tend to pass, and thus are formed vomica, the matter of which being evacuated into the bronchial tubes, leave the form of lesion next to be mentioned. 4. Lastly, we find cavities or excavations very various in number and form, and of sizes from that of a cherry-stone upwards to the extent of a whole lobe. Sometimes they contain more or less of the remains of the softened tubercle, or a more liquid pus, or a mixed serous, mucus, and purulent fluid tinged with blood, or they may be empty. They communicate with the air-tubes, and often with each other,—the process of softening and ulceration having opened the pas- sage; but blood-vessels and interlobular septa are often found to have escaped the destructive process, and form cords or bands across the cavities. The blood- vessels are, however, almost always impervious in these cases, and the septa are thickened by the deposition of lymph. The walls of the cavities are composed of the consolidated tissue of the lung, rough, and sometimes sloughy; or of an irre- gular coat of lymph; or, in old cavities, of a kind of new membrane, which in some cases is thin and fine like a mucous membrane, and in others thick, rigid, and more of a fibro-cartilaginous character. When these cavities approach to the pleural surface of the lung, there is often a coating of lymph or false membrane on the pleura at the part, which either thickens in it, or unites it by adhesions to the costal pleura. Sometimes, however, there is no such deposite or adhesion; and it occasionally happens that the pleura is also ulcerated, and being perfo- rated, allows the contents of the cavity, and the air from the bronchi, to pass into the pleural sac, causing pneumothorax and pleuretic inflammation. There is this remarkable in the position and size of the cavities,—that they are almost always largest and most numerous near the summits of the lungs; there being often one or more cavities there, when in the inferior lobes there are only scattered indurations. In fact, it may generally be observed of all the lesions connected with phthisis, that they affect the upper and posterior more than the lower and anterior lobes; and that they are more advanced in the former. This is, however, more remarkable with the circumscribed indurations and tubercles; for with the diffused consolida- tions especially of the light opaque kind (tuberculous infiltration,) the middle and inferior lobes are often also affected, and cavities are commonly found in every part. Besides these chief and more essential changes of the lungs in phthisis, many others are often found of a more accidental character, such as haemorrhagic effusion and consolidation; inflammatory congestion and hepatisation of the lung; products of inflammation in the pleura; inflammation, ulceration, thickening, and dilatation of the bronchial tubes; irregular dilatation of the air-cells, sometimes with increased flaccidity, sometimes with rigidity; enlargement and induration of the bronchial glands, with yellow tuberculous matter in its different states in them. The last affection is of common occurrence in children; and, according to Dr. Carswell, sometimes exist to such an extent as to cause the glands to swell and press on the trachea near its bifurcation. Besides in the lungs, various lesions are frequently found in other organs in the consumptive. The trachea and larynx are not uncommonly ulcerated, particu- larly in those parts over which the matter expectorated most commonly passes. Hence the side of the trachea and branches next to large cavities in the lungs, and the under surface of the vocal cords and epiglottis, are more commonly the seat of these ulcerations. Louis met with ulceration of the larynx in one-fifth of the cases of phthisis which he examined, and of the trachea in a third; whilst these lesions were met with only once in 122 cases not phthisical. MM. Trousseau and Belloc have also shown that ulceration of the larynx is generally, but not constantly, connected with pulmonary tubercles. The ulcers are very various in number and size, and they do not often extend below the mucous and sub-mucous membranes. Tuberculous disease is found in other parts besides the lungs, in a large pro- portion of consumptive casei; the situation of its prevalence varying with the age 364 TUBERCULOUS DISEASE OF THE LUNG, OR of the subject. Thus Papavoine found it, in children especially to occur in the cervical and mesenteric glands, in the spleen, pleura, liver, and small intestines; less frequently in the peritoneum, large intestines; and rarely in other parts. In the consumptive cases above the age of fifteen, examined by Louis, tubercles were found in the small intestines in one-third of the whole; in the mesenteric glands in a fourth; in the large intestines in a ninth; in the cervical glands in a tenth; in the lumbar glands in a twelfth; in the spleen in a fourteenth, of all the cases; and in other parts in smaller proportions. In by far the greater number of cases, the tubercle in these different parts seems to be of more recent date than those in the lungs. The intestines are very commonly more or less ulcerated in pulmonary con- sumption. Louis found this lesion in five-sixths of his cases; and in the large in- testines, besides ulceration, there were thickening, softening, and increased redness; and out of the whole number which he examined, in three instances only were the large intestines found quite healthy. The liver not uncommonly pre- sents a very peculiar appearance in phthisical subjects. Louis remarked, that in two-thirds of his cases the stomach was remarkably distended, sometimes acquiring double or treble its usual size, and reaching down to the pubis; a condition rarely to be met with in other diseases. A very remarkable change is often found in the liver of phthisical subjects, caused by the deposition of a kind of fatty matter in its structure. The bulk of the organ is generally increased; it is softer than usual, and of a paler colour, and on being cut greases the knife, or more evidently shows its oily quality on a slice of it being heated on paper. This state of the liver does not occur in all cases of phthisis, and is more common in females than in males: it is found in rapid as much as in prolonged cases. The function of the liver does not seem to be much impaired by this change, for the ducts contain bile as usual. Pathology of pulmonary tubercle. The characteristic changes which anatomy discovers in the lungs of the consumptive, may for the most part be reduced to two. 1. Consolidation, generally indurated, either almost colourless and semi- transparent, or pearly gray, or reddish drab, or of a dark red or more dingy colour. 2. An opaque yellowish-white or parsnep-coloured friable matter, of various de- grees of consistency, being first more or less hard, and afterwards becoming soft and forming vomicae: this lighter opaque matter, which is properly called tuber- culous, is produced commonly within the consolidations just named, but some- times elsewhere. We proceed to advert shortly to the opinions of some eminent modern pathologists on the nature and origin of these lesions. Laennec considered tubercles, " accidental productions—that is, real foreign bodies—which spring up in the substance of the lungs, and may be developed in any other texture of the body." We owe great respect to the name of Laennec, but we must in candour confess that his views of the nature and origin of tuber- cle are neither satisfactory nor altogether intelligible. It may be collected from his writings, that tubercles are parasitical bodies originating in an unknown way, possessing a life and structure of their own, growing by attracting matter to them, and tending by their own inherent properties to go through a certain series of changes. The transparent miliary granulations of Bavle, the gray miliary tuber- cles, the gray diffused induration, and a kind of gelatinous infiltration, he looked on as varieties of these bodies in their first stage, and as all tending, per se, first to become opaque and yellow, or crude tubercle, which is still hard; and after- wards to soften into a cheesy or pasty liquid, which is the mature tubercle. Now this view involves several assumptions little supported by analogy;__for instance, that bodies so different in physical character and texture are the same; and that the stages through which they pass are produced by assumed inherent properties, and not by the modified properties of the tissue of the organ;—and it farther as- sumes what has been disproved by extended observation,—that the opaque yel- low tubercle is always preceded by the gray or semi-transparent, and that the gray induration must always in time become yellow tubercle. Whilst we admit the PULMONARY CONSUMPTION, (Pathology.) 365 accuracy of Laennec's observation, that the gray and semi-transparent indurations tend generally to become yellow tubercle, we must consider his view of the change to be too hypothetical and unsupported to be received as satisfactory. The view of M.'Andral is far more simple, and involves fewer assumptions. He considers tubercles generally to be the result of a modified nutrition of the textures; and that they are produced and go through their changes by the agency of the vessels of the part, and the blood which circulates in them. Although he admits that the miliary and diffused indurations precede the production of yellow tuberculous matter, he supposes them to be not an early stage of this matter, but the result of chronic inflammation affecting the individual vesicles, or the general texture. The chief peculiarity of this view is, the explanation of the regular form and size of miliary tubercles, by locating them in the individual air-vesicles, just as the same author first accounted for the granulations of a hepatised lung. That the diffused induration, called by Laennec the first stage of tubercle, is the result of chronic inflammation, has been admitted by Chomel and Louis, who otherwise rather incline to Laennec's views. The most recent writer on this subject is Dr. Carswell, who has developed his views in his admirable Illustrations of the Elementary Forms of Disease. He neither adopts the opinion that the indurations are an early stage of yellow tuber- cle, nor does he admit that they are more than accidentally connected with it. He supposes yellow tubercle to be a peculiar secretion, which takes place espe- cially from mucous membranes; but that it may accompany other secretions, such as that of inspissated mucus in the air-vesicles, or of dense false membranes on the pleura or peritoneum; and thus he accounts for the gray miliary bodies with specks of yellow tuberculous matter, and the similar admixmre of this matter with deposites on serous membranes. But on minutely examining the miliary granu- lations of the lungs, we find no inspissated mucus in them to account for their hardness; the induration is obviously in the texture itself, and not merely con- tained within the cells. Dr. Carswell's view, therefore, throws no light on the manner in which yellow tubercle is produced in the gray or dark indurations, whether miliary or diffused; yet this is a point as well established as any in the pathology of phthisis. It would take more space than we can spare, to enter into farther particulars of the different opinions which have been held in regard to tubercle. If we consider the subject of the pathological changes of the lungs in phthisis, rationally, and in connexion with what we have learnt of those in other textures, and other diseases, we may hope to attain a more consistent and satisfactory view of the subject. The researches and opinions of Professor Alison have led the way in this inquiry, and we are indebted to him for some of the succeeding observations. If we examine the induration that commonly precedes the production of yellow tubercle, we find that it differs from the healthy structure, certainly in these re- spects,—that it contains a greatly increased quantity of matter, and that this mat- ter is generally harder than the healthy tissue. Now, this increase of substance implies either increased secretion or diminished absorption: that absorption is not diminished in the tissue, is plain, from the fact that portions of the healthy tex- ture are at the same time removed by this process, around the indurations; and that increased secretion is present, is proved by the fact, that the indurated tex- ture presents new characters, and is not a simple accumulation of the matter of the natural tissue. Now, to produce an increase in the nutritive secretion, there must> according to a well-established pathological law, be an increased determi- nation of blood to the part. Let us now inquire, whether increased determination of blood in other cases leads to the production of matter like that of the indura- tions; and as the most distinct form of determination of blood, we first take inflam- mation. In treating of pleurisy, we found that acute inflammation of the pleura, causes an overflow of the nutritive secretion, in the form of coagulable Ivmph, which mav soon become well organized into a soft cellular or serous membrane; but when 366 TUBERCULOUS DISEASE OF THE LUNG, OR the inflammation is of a lower and more chronic character, the effused matter is slower in the process of organization, and forms a harder texture of lower vita- lity ,—a kind of fibrous or fibro-cartilaginous structure. The same observations will apply to the parenchyma of the lung. The overflow of the nutritive secre- tion, caused by acute pneumonia, we have found to constitute red hepatisation, whether granular or diffused; but on examining the effect of lower and more pro- longed inflammation on the tissue of the lung, we formerly described a dark con- solidation with increased density, in no essential particular differing from some forms of the indurations of phthisical lungs. Thus the hard, compact, granular consolidations occurring around excavations, gangrenous as well as tuberculous, and admitted, even by Laennec, to be the result of chronic inflammation, has some- times the colour and consistence of the indurations which precede the formation of yellow tubercles; and as we have shown th^t there is a non-granulur form of acute hepatisation, so it is reasonable to expect that there may be a uniform or diffused kind of consolidation, resulting from chronic inflammation, affecting the interstitial more than the vesicular tissue. To such a condition, the gray dif- fused induration, called by Laennec the first stage of tubercle, so exactly answers, that Andral, Chomel, Louis, and Carswell, all concur in considering it a chronic form of hepatisation. When it is the sequel of the acute disease, or of long con- tinued pulmonary congestion, there is often much redness in the induration; but where the irritation has been of long continuance, and unattended with the more sthenic degrees of vascular action, or a very congested state of the lung, the tex- ture is more semi-transparent, dense, and gray, or variously modified by the black pulmonary matter in it. The more uniform or colourless masses occasion- ally present, may be fraced to be the interlobular septa, or cellular tissue around the vessel, in a state of indurated hypertrophy. In these bloodless and almost carti- laginous portions, we see the exact characters of the matter of which the mi- liary granulations or gray miliary tubercles are minute samples; and if we adopt the view of Andral, that the regular size of these depends on the chronic induration being located in the coats of individual vesicles, we shall see a sufficient reason for their being regular in form, and isolated or in clusters. Moreover, as we have traced the diffused consolidations of the lung through various gradations, from acute soft red hepatisation, down to gray induration, so M. Andral has found the miliary bodies presenting the same gradations, being sometimes soft and red, in other cases, livid and harder, whilst the same lung may contain also the granulations similar in size, but pale or gray, and of different degrees of induration. We have twice met with the more rare transparent miliary granulations of Bayle, on the pleura and peritoneum, in conjunction with dense false membranes, and without any yellow tubercles there or elsewhere. As to the common pale granular de- posites on serous membranes, they are the acknowledged products of chronic in- flammation, and their numbers and circumscribed form constitute another point of resemblance to the miliary indurations, which in the lung pass into the state of yellow tubercle. Without, then, going so far as to assert that the miliary indura- tions of the pulmonary tissue are always dependent on chronic inflammation, we may fairly say that both they and the diffused induration are more akin to the products of this process, than to any other that we are acquainted with. The condition of the blood we found to be a material element in determining the products of inflammation in the case of pleurisy; so, doubtless, it is likewise concerned in the modified putritive secretions of other textures. The more vital and organizable products are furnished by blood rich in fibrin ; and they are easily re- absorbed; or if organized, are mobile, and sufficiently like the tissues of the part, not to incommode or irritate them. But if the blood be poor in nutrient matter, the deposite from it may be susceptible of only a low degree of organization, and will consequently be not only more difficult of absorption, but less assimilable to the texture of the part, and more calculated to irritate it as a foreign body. It will thus appear, that although the lowest degrees of inflammation may be alone capable of producing the chronic indurations, when the blood is healthy, vet. PULMONARY CONSUMPTION, (Pathology.) 367 when it is diseased, various degrees of inflammation or congestion—nay, even the ordinary nutrient process, without hyperaemia, may be accompanied by the deposition of a lymph of degraded character, and organizable only into a dense semi-cartilaginous tissue. The semi-transparent gray or dark induration is always converted into crude yellow tubercle. Sometimes it is the seat of vomica* which contain a dirty or bloody pus; and, although even in this the curdy matter of tubercle is sometimes seen, it is plain that these vomicae result from a more distinct and speedy process of ulceration or irregular suppuration; another analogous result of continued irrita- tion in the condensed tissue. Let us now pursue the same inquiry with regard to the opaque pale yellow mat- ter which characterizes the second class of phthisical lesions. Laennec calls this the second stage of tubercle; but neither for its formation, nor for its -subsequent softening, does he assign any other cause than an assumed and unintelligible " inherent property." Dr. Carswell is more explicit on this point; and all his de- scriptions of tubercle apply only to this kind of matter. He considers it to be a secretion sui generis, totally destitute of organization; an effete matter, conti- nually separated from blood in an unhealthy state; thrown out chiefly on the free surface of mucous membranes; and producing bad consequences only in pro- portion as it accumulates in organs, impedes their functions, and acts on them as foreign matter. This opinion, so far as it relates to the nature of tuberculous matter, does not differ materially from that long since published by M. Andral, who regards tuberculous matter as a peculiar secretion, formed under the influence of a particular diathesis or condition of the blood, and especially in connexion with an irritation, inflammation, or congestion of the blood-vessels of the part. If we survey the general characters of tuberculous matter, consisting of pale opaque albuminous particles, generally deposited in a tissue previously consoli- dated, and the manner in which it tends to become liquid, forming circumscribed collections, like abscesses, or infiltrated through the texture, from which it is expelled like foreign matter, we cannot fail to see some general resemblances to the process of suppuration. We have found that the consolidating lymph of a hepatized lung becomes opaque and light-coloured before it softens into pus; but the changes here are too rapid to admit of their being fully watched. But when an analogous process goes on more slowly, and in a simple structure as the pleura, we can better trace the resemblance. Thus, in the latent and more protracted forms of pleurisy, the lymph first effused forms a dense tissue of low vitality, and resembling cartilage in hardness and colour. If the irritation still continue, this new structure throws out a lymph of still lower vitality, in friable shreds, and in some instances in form of a curdy matter, totally incapable of organization, which, mixing with the effused serum, constitutes one kind of em- pyema. Now such a process in the pulmonary tissue would resemble all the changes which we have been describing in the production successively of the gray induration, crude tuburcle, and softened tubercle. Thus a portion of this tis- sue (whether a single vesicle, or part of a lobe) generally under the influence of chronic inflammation, or local congestion, becomes indurated by the effusion of lymph susceptible of a low organization. The original irritation continuing, or the very induration itself determining an increased flow of blood to the part, the new structure evolves, in the looser parts of its substance, a still less organic form of albuminous matter, a pale, opaque, curdy substance; but as this cannot be (like that from the pleura) thrown off, it presses on its indurated matrix, and, causing its absorption, accumulates in its place: thus is effected the conversion of the gray induration into crude yellow tubercle. This entirely inorganized sub- stance, acting as a foreign body on the abjoining tissues and the remains of the living texture within it, causes irritation, ulceration, and the effusion of serum and pus, which, as M. Lombard first explained, softens and breaks up the crude tu- bercle into the curdy grumou* matter of the mature tubercle. The same irrita- 368 TUBERCULOUS DISEASE OF THE LUNG, OR tion and ulceration gives vent to the matter through one or more bronchial tubes; and thus are formed the tuberculous cavities. But we have seen that yellow tuberculous matter is produced not only in the gray indurations, whether granular or diffused, but also in softer consolidations like that of hepatisation. It is sometimes seen in rounded circumscribed masses in a hepatised lung; in other instances, it pervades, with its opaque yellowish- gray or mottled colour, a whole consolidated lobe. In this—the infiltrated tu- bercle of Laennec, the gray hepatisation of Andral—there are often here and there cavities containing a curdy pus, and communicating with the ulcerated bronchi. There are also occasionally found in it circumscribed indurations and tubercles of older date; but in other instances, no other form of chronic lesion is present, and the lung has the appearance of inflammatory engorgement in some parts, of common red hepatisation in others, whilst other portions of the same consistence have the opaque yellowish colour of tubercle; and these conditions pass by such imperceptible gradations into each other, that it is impossible to avoid the conclusion that they are parts of the same process. We see a similar variety sometimes poured out by the inflamed pleura, where one part is covered with good lymph, another with a curdy matter like crude tubercle, whilst many albuminous particles, also in an unorganizable state, are thrown off with the liquid into the sac. So, also, in the very masses of coagulable lymph that an inflamed pleura or peritoneum throws out, there have been found distinct puru- lent and tuberculous deposites. Nor is this surprising, when we consider that lymph, pus, and tubercle are the same albuminous matter, and differ from each other in mechanical condition, and susceptibility of organization, rather than in their chemical nature. According to the microscopic researches of Gendrin, part of which we have followed, lymph is composed of regular globules, which by a vital attraction, string themselves into fibres and films, which may become or- ganized and form membranes. Pus consists of larger and less regular globules suspended in serum; but these globules have no vital attraction for each other, and remain loose, and consequently insusceptible of farther organization. Tuber- culous matter is wholly devoid of organic form; its particles not even being globular, but irregular, like those of mere dirt or clay; and it must remain where formed, a dead inert mass, until decomposed by chemical agency, or changed by the operation of the surrounding tissues. It is obvious that these different pro- perties, although possessed by matter chemically the same, and from the same source, may lead to all that variety of results which we know to follow organiza- ble, purulent, and tuberculous deposites. But the characters of these matters are not always distinct; lymph is not always equally organizable; nor is it always free from the greenish colour and less coherent globularity of pus, nor even from the lifeless curdy particles of tubercle; and tuberculous matter often contains flakes or films of imperfect lymph. The diffused tuberculation or infiltration of the lung from inflammation, lately noticed, generally presents matter in this transition state. It is neither good organizable lymph, nor wholly unorganized tubeicle; and the albuminous effusions on serous and mucous surfaces not unfre- quently present such an intermediate state, that it is difficult to determine to which class they belong. But, lastly, we have found that tuberculous matter is sometimes deposited in tissues bearing no marks of inflammation or other disease. The structures thus affected are commonly those either very vascular naturally, or peculiarly liable to congestion of blood; and viewing tuberculous matter as a deposite of unhealthy fibrin from the blood, we see a reason, as Dr. Carswell observes, why it is most likely to be found in those organs where the blood accumulates or passes slowly. Whatever be the cause which in these cases determines the deposite of tubercle, we know that pus also is sometimes secreted in parts unaffected with inflamma- tion, as in the purulent deposites in the viscera after injuries or surgical opera- tions; and in the profusp purulent discharges from the bronchial membrane, PULMONARY CONSUMPTION, (Pathology.) 369 where it is found after death free from all trace of inflammation; nay, something like pus has been found in the blood and in the centre of fibrinous coagula in the heart, when no suppurating surface existed in the body: so, likewise, tubercu- lous matter has been met with in coagula in the heart, spleen, and blood-vessels. This tends to show that the fibrin of the blood is liable to be converted into tubercle independently of any action of the vessels; it loses its vitality, and may in proportion be merely deposited in tissues or on surfaces, independently of irritation. Here, again, as with the gray indurations, we are led to trace to the condition of the blood one cause of consumptive disease of the lung; and it is probably a diseased state of this fluid that constitutes what is called the tubercu- lous or scrofulous diathesis, in which there is a tendency, by vessels in different degrees of activity, to deposite tubercle instead of lymph; and when this diseased state exists to a great extent, the tuberculous matter is excreted from the blood without any increased vascular action, and merely as an accompaniment of the natural secretion of a membrane, or instead of the ordinary nutriment deposite of a tissue. Whatever, in such cases, determines the first deposition of tubercle in a tissue, will with greater facility effect its increase, by the addition of similar matter to a ready-formed nucleus. The tendency to the deposite of yellow tu- bercle independently of irritation, implies a condition of the blood even more depraved than that which leads, under the same circumstances, to the formation of the chronic indurations; it is an ulterior degradation of the fibrinous nutriment of the tissues, replacing them by a matter not merely inapt in texture, and of lower vitality, but wholly destitute of life, the principle of organization. When, therefore, tuberculous matter is found in an uninflamed tissue, it may be regarded as a sign of the most decided constitutional taint. In such conditions of the sys- tem, tuberculous depositions may take place with great rapidity; and as they are already almost ripe for elimination, the ulceration and destruction of the lung will soon follow. But nothing can give development to the tuberculous disease with such fearful rapidity, as the occurrence of acute inflammation in the pul- monary tissue. It is, we believe, from this process in a highly tuberculous con- stitution, that the general tuberculous consolidation, called infiltrated tubercle, takes place. The matter deposited is often a mixture, or intermediate state of lymph and tubercle, one product predominating in some parts, and the other elsewhere; but it is altogether beyond the reach of the sorbefacient remedies, which avail in pneumonia to promote the absorption of simple lymph; and if it do not destroy life by its solid interference with the function of the lung, it speedily runs in many points into softening and suppuration, and the patient is carried off by a galloping consumption. In this case the lungs are found exten- sively solidified, and, on incision, incipient cavities are seen almost in every part; but there is no induration; the most solid parts have scarcely more sub- stance than a hepatised lung, and they even more readily break down under the fingers. The development of the indurations is a work of more time; and their structure makes the destructive process which they induce more tardy; nay, the diffused indurations which form the walls of softened tubercles and vomicae seem to be a provision of nature against the spread of the consuming disease; but under certain circumstances, even the indurations are formed to such an extent and so soon, that the patient is destroyed by their first development, or rather by the effusion of mucus or of serum which they excite. In most cases, the first formation of granulations is not sufficient to prove fatal; but as some of these are becoming changed to tubercle and vomica?, another deposition or crop of them (as Laennec terms it) takes place and causes suffocation. After what has been stated, it will hardly be necessary to discuss the question of the seat of the hard gray and the yellow tuberculous deposition. If the tuber- cle be, as we suppose, a degraded condition of the fibrin or nutrient principle of the blood, we may expect it to be deposited wherever the nutritive or the secreting process is carried on, wherever lymph or pus is occasionally found,—wherever, Vol. II.—47 370 TUBERCULOUS DISEASE OF THE LUNGS, OR in short, blood-vessels run. We cannot assent to the opinion of Dr. Carswell, that tuberculous matter is in the early stage of the disease secreted in equal abun- dance from all parts of the mucous membrane, and that the only reason why it accumulates sooner and more in the upper lobes is, that their smaller extent of motion prevents its perfect elimination from those parts; were this the true view, how easy would be the diagnosis of consumption in its earliest stage ! For there would be abundant expectoration of tuberculous matter from the lower lobes, whilst the accumulation takes place in the upper; yet it is rare to see any expecto- ration in the earliest stage, except a thin transparent mucus. More probable is the opinion of Broussais, that the upper lobes are the first and most exten- sive seat of tuberculous change, because the bronchial tubes are shorter, and more readily permit inflammation and irritation to pass to the cells. But we apprehend that the real reason of their peculiar liability is in the greater abundance of intersti- tial tissue in them. The bronchi, instead of being lengthened out into mere mem- branous tubes before they terminate in cells, divide more immediately and ab- ruptly into short branches and cells; and the delicate vesicular structure is thus mixed up with a good deal of the interstitial cellular tissue that every where sur- rounds the earlier bronchial divisions. The smaller capability of motion possessed by the upper lobes of the lungs may, too, have a share in disposing them to become the seat of tubercular deposite, not by permitting it to accumulate, but by favour- ing bronchial obstructions to the respiration, and causing local congestions of blood, which may promote the formation of tubercles. It is not the yellow tuber- cle chiefly that predominates in the upper parts of the lung; it is rather the gray indurations which become afterwards converted into yellow tubercle. Primary tuberculous deposites are nearly as common in other parts of the lung as at the apex. We have described the ordinary changes of tubercle from its primary deposi- tion to its softening and evacuation, and the formation of an ulcerous cavern. These caverns become, if life last, lined with a deposite of a mixed nature, but with an albuminous lymph for its basis; and this is commonly mingled with tu- berculous and purulent matter. Hence it seldom lasts long, but is broken up, detached, and expectorated. When the constitutional powers are stronger, and the lung less extensively diseased, the coating of the cavity is susceptible of organization, and in time forms a fibrous or fibro-cartilaginous membrane which pretty smoothly lines the cavity. If the cavity communicate pretty freely with the bronchi, it will be kept by the pressure of the air from any considerable con- traction to which it naturally tends: but in some instances the tubes become ob- structed, and the membrane contracts, and tends to obliterate the cavitv, some- times leaving only a cicatrix. Such contracted cavities and cicatrices are not unfrequently met with in the lungs of old people; but they are rarely quite empty; they contain more or less of a pale yellow plaster-like matter, consisting chiefly of carbonate and phosphate of lime; and sometimes there are concretions of the same matter. The contraction is evident from the puckering of the pulmonary tissue visible on the pleural surface near the cavity, and some of the adjoining vesicles are generally dilated to fill up the space. There are often, also, some remains of gray induration around them. The cretaceous matter is probablv se- creted by the walls of the cavity; but it may be the debris of tuberculous or puru- lent matter, the animal matter being absorbed away, and the earthy insoluble salts left, accumulated from successive depositions. This earthv matter is sometimes connected with an earlier stage of tuberculous formation. We have, in lungs not extensively diseased, found pale yellowish tubercles, composed of concentric layers of almost cartilaginous hardness; in another part of the same lung, these layers are loosened by a plaster-like gritty matter of a calcareous nature; and in another part a whole tubercle may consist of this, having only a few flakes of albuminous matter in it, and sometimes containing concretions. This more resembles what is commonly called the atheromatous structure, which especially invades the coats of the arteries and the fibrous parts of the valves of the heart. It is to be classed with gray and yellow tubercle, in so far as it is another variety pulmonary consumption, (Symptoms.) 371 of matter, low in the scale of organization, and formed of lymph of defective vitality. In these latter cases there is no puckering or contraction about the tuber- cle until it has evacuated its contents; which it is very slow to do; for it has not the tendency to soften and cause ulceration that makes common scrofulous tuber- cle so destructive. We have repeatedly seen a few of these tubercles in lungs otherwise healthy, the individuals having died of some other disease. Symptoms. As -we have made the anatomical and pathological changes of phthisis the basis of our description of this disease, it will be convenient and in- structive to classify, as far as we can, the symptoms, in reference to these changes. The course of consumption is generally divided into three stages, according to the state of the lesions of the lungs. The first stage is that of the formation of the indurations, grannular or diffused; the second is that of the conversion of these into yellow tubercle, with the extension of this lesion to other parts; the third is that of their softening and evacuation, and the formation of vomicae. First stage. The symptoms produced by the indurations may be divided into those of irritation, and those of obstruction. The indurations are generally accompanied by various irritations, both local and general. Of the local irritations, the earliest is cough, which at first is gene- rally slight and merely hacking, but more or less constant; at least, although it may not be frequent, it does not cease for a whole day together. It is either dry, or accompanied by a thin transparent expectoration. Another occasional sign of local irritation is pain in the chest, commonly referred to the sternum: in some instances it is a stitch in the side; sometimes it is a soreness, or an unusual sensi- bility to cold or exertion, more than actual pain; not unfrequently it is absent. These varieties of pain are sometimes merely irritations; but not unfrequently they are the result of real local inflammation, excited in the lungs, the bronchi, or the pleura, by the indurations. Of the more general irritations, quickness of the pulse is the most constant; but even this is not universal. The quickness is often not uniform at first, but depends on any cause of excitement, however trifling; and the pulse may be very slow and weak in the intervals: but as the organic lesion increases, it gradually becomes more constant, and is accompanied by an irritated state of other functions;—a general febrile state. But even then there is not power enough in the circulation to maintain a general or constantly increased heat; it is manifested most towards night, after the accumulated excite- ments of the day, when the fulness as well as the frequency of the pulse increases, and there is a flushing of the face and heat in the palms of the hands and soles of the feet, where the thickness and hardness of the cuticle prevent the perspira- tion and evaporation which moderate the temperature of other parts. Like other weak and intermittent febrile movements, this generally terminates by perspira- tion more or less profuse, which, occurring in the night, leaves the pulse lowered, but the frame weakened and exhausted in the morning. It is only in the severe cases that this general irritation, or hectic fever, as it is termed, becomes marked at this early stage of the disease. Often there is gastric irritation, with a white tongue, red at the edges, thirst, costive bowels, and turbid urine. These symp- toms are generally more remarkable in this than in the after stages, when the irritation is more confined to the organs of circulation and respiration. They are almost always attended by some diminution of flesh and strength, which", how- ever, varies greatly in degree in different instances. The symptoms from obstruction comprehend those from obstructions to the passage of the air, to that of the blood, and to the motions of the lungs in respi- ration. The indurations, granular and diffused, when extensive, by obstructing the passage of air to more or fewer of the air-cells, cause the shortness of breath, felt at first only on exertion, so common even in the early stage of consumption. Nay, cases happen, in which an abundant formation of miliary tubercles, together with the oedema, or bronchorrhcea, which they excite, prove fatal in the first stage, by the obstruction which they cause to the passage of the air. In such cases there is generally considerable fever, with short frequent cough, very quick 372 TUBERCULOUS DISEASE OF THE LUNG, OR pulse, and heat of skin, with other symptoms resembling an acute attack of bron- chitis or pneumonia; for which they may be mistaken, but for the less sustained character of the fever, the greater permanency of the disorder of the respiratory organs, the physical signs, and the expectoration, which, instead of exhibiting the peculiar aspect of that of pneumonia, or the successive changes of that of bron- chitis, continues mucous and frothy, sometimes abundant, but often in small pro- portion to the cough and dyspncea. Partial indurations sometimes cause short- ness of breath, not only by their direct impediment, but also by occasioning a dilatation of the air-cells. The indurations, by obstructing the blood-vessels, give rise to many formidable pathological effects. They may thus cause sanguineous congestion, haemorrhage, inflammation, oedema, gangrene, and atrophy of the pulmonary texture, haemop- tysis, profuse bronchial secretion, effusion into the pleura, disease of the heart, &c; and the symptoms which these lesions produce may be variously grouped in the history of different cases of phthisis. The haemoptysis occurring in the early stages of phthisis is generally from this cause; and it is a serious symptom, not only because it may endanger life by loss of blood or direct suffocation, but also because it is often accompanied by haemorrhagic consolidation and rupture of the texture of the lung, which tend to accelerate the disorganizing process, and promote the farther deposition of tubercle. In some instances, however, haemop- tysis is followed by decided relief to the dyspncea and cough, having removed a congested state of the blood-vessels. Obstruction to the motion of the lungs may be caused by the same circum- stances which impede the free admission of air to them; but in case of extensive solid deposition, it may also result from their mechanical resistance to the mo- tions of the chest; and this not only constitutes a phthisical sign, which we shall hereafter consider, but it also keeps the intervening unaffected tissue in a fixed state, liable to constant congestion and farther deposite, and thus adds farther to the incapacity of the organs. When once the integrity of a nicely adjusted ap- paratus like that of respiration is extensively injured, disorder begets disorder, and unless the counteracting or respiratory powers soon come into operation, un- less the indurations are soon diminished, or the blood-vessels closed, the whole of that part of the lung may soon become a solid mass. Thus, we believe, some- times arise those extensive masses of induration which are so commonly met with in the upper parts of the lung. Second stage. On the conversion of the gray or dark red indurations into crude yellow tubercle, and during the original deposition of this matter, besides the symptoms of irritation and obstruction, which still continue, there are indica- tions of increasing cachexia, languor, loss of flesh and strength, and a general depression of the functions. The pulse loses strength, although it is as frequent as before; the evening chills are more severe; the fever is of shorter duration; the sweats are more profuse. Except at times of excitement, the colour of the cheek fades, or is reduced to a circumscribed hectic patch: the expectoration be- comes more abundant, or less thin and transparent, and particles of curdy or cheesy matter can sometimes be detected in it; occasionally it is streaked with blood; and in a few cases there may be haemoptysis to a considerable extent. There is often less feeling of oppression or pain in the chest than before, but the shortness of breath on exertion is undiminished, if not increased; and there are frequently transient pains in the shoulder or under the clavicle of one side, which the patient commonly considers to be rheumatic. Third stage. The more truly consumptive symptoms which had begun to manifest themselves in the second st;ige, are developed fully when the tubercles become soft, partially or entirely liquid, and are evacuated, by the aid of the se- cretion and ulceration of the adjoining textures. Then comes on, in addition to the symptoms before described, a copious and heterogeneous expectoration of pus, mucus, softened and occasionally solid tubercle, blood, shreds of lymph and rarely portions of pulmonary tissue in a sloughy fetid state. Then occur the usual pulmonary consumption, (Symptoms.) 373 constitutional concomitants of extensive unhealthy suppurating ulcers, confirmed hectic with its successive chills, heats, and sweating, occasionally diarrhoea, and the increasing marasmus, in this case rendered more pronounced by the importance of the organ affected and the relations which it bears to the process of sanguifica- tion. Then are the dyspncea and cough increased by the continual discharge of matter into the air-passages, and by the extension of the diseased depositions and ulcerations of the tissue. Yet it is a curious circumstance, that these symptoms are often inconsiderable in proportion to the terrible extent of the organic mis- chief which has been produced; the dyspncea often is not painful like that of asthma; it is a state of breathlessness rather than of distressing oppression; the cough is commonly less violent than in chronic bronchitis; the pain may be slight, or there may be none at all; the countenance, though thinned, tremulous, with the sharpened nostrils, habitually moving at every breath, may have a clear- ness in it, with colour in the lips, and a brightness of the eye which are never seen in other serious diseases; and the frame of mind is often in the same uncon- scious and hopeful state, indicating a degree of freedom from those painful strug- gles in which the vital powers commonly contend with other serious disorders. Now, we apprehend the chief reason for this exemption from suffering lies in a sort of balance that is maintained among the injured functions. The available parts of the lungs are reduced to a great extent; but so is the mass of blood that has to pass through them. The free expectoration and the colliquative discharges from the skin and bowels are continually bringing down the bulk of the circulating fluids to the lessening capacity of the remaining lung. The night sweats, espe- cially, are a periodic discharge of the amount of fluid which is beyond what the reduced system of blood-vessels can quietly hold; they often cease when the fluid ingesta are judiciously reduced. So the secondary pulmonary irritations, conges- tions, and inflammations are continually relieved by the purulent expectoration; it is a safety valve which gives vent to these local lesions before they cause much distress; and although the destructive process is perpetually proceeding, the lungs decaying, the body wasting, and the strength failing, yet it is all by even degrees, afecilis descensus: the thread of life dwindles away, fibre by fibre, without struggle or shock; and gentle is the parting of the last filament, when the body drops to earth and the soul rises to eternity. But the progress of consumptive disease is by no means generally thus painless and unharassed: the sufferings from dyspnoea, cough, pain, chills, heat, and feel- ings of extreme weakness and faintness, are sometimes very severe. In some persons, the animal sensibihty is more acute than the organic life is active; to such, any disorder is distressing; and even in consumption, the cough, the pains in the chest, side, or shoulders, the alternate chills and heats, the oppression of dyspncea, the languor and faintness of debility, besides various pains and aches in different parts of the body, are perpetual sources of complaint. But without any unusual sensibility in the subject, the course of consumptive disease may be rendered rough and painful by what may be called the accidental or accessory lesions, con- tingent upon it. Intercurrent congestions, hemorrhages, and inflammations taking place in the lungs or in their investing membranes, are very common, and may give rise to the symptoms of these several acute lesions superadded to those of phthisis. Hence the increase of cough, dyspncea, and fever, occasionally with pain, in case of bronchitis, pneumonia, or pleurisy, occurring in the course of the disease; and haemoptysis, with the faintness and other effects of loss of blood, if this be considerable, or with greatly increased oppression if the effusion is more confined to the tissue of lungs. We can confirm the observation of Dr. Stokes, that free expectoration tends to prevent these accidental complications; and accor- dingly their occurrence is often preceded or accompanied by a suppression of this discharge, or an alteration in its quantity. But there is an accident which especi- ally tends to ruffle and hasten the course even of the most latent forms of con sumptive disease; this is perforation of the pleura, and the consequent pneumotho- rax and acute pleurisy which it produces. As we have already described this 374 TUBERCULOUS DISEASE OF THE LUNG, OR lesion and its symptoms, we need here only remark how characteristic the^ sudden increase of dyspnoea and cough and accession of sharp pleuritic pain must beim the cases that were before most insidious, and how much the addition ot these lesions must increase the distress of the patient and hurry him to^ardtshph^f.^ Spontaneous perforation of the pleura seems to occur chiefly where the constitu- tion is decidedly tuberculous ; and it implies a want of that self-preserving energy bv which the mischief of ulceration is bounded by the timely effusion of plastic lymph This is a part of the nutrient function; and perhaps it is because this function is more active in women than in men, that perforation of the lung is com- paratively rare in females. Such, at least is the result of our experience, not having met with one instance in about thirty cases of this complicated lesion that have fallen under our observation; and there are very few instances recorded by others of its occurrence in females. In a few instances, the perforation appears to have been the result of adhesions partially attaching the lung to the walls of the chest, and thus exposing it, in case of external violence or internal pressure, to a lacerating force, as noticed under the head of pneumothorax. Other symptoms unconnected with the chest frequently attend pulmonary con- sumption. The larynx is very often the seat of disease, and hoarseness or loss of voice is frequently an early symptom, sometimes taking attention from the seat of the more important lesion. It appears from the researches of MM. Trousseau and Belloc, that ulceration and other structural disease of the larynx do sometimes occur when there are no turbercles in the lungs ; but these are very rare cases, and in by far the majority of instances these lesions are associated with tubercu- lous disease of the lungs, and perhaps in all are connected with a tuberculous con- stitution. Dr. Stokes considers this complication to be universally fatal; but it is not always speedily so, for we know at present three instances in persons now alive of its having lasted from five to eight years. The disorder of the digestive organs, which, in the earliest and irritative stage of the disease, had something of the gastritic character, with red-tipped tongue, thirst, sometimes pain or oppression after eating, occasionally tenderness of the epigastrium and other symptoms of indigestion, generally passes away as the pul- monary irritation is relieved by the discharge. In a few instances, occasional severe pain of the stomach, and vomiting, continue to the fatal termination, greatly adding to the distress and weakness of the patient In most instances, sooner or later, the bowels become disordered; constipation and diarrhoea alternately prevail, depen- dent on inflammation and ulceration, often complicated with tuberculous deposi- tion in the follicular structure of the mucous membrane of the intestines. The mesenteric glands frequently become involved in the same disease, particularly in young subjects; and thus arise additional causes of exhaustion and atrophy, in the colliquative discharges and obstruction to nutrition that ensue. There is often but little pain with all these serious lesions. The alvine secretions sometimes show a deficiency of bile; but this is a symptom which more frequently precedes phthisis than accompanies it. Sometimes there are great tenderness and even pain in the abdomen during the whole course of the disease, with occasional exacerbations; these symptoms generally depend on granular or tuberculous depositions on the peritoneum, combined occasionally with inflammation of the membrane, which may lead to the agglutination together of the folds of the intestines. More rarely tubercles occur in the brain or spinal marrow, or their membranes, and cause symptoms of mental disorder, convulsions, or paralysis. Acute hydro- cephalus seems to have connexion with scrofulous or tuberculous disease farther than what can be traced to the existence of tubercles in the encephalon; for it sometimes coexists with tuberculous disease in other parts, when none can be de- tected in the brain. The catamenia, in females, are generally defective, or absent, at an early stage of consumptive disease; but they are not so constantly so as Laen- nec supposed. Their suppression is, on many accounts, an unfavourable sign- We have not space to dwell on the details of other symptoms arising from the irri- tations or obstructions, the weakness or the wasting, which tuberculous consump- pulmonary consumption, (Physical Signs.) 375 tion brings in its train. The emaciation in the last stages is very great, especially in the less acute cases; yet it is surpassed by that from scirrhus of the stomach, and tabes mesenterica. There is a blanching with emaciation, which is more re- markable than its degree; the blood-vessels are reduced, as well as other textures; hence it is rare in tuberculous consumption to see the redness of the knuckles, and distinctness of the veins of the hands, which accompany even greater degrees of emaciation from chrome diseases of the abdomen. Physical signs. We proceed to trace the physical signs in the different stages of the textural lesions which we have described as the essential causes of pulmonary consumption. First stage. In proportion as the indurations which characterize the first stage are of great or small amount, and are concentrated within a small space, or scat- tered widely through the lung, they will produce more or less appreciable signs. Thus, the miliary indurations, even in considerable number, may be scattered through the tissue of the lung without producing any distinct diminution or change in the respiratory sound, or in the resonance of the chest on percussion. Some- times there is a general sub-mucous or sub-crepitant rhonchus; but this proceeds less from the tubercles than from the secretion which their irritation causes in the bronchial tubes: it is the sign of a partial bronchitis or bronchorrhoea, therefore, and can be taken in evidence of the probable presence of tubercles, only when it continues permanently, or recurs in the same places day after day, instead offend- ing to become sibilant, and to cease, as the rhonchi of common bronchitis do. But it seldom happens that even the early indurations are equally scattered through both lungs. Their tendency is to accumulate in greater numbers in little clusters near the apices of the lungs, and generally more on one side than on the other. Here there will be a concentration of their effect, and an inequality between the two sides of the chest; and on exploring the corresponding regions outside, which are the clavicles and the space below them, and the upper ridge of the scapulae, we may find differences in the sound on percussion, or those of respiration, and the voice, which, according to known principles, may be interpreted as signs. The clavicle on one side, when lightly struck downwards on its centre, yields a sound duller than that on the other; and especially if this difference extends to the other parts just mentioned, it is exceedingly probable that there is consolidation of the lung in that part. Great care must be taken to strike both clavicles at the same point, or both infra-clavian spaces in the same mode, or the comparison will not be a fair one. To avoid error, the parts should be quite uncovered; and va- rious kinds of percussion should be tried in doubtful cases, as tapping with a sin- gle finger, and with the flat of several fingers, and in different stages of the respi- ratory act, on a full breath, and after exhausting the lungs. Sometimes the gen- tlest possible patting of the sub-clavian spaces is the only mode in which any diffe- rence can be discovered. In the posterior region, and on the scapular ridge, strong mediate percussion with the finger is necessary to elicit any sound, compa- rison being made, as usual, of the sounds on the two sides. Differences in the sounds are to be sought where differences ought not to exist; and although the mode and force of percussion should be varied at different times, they should be carefully the same in each act of comparison. Between the scapulae is not an un- frequent seat of dulness, especially in children, where the disease occupies the bron- chial glands. The eyes should likewise be used to scrutinize the motions of the chest, when the patient is placed in a good light opposite to the observer, and is desired to take a full breath several times. It requires more consolidation than is common in the more doubtful stages of the disease, to produce any considerable irregu- larity in the shape or motions of the chest; but we can often perceive a slight difference between the two sides; the upper ribs do not move quite so much on one side as on the other. The stethoscopic signs are more delicate, and, perhaps, more equivocal, than those of percussion. The indurations may form slight partial obstructions to the 376 TUBERCULOUS DISEASE OF THE LUNG, OR passage of air, and thus cause a permanent slight wheezing, whistling, or^rough- ness in the respiratory sound, not removed by full inspiration or cough, f more numerous or extensive, they may transmit the sound of whiffing or bronchial S?taparts'where naturall/the vesicular only is heard, whilst the soft vesi- cular brea hinff is impaired in its force. The sound of expiration may become unuLany audible, so as nearly or quite to equal that of the inspiration which naturally is almost the only sound heard in pure vesicular respiration When, as it often happens, the partial indurations are accompanied by a dilated or emphy- sematous state of the neighbouring air-cells, the sound of percussion will be less changed than usual; but the breathing will be more whiffing, or more obscure, according as the dilated cells are more flaccid or more ngid than usual. The sound of the voice is transmitted by the indurations in an unusual degree; some- times only in a diffused resonance; sometimes in a more circumscribed vocal note but without the articulation of the oral voice. So, also, below the clavicles, the sounds are sometimes transmitted with unusual clearness from the subjacent arteries being either double from those of the heart, or single from the mere im- pulse; and occasionally the single pulse is accompanied by a whizzing or blow- ing confined to the part, which, probably, indicates a partial obstruction of the sut)-clavian arteries by the pressure of indurations at the apex of the lung. This has been noticed by Dr. Stokes as a sign of incipient phthisis. It is not to be de- pended on, as such a murmur is not uncommonly induced in some healthy sub- jects under slight excitement, probably from the artery pressing on the clavicle or upper rib. It often intermits, being confined to certain stages of the respiratory movements. ,.*,/• ^ All the stethoscopic signs derive their importance directly from the situation m which they are heard, and from their comparison with the sounds of other parts. There are often natural bronchophony and bronchial respiration near the ster- num between the scapulae, and in the axillae: such signs in these parts, there- fore 'are not to be considered morbid, unless they be either much more distinct on 'one side than on the other, or accompanied by dulness on purcussion. They may be better trusted towards the humeral end of the clavicle: the angle formed by this bone and the shoulder is the proper stethoscopic corner, and the signs heard there, and at the humeral portion of the scapular ridge, are the most un- equivocal ; but even here a permanent discrepancy between the two sides gives the surest indication of disease, for the natural sounds present some variety. It is also necessary to bear in mind that the vocal resonance is often slightly louder on the right than on the left side. In the early stage of numerous diffused gra- nulations, there is sometimes dulness on percussion with obscure or sub-mucous respiration in the lower dorsal regions of the chest, probably dependent on con- gestion of the pulmonary plexus of vessels in these parts. = Besides the more direct physical signs of the indurations, the mucous or sub- mucous rhonchus caused by the secretion of the bronchial tubes, may render their existence probable when it continues long, or returns frequently to the same part. This observation was first made by Dr. Stokes, who has well remarked that this symptomatic bronchitis differs from simple bronchitis in being first circum- scribed and confined to the upper lobes, whence it may spread downwards; but before it reaches the middle and lower lobes, the common seat of ordinary bron- chitis, the tubercles in the upper become manifest by various obvious signs. The diagnosis of the early stage of phthisis is often a matter of extreme diffi- culty; depending, as it does, on a proper consideration of the general symptoms, as well as on a careful examination and interpretation of the physical signs, it cannot be mastered without considerable experience as well as tact on the part of the observer. Second staye. The conversion of the semi-transparent gray, or dark consoli- dation of the lung into yellow tubercle is a point only deduced from anatomical examinations, for there are no certain signs of this change during life. There is sometimes an abatement of the more irritative symptoms during this change, PULMONARY CONSUMPTION, (Physical SignSt) 377 and at the same time an increased expectoration, and the sub-mucous and mu- cous rhonchi become more marked. But the change to yellow tubercle can scarcely take place without some augmentation of the consolidation; the indura- tions increase in extent and some yellow tubercle is sometimes deposited in other parts. Hence there is often a fuller development of the signs of an increased density of the lung; the partial dulness on percussion becomes more marked; the respiration becomes more obscure or more bronchial, and it may be accompanied by a permanent fine crepitation. The vocal resonance may also increase is de- gree and extent, and altogether the signs become more localized, and therefore less equivocal. These, taken with the change in the general symptoms before de- scribed, may be taken in evidence that the consolidations have become more or less tuberculous. Third stage. But the softening and evacuation of tuberculous matter, produce the most remarkable and cognizable changes in the physical signs; and these also often give to the expectoration something of the precision of a physical^sign. The sputa before may have been sometimes opaque and muco-purulent, as in bron- chitis; but they now become decidedly purulent, often sink in water, and, if nar- rowly examined, may sometimes be found to contain particles of a curdy or clotted matter, like cheese softened in water, which is tuberculous; it is not foetid like the similar concretions from the tonsils. There may also be little streaks or even clots of blood; but this is uncertain. There is generally, besides, more or less mucus, which gives tenacity to parts of the expectorated matter; but on close examination, it may often be seen that some sputa are opaque purulent clots, almost without mucus; it is these which come directly from the cavities. In whatever part of the chest these changes take place, generally under one of the clavicles, or above the spine of one of the scapulae, there may be heard a click- ing or bubbling sound, which is coarser, and gives the idea of being produced in a larger space than any of the common sounds of these parts. This sign is the more conclusive, the finer and more completely vesicular is the natural structure of the lung in the part in which it is best heard. In listening for it the patient should be desired to cough or to take a full inspiration; when at first there may be heard only one or two clicks from the entry of single bubbles: but as the eva- cuation of the softened matter proceeds, and there is more room for the entrance of air, there is then a more continued bubbling or gurgling sound, and this will be coarse and distinct in proportion to the extent of the vomica and its communi- cation with the air-tubes. This gurgling or cavernous rhonchus will also some- what vary according to the quantity and liquidity of the contents of the cavity, becoming less crackling and more whining as these diminish. When it is heard over an extended space, there are probably several cavities communicating with each other, and all containing more or less liquid. It may present other varie- ties, which are quite intelligible when the mode of its production is known. The softening and evacuation of the vomica being complete or nearly so, there is left an ulcerous cavity or Cavern, which becomes the seat of farther phenomena. Even before all the liquid is evacuated, we sometimes hear in the corresponding part of the chest, with the gurgling, a hollow whiffing or blowing sound; and when the patient speaks, a sort of snuffling voice interrupted, broken up by the gurgling. When the Cavern is empty, these pass into cavernous respiration and pectoriloquy*, Cavernous respiration resembles that heard on listening with the stethoscope to the front of the neck over the windpipe; but it is more circum- scribed, and does not give the same impression of a rush of air. It may better be imitated by blowing into shells or thimbles of different sizes. It may present considerable variety, according to the size and shape of the cavity, and the free- dom with which the air passes into and out of it from the bronchi. When of very large extent^ the sound becomes amphoric, like that produced by blowing into an empty phial, and precisely on the same principle. All these phenomena are best obtained with quick forcible respiration or slight coughing, which in- creases the force and velocity of the passing air, and exaggerates the sounds. Vol. II.—48 378 TUBERCULOUS DISEASE OF THE LUNG, OR Pectoriloquy is another very striking sign of a cavity in the lungs. Its value was perhaps over-rated by Laennec; but we think that it has neither been appre- ciated nor understood by subsequent writers. We formerly explained that the voice, although formed in the larynx, vibrates in full strength, through the windpipe and its branches, until it becomes broken up and muffled in the smaller tubes and soft porous tissue of the lung. But if a cavity be formed in this parenchyma, commu- nicating freely with the tubes in which the voice is strong, it will form a part of those tubes, and the vibrations will be continued in system from them to it; and there may thus be heard near the surface of the lung, a voice from the chest like that heard over the trachea,—Mts distinctness and intensity being more or less per- fect, according as the cavity is adapted to receive the vocal resonance from the tubes, and to transmit it to the wails of the chest. Laennec made an artificial distinction between the degrees of pectoriloquy, according to whether the voice does or does not give to the ear the impression of passing up the stethoscope when the stopper is in. In the perfect kind the words are so distinct that it seems as if the patient had his mouth to the tube: where this impression is not produced, the pectoriloquy is imperfect. But this is only a difference of degree, and of doubtful importance. We consider the character of the sound and its circum- scribed position a more serviceable distinction. The sound is not a mere vocal resonance, like the bronchophony from consolidation, which is often as loud or louder, and may seem to pass up the tube quite as much; but it is ah articulate although indistinct speaking, and sometimes accompanies a loud whisper as well as vocal utterance. There is in it another feature which is characteristic, and dis- tinguishes it from bronchophony; it is accompanied or followed either by whiffs of cavernous respiration, which give the pectoriloquy a snuffling character, or by a hollow or fistular resonance, like that produced on speaking at the orifice of the tube of a Pan-pipe, the pipe of a large key, a shell, or any such hollow body. This accompaniment is sometimes heard when the pectoriloquy or the transmis- sion of the articulate voice is very imperfect; but we have found it to be more dis- tinctive of a cavity than the loudest vocal sound without it. It may be supposed to depend on the same physical cause as that of the similar sound in the hollow bodies to which we have compared it; the cavity in the lungs being in the same relation to the bronchial voice, as they are to the oral voice. When the cavity is large, the resonance is more amphoric or bottle-like; and if the communication with the bronchi be at the same time narrow, the voice may be scarcely trans- mitted to it, but excites in it only a tinkling echo—a metallic tinkling, as in pneu- mothorax. All these hollow, fistular, or tinkling characters may be also perceived in the breathing and cough, especially in the latter, but not in a proportionate degree, and sometimes are only perceptible with the voice. These differences must depend on the relations of the cavity to the air-tubes communicating with it: if this open into them so as to catch the current of air passing through them, its interior will be thrown into vibrations; otherwise the air in the cavity may only receive the stronger and more pervading vibrations of the voice. So, also, if there be much consolidation about and beyond the cavity, there mav be very little passage of air in the tubes, and therefore but little cavernous breathing. The circumscription of pectoriloquy is another of its peculiar characters, and by this it may generally be distinguished from the loud bronchophony of condensed lungs, which is diffused over some extent of surface. To observe this difference, it is necessary to limit the point of examination, by using the stopper in the stetho- scope. By this mode we can trace the precise boundaries of the pectoriloquy of a cavity; but when we try to trace where the resonance of the bronchophony ceases, we find no exact limits; it gradually loses force as the tubes become smaller, or the superjacent lung more porous. Pectoriloquy is most characteristic when it forms a little island of voice under a clavicle, and little or no sound is trans- mitted nearer the sternum. The pectoriloquous bronchophony of a lung consoli- dated by inflammation, or compressed against the walls of the chest by a liquid effusion, never has this isolated character, but is generally louder in proportion to pulmonary coxsumption, (Physical Signs.) 379 the size of the tubes involved in the condensation. It is however true, that some- times the pectoriloquy of phthisis is not circumscribed; for besides the cavities there may be extensive consolidation of the lung, and consequently free transmis- sion of the voice over an extent of surface. Even in this case a practised auscul- tator can distinguish the peculiar phenomena of cavities, in the snuffling, blowing or tinkling, and the more articulate voice that certain spots present, or in a coarser gurgling if there be liquid. It is obvious that all these phenomena are liable to be interrupted or modified by the accumulation of the matter secreted by the cavities and adjoining tubes; and that, after cough and expectoration, a spot that before gave no sound in common breathing, and gurgling on forced breathing, yields the cavernous breathing and pectoriloquy. So, also, as in time the disease advances, the excavations become extended, and the gurgling first and the pectoriloquy afterwards, are heard in new spots. Although, after the excavation of tubercles, there is more air in the chest, yet the sound on percussion generally remains dull, for there is much solid deposite about the walls of the cavities, and the irregular density and flaccidity of the parts, as well as the defect of air in the peripheral structure of the lung, still tend to check and to muffle the vibrations of the walls of the chest, and prevent them from yielding a clear sound. Even where the cavity is so large as to be the seat of a tinkling echo, the resonance on percussion is irregular and imperfect; and thus may this case of metallic tinkling be distinguished from that of pneumothorax, in which some part of the chest must have an unnaturally clear sound. Sometimes the percussion is clearer in consequence of a general dilatation of the superficial cells; and as this is commonly of the flaccid kind, it may be accompanied by a sharp puerile kind of respiratory sound: both these circumstances may disguise the phthisical signs, but only partially, for there will still be some decided irregu- larities in the sound of percussion, and enough of the signs of the subjacent cavi- ties to declare the case to the wary observer. Occasionally a hollow or bottle-like sound is produced by percussion over a cavity; this is when its walls are pretty dense, and it communicates freely with the bronchi. More commonly there is an opposite condition: the walls of the cavity are loose and yielding; and if it be large, percussion may sometimes cause a motion of its contents, and a gurgling or tink- ling expulsion of air from it, which gives a muffled metallic sound, like that of money in the nearly closed hands, or more like the imitation of that noise which may be made by striking the hands hollow and closed upon the knee. Laennec compared the sound to that emitted by a cracked jar when it is struck, With the irregular and deficient sound on percussion, generally most evident under the clavicles or in other parts of the upper regions of the chest, there is very commonly associated a collapse or sinking in of the walls of the chest, forming below the clavicles a hollow, generally more conspicuous on one side than on the other. There is very commonly, also, some defect and irregularity in the movements of the chest, the upper ribs of one side being but little raised, and the lower parts altogether exhibiting the most motion. But there is rarely that complete fixing of the side that we see in chronic pleurisy, in which case, too, the upper part is generally more mobile than the lower. We might class with the physical signs the characters of the sputa in the third stage of consumption, if they came only from the cavities which are peculiar to it The expectoration of distinct portions of tubercle, or of pulmonary tissue, which are seen in a few cases, constitutes a physical sign of the clearest cha- racter; they must come from cavities. If patients could save all their expectora- tion, and this were inspected daily, this unequivocal sign might be more fre- quently met with. But the inflamed air-tubes are, in a great measure, the source of the expectorated matter, which, therefore, presents much of the same aspect as in chronic bronchitis. The large size, and almost perfectly purulent character of the masses sometimes expectorated, which are like irregular balls of flock or wool of a yellow or greenish colour, sinking and breaking down in water, go far to prove the existence of cavities in the lungs. These have been particularly 380 TUBERCULOUS DISEASE OF THE LUNG, OR noticed by Dr. Forbes. A dirty yellowish-brown or greenish matter, occasion- ally fringed or streaked with blood, flattening like a piece of money when sepa- rate, and in masses forming a smooth sluggish purilage, are more characteristic of phthisis, and generally occur in the most advanced stage. The general pul- monary congestion which frequently precedes death, is often announced by the darker reddish or green hue of the purulent sputa. Profuse haemoptysis does not often occur in the advanced stages of consumption; for the vessels soon be- come plugged with fibrin, and obliterated in the diseased portions of lung, and the mass of blood is reduced to the capacity of those that remain free. When it takes place, however, it is usually followed by speedy, sometimes by immediate death. I have seen several cases in which a sudden effort, or a paroxysm of coughing, pro- duced a gush of blood into the bronchial tubes from a large vessel in the cavity. In these cases a portion of the blood is discharged from the mouth,, more by vomiting than spitting, and a portion flows into the stomach and forms a coagulum. G. Complications* It is very common for phthisis to become complicated with other diseases of the chest, particularly bronchitis, pneumonia, and pleurisy; and the attacks of these additional lesions sometimes prove fatal, even when the phthi- sical changes are not extensive. Partial bronchitis is an almost constant concomi- tant of tuberculous disease of the lung; but more general attacks also sometimes occur from the ordinary causes, such as exposure to cold, the epidemic preva- lence of influenza, and febrile diseases: they then bear a character more formida- ble than usual, being themselves less tractable, and may cause suffocation; or they may accelerate the progress of the phthisical disease. It is also very com- mon to find general pneumonia attacking a lung in which there are miliary tuber- cles, which must have existed prior to the inflammation, and would probably not have run their course for several months. This complication greatly increases the danger of the pneumonia also, which, unless it be stopped at its very onset, generally proves fatal. In some instances, especially in the young, we find a reason for the intractability of such a pneumonia, in the tuberculous character of the hepatisation, which has the grayish or boiled-liver aspect, with considerable softening, instead of the redder deposite of common hepatisation; on the pleura there is sometimes seen, at the same time, an opaque friable lymph which borders closely on real tuberculous matter. In other instances, where the disease has not advanced far enough to present these appearances, we can still under- stand that there may be in the deposite enough of that defect of vitality, which renders tubereulous matter so difficult of absorption. The supervention of the signs of an extensive pneumonia, crepitation with increasing dulness on percus- sion, affecting the posterior lobes of one or both lungs, together with the in- creased heat, febrile disturbance, and the rusty tinge of the sputa, must be looked on as indicative of extreme danger to patients with any extent of phthisical dis- ease; for if it do not itself prove fatal, as it commonly does, the inflammatory attack will not fail to hasten and increase the phthisical disease. It is different with the circumscribed pneumonia which sometimes attacks portions of lung in the progress of tuberculous disease: these come on without much disturbance, and subside without causing much mischief, being probably the result of mere local obstruction or irritation. The same remark applies to the slight pleuritic attacks, which are very common in phthisis; the effects of which arc seen in the adhesions of the pleura, so generally found in phthisical subjects. We have re- peatedly heard a sound of frietion in a part of the chest which lasted for several days, and the chest after death exhibited adhesions at this point. Probablv the inequalities occasioned by the deposites in the lung, as well as the textural irrita- tion, cause these local inflammations of the pleura. They rarely produce much effusion, but soon terminate by adhesion. Liquid effusion* do occasionally occur, from a more general cause of inflammation, such as the bursting of a vomica into the pleura. If the vomica also communicate with the bronchi, there will be pulmonary consumption, (Duration.) 381 pneumothorax as well as liquid effusion. In either case, the pleurisy is a serious and untractable addition to the consumptive disease, and may prove fatal in a few hours. Pulmonary haemorrhage is another serious accident, most commonly occurring in the early stages of phthisis. It may prove fatal, by loss of blood, or by suffocation; or the effusion of blood may break up the tissue of the lung to a great extent, and the patient may sink from the sloughy suppuration which ensues; or, after the haemorrhage has ceased, inflammation may arise in and about the haemorrhagic consolidation, and involve the lung in a destructive sup- puration, which may be more or less of a tuberculous character. Varieties. The varieties which pulmonary consumption presents are very; con- siderable, and even recent authors, such as Laennec, Clark, and Stokes, have thought several deserving a distinct consideration. Laennec recognises five: 1. Regular manifest phthisis; 2. Irregular manifest phthisis; 3. Latent phthisis; 4. Acute phthisis; 5. Chronic phthisis. •■ Sir James Clark also notices five: 1. Acute; 2. Febrile; 3. Chronic; 4. Latent; 5. Infantile. Dr. Stokes specifies no less than six varieties of phthisis besides those diversified by complications; 1. Acute non- suppurative; 2. Acute suppurative; 3. Chronic progressive; 4. Chronic ulceration following pneumonia; 5. Tubercle consequent on chronic bronchitis; 6. Tubercle consequent on the cure of empyema. None of these divisions is sufficiently com- prehensive to include all the varieties of pulmonary consumption, which may take a peculiar stamp from the nature of its causes; from the constitution of the sub- ject ; from the predominance of particular symptoms, such as those of irritation or those of colliquative secretion and decay; from the extent and progress of the local lesions of the lungs; and from the complications with lesions of other organs. It is highly important to observe these differences in relation to the diagnosis, prog- nosis and treatment of individual cases; but to describe them all as distinct varie- ties would lead to needless refinement and prolixity. It will be sufficient for our purpose to distinguish two kinds of consumption, the acute and the chronic, without however professing that the fine between them is always well marked, and admitting that each may present considerable variety in its predominant symptoms. Acute or rapid Phthisis. Sir J. Clark states, from collating the observations of Heberden, Bayle, Andral, and Louis, that the average duration of consumption ranges from nine months to two years; in the acute form it may prove fatal, in from three weeks to two or three months. In some of such cases the symptoms and stages do not differ from those already described, but they are unusually se- vere and rapid in their course; emaciation does not proceed so far; and the physi- cal signs during life, as well as the examination after death, show that the extensive tuberculous deposite, and the consequent lesions of the lung, have been'the sufficient cause of this rapid progress. This is what is popularly called " galloping consump- tion ;" it commonly occurs in very scrofulous constitutions, particularly in young subjects, and is often developed by an attack of inflammation of the lungs or their membranes. In other cases, miliary tubercles are developed in such great num- bers, that they prove fatal in their first stage, few of them having suppurated. In such instances there is generally a predominance of the signs of irritation and ob- struction; dyspncea; frequent cough, with little or only bronchitic expectoration; much fever and quickness of pulse; frequently palpitation; sometimes haemoptysis; and the disease may prove fatal in from three weeks to two months, often without considerable emaciation, but with increasing oppression to the function of respira- tion. The lungs are found thickly studded with miliary tubercles, or with nume- rous nodules of tuberculous consolidation of a gray or a drab colour and moderate consistence, none of which have become excavated, except perhaps in the upper parts of the lungs, where a few have become soft and have formed small vomica?. The intermediate tissue is sometimes in the first stage of inflammation; sometimes it is unaffected or partially emphysematous. The bronchi are almost always in- flamed, and filled with a spumous mucus, and not unfrequently they are partially dilated. This non-suppurative variety of acute phthisis is noticed by Dr. Stokes 382 tuberculous disease of the lung, or as usually succeeding to fever, particularly that of a typhoid kind.* From the general prevalence of fever throughout its course, Sir J. Clark terms it febrile phthisis; but he does not sufficiently distinguish it from his other acute variety, in which the tuberculous changes are more complete, and in which the tuberculous deposition is often in the infiltrated or diffused form. From the general symp- toms, this form of acute phthisis is liable to be mistaken for bronchitis or pneu- monia, and it is only by attention to the physical signs, as well as the progress of the whole case, that the distinction can be made. Of this we shall speak under the head Diagnosis. Chronic Phthisis. Tuberculous consumption is in its ordinary career a chronic disease; but the cases that especially deserve this title, are those in which the dis- ease lasts for many years. Bayle and Laennec record instances in which patients appear to have had the disease thirty and forty years. But it is not to be sup- posed that in chronic cases the disease is always progressive. It owes its long duration to its limited extent; and although the lungs are never free from some of the lesions described as characteristic of phthisis, yet the continuance of the disease is chiefly marked by many successive attacks and partial recoveries, dependent on the partial development of new tubercles and their successive changes and elimination. As the rapid form of the disease occurs chiefly in young subjects, so this in most instances is met with at or after middle age; but it is by no means confined to any period of life. In many instances it wears the garb of a common pectoral catarrh, recurring frequently in cold weather, and in great measure sub- siding during the warm season; but on attentive observation it will be found that the attacks, although in great measure bronchitic, are attended with more purulent expectoration, hectic fever, and loss of flesh than those of simple bronchitis, and that the cough is never entirely removed, and the patient rarely quite recovers his flesh and strength. He may return to his usual pursuits, and consider himself recovered, but he is somewhat short-breathed, and suffers from any unusual exer- tion, which may sometimes induce haemoptysis. With the return of winter the pectoral symptoms recur, to be again alleviated or removed in the stunmer, until at last one attack, more severe than the rest, proves fatal, or the disease makes more rapid and decisive progress in consequence of the faDure of the constitution or the spread of the local disease. The physical examination of such cases, even at an early period, generally furnishes pretty clear evidence of the existence of phthisical lesions; for although these are hmited in extent, they produce signs the more contrasted with those of the healthy parts of the lung. Hence under a clavi- cle, at a scapular ridge, or in some circumscribed spot in the chest, there are dul- ness on percussion, deficient or bronchial respiration, and undue resonance of the voice, or, as the disease advances, the different signs of a cavity before described. In such cases the long continuance or frequent recurrence of bronchial rhonchi in one particular spot, affords, as Dr. Stokes has observed, strong presumptive proof that tubercles are there irritating and pressing on the air-tubes. It is this chronic or limited form of tuberculous disease that affords the best chance for the remedial powers of nature and art; and there can be little doubt that a considerable num- ber of cases are cured.f The lungs of those who have died of chronic phthisis present appearances that can be distinctly referred to different dates. In the upper parts there are often old cavities lined with a false membrane with hard black tissue around them, the exterior of the lung being irregularly puckered and nodu- lated by the indurations, the contraction of membranes, and the emphysematous distention of the uncondensed texture. The old date of these changes is plain from their hardness, and gray colour, and the complete organization of the false membranes lining the cavities, or uniting their sides. Near the same parts, but more abundantly in the middle and lower parts of the lung, there may be cavities * It would be more correct to say often.—[Am. Ed.] t There is no doubt that many such cases recover. Cicatrices or calcareous tubercles remain often in healthy persons.—[Am. Ed.] pulmonary consumption, (Origin and Causes.) 383 of more recent formation, with their walls, comparatively soft, ragged, or imper- fectly lined by albuminous matter; and there may be likewise more or less of the different kinds of consolidation—circumscribed and diffused, gray, red, and dark- coloured,—which constitute the earlier stage of phthisical lesions, in parts gene- rally exhibiting the changes into crude and soft tubercle. It is sometimes not difficult to recognise, in these different appearances, the lesions which have been connected with the several successive attacks which the history of the patient re- cords. Laennec adverts to these successive productions of tuberculous disease, which he calls crops of tubercles. But many of those affected with chronic phthisis, or circumscribed tubercle of the lung, die sometimes from other diseases connected with this lesion, such as haemoptysis, pneumonia, bronchitis, pleurisy, perforation of the pleura; sometimes from causes unconnected with it, such as fevers, inflammations of other viscera, accidents, &c. These cases give us the opportunity of seeing consumptive disease in its slighter forms; and they are so common beyond middle age as to have been met with in more than half the cases in which we have thoroughly examined the lungs of subjects who have died of various diseases in London and Paris. It is easy to discover these partial lesions, on feeling the lungs between the fingers, and cutting into any resisting or indurated portion, which will be found to be a gray or red induration, a yellow or cretaceous tubercle, or the remains of one, a smooth cavity or a cicatrix, to which may sometimes be traced obliterated bronchial tubes. In a few instances we have met with cavities of a considerable extent, without any remains of tubercle, the walls only being composed of condensed pulmonary tissue, smoothly lined by a false membrane, which sometimes is opaque, fibrous, and rather thick, and sometimes as thin as mucous membrane. We shall presently revert to these facts as proving that phthisical lesions are generally destructive, on account rather of their extent and constitutional origin than of their nature. Laennec and several subsequent writers have treated of latent phthisis as a distinct variety: but seeing that the cases falling under this denomination differ from the common, the acute, or the chronic forms of consumption, only in their general symptoms being less marked than usual, or being disguised by the symp- toms of various other affections with which the disease is complicated, it does not seem correct to separate them into a distinct variety. But it is highly important to know that all the varieties of phthisis may present veiy different degrees of pro- minence in the usual symptoms, and that they may be masked, even to their last stages, by affections of other organs, particularly of the stomach, intestines, and liver, and by various fevers, as well as by previously existing or concomitant affections of the respiratory apparatus, especially bronchitis, laryngitis, pleurisy, and pneu- monia. In all these cases the physical signs will generally furnish the means of diagnosis: but in many instances the general symptoms likewise, if attentively studied, will indicate the nature of the disease; and it is from' inadvertency on the part of medical men, and from their preconceived notions and those of the patients, as much as from the obscurity of the symptoms, that phthisis is so frequently over- looked. We think it neccessary to warn the young practitioner not to conclude that a cough is merely a " stomach cough," a " liver cough," or an " hysterical cough," because there is marked disorder of the corresponding organs, nor that shortness of breath and night sweats proceed from general debility; nor that symptoms are not phthisical because the patient has long suffered from pulmonary catarrh or chronic laryngitis, until he has found, on repeated examination, no physical signs of phthisis in the chest. Origin and causes. If we attend to the history of different cases of pulmo- nary consumption, we shall find that they may be classed in three groups. 1. Those in which the individuals had enjoyed very good health until they were at- tacked with one or more severe colds or inflammations of the chest, or a fever accompanied by pectoral symptoms, sooner or later after which the phthisical disease commenced. 2. In other cases, again, the cough and other symptoms begin very gradually, without any very obvious cause, and, with as little appa- 384 TUBERCULOUS DISEASE OF THE LUNG, OR rent external reason, soon increase to a serious extent, and the consumption runs a more or less rapid career. 3. In a third class of cases, the patients have been out of health, in a debilitated or cachectic state before the commencement of the cough and other local symptoms, which become developed after exposure to cold, the stoppage of an habitual evacuation, or some other cause likely to occasion local irritation or plethora. 1. In the first class of cases we have the development of phthisis from local inflammation or irritation without any evidence of prior constitutional disorder, unless an hereditary predisposition, which may be traced in some of these cases, may be considered as such. The acute inflammation, whether pulmonic, pleu- ritic or bronchial, imperfectly treated and only partially subdued, passes into a chronic form, and either immediately developes phthisical indurations in the lungs, or by generally lowering the vital powers leads to their formation from perverted nutrition, or from the irritation of any fresh exciting cause. Under any of these circumstances, chronic inflammation, either by its own local effects, or by its depressing influence on the constitution, or by both combined, becomes a sufficient cause of pulmonary consumption. As it might be anticipated, con- sumptive disease arising in this way is often more limited in its extent, and manageable in its course, than that arising from a prior constitutional disorder. As the cause is more local, so the lesion is more confined to a part; and we see instances of it in the very partial indurations and other phthisical lesions, or the traces of them, which we have lately noticed as occurring frequently in the lungs of persons who have died of other complaints. The physical character of these lesions in many such cases clearly identifies them with those which in greater extent constitute chronic phthisical disease. Yet the same local causes that pro- duced these limited or solitary tubercles may engender many; and the greater the number that the local cause thus developes, the more effect will it have on the constitution which in a manner takes on a disposition to evolve the new pro- duction; hence, therefore, out of a local cause, such as latent or neglected pneu- monia, pleurisy, or peritonitis, may arise a general tuberculous disease, involving more or less the whole system. Among the local causes of consumption is to be reckoned the habitual inhalation of fine solid particles, which is contingent on certain occupations, such as those of needle pointers, dry grinders, stone-masons, miners, colliers, and such like. The lesions in these cases are, as might be an- ticipated, bronchial as well as parenchymatous; and it has been questioned whether the consolidation of the lung which is found is really tuberculous; but seeing that it tends in the same manner to softening and the formation of vomicae, that granular indurations and distinct yellow tubercle sometimes accompany it, and that the symptoms and signs are those of pulmonary consumption, we see no reason for distinguishing between them. The dependence of the disease, in these cases, on the mechanical irritation of the inhaled particles, is sufficiently proved by the fact that these particles have been found in considerable abundance in the indurated lung, particularly in the case of the Edinburgh stone masons and the workers in coal mines, the texture being in the latter case completely black- ened by the coal dust. In the case of the steel-vvorkers at Sheffield, described by Dr. Knight, the fork-grinders, which grind dry, do not reach thirty-two years of age, whilst the knife-grinders who work on wet stones, generally live to forty or fifty; The workmen employed in making gun-flints in the quarries of St. Rock are said by MM. Benoistori de Ch&teauneuf and CloZier to be sooner or later at- tacked with pulmonary disease, generally tuberculous; and, however robust, originally, few pass the age of forty. With such cases may be associated the results of the experiments of Saunders, Cruveilhier, and others, in which lesions resembling those of phthisis were produced in the lungs of animals after the in- jection of mercury into the air-tubes or blood-vessels. The inhalation of vege- table or animal dust or particles does not appear to be so injurious, except in the case of the feather-dressers, brush-makers, and flock-carders. According to M. Benoiston, the average mortality in the former from phthisis only amounts to pulmonary consumption, (Origin and Causes.) 385 1\ per cent, for males and 114 for females. The injurious character of these employments may be explained, when we consider the irritating character of par- ticles of feathers and hair, and how little they can be softened or decomposed by the animal fluids. It has been maintained that the production of tuberculous dis- ease in these different employments, is due as much to a bad state of the consti- tution induced by confinement, abuse of spirituous liquors, &c, as to the local irritation: we do not deny that this may have a share; but the greater influence of the perpetual local irritation is apparent from the fact, that in other occupa- tions in which the confinement and habits are quite as bad, not one-fourth so many die of consumption. 2, 3. We may well consider the second and third classes of cases together, for in both the disease has its root distinctly in a state of the constitution, and they are distinguished only by an occasional or local cause being obviously added in one class, and not in the other. Unfortunately these form the most numerous group of consumptive cases, and those over which, when once formed, medicine has but little control. The cachectic condition of the system which precedes the formation of tubercle, as well as the circumstances that seem to occasion it, fully correspond with the pathological views which we have taken of its nature. Im- perfect nutrition, whether from deficient or improper food, or from a permanently disordered state of the digestive or assimilative organs; unhealthy air, whether from closeness, humidity, or impurities; long continued exposure to cold, as from insufficient clothing, where there is not enough vascular irritability to lead to inflammation; depressing passions, such a disappointed love, anxiety* or distress from reverses of fortune or other severe calamity; venereal excesses; repeated courses of mercury; profuse and very weakening discharges; adynamic fevers, and the atonic state that sometimes succeeds to exanthematous fevers; irregula- rities of the uterine function, especially those that lead to chlorosis; the sudden suppression of habitual discharges or of long established cutaneous eruptions; these singly or combined are the most common causes of the constitutional origin of tuberculous disease. They all tend to destroy the balance of the func- tions and diminish the tone of the system, and with it that rich fibrinous and vital condition of the blood, by which proper nutrition and the organic func- tions are sustained. The impoverished blood, defective in that vital albu- men with which the tissues are fed and renewed, deposites in its stead a de- graded matter, imperfectly or not at all organizable, like that resulting from the lower degrees of local irritation or inflammation. The lungs, the lym- phatic glands, and a few other organs, become the first seat of these deposites, because their textures are in fuller relation with the blood than those of other parts are; and if there be in these organs also a congestion, an irritation, or an inflammation, the deposition becomes more extensive and rapid in proportion: although the inflammation be acute, it may also produce organizable lymph, toge- ther with the degraded albumen, tubercle; so, also, we find, that according to the natural activity of the nutritive process will be the rapidity of the tuberculous deposition and the progress of the disease. In young persons nutrition is most active,»so is consumption more commonly spontaneous and rapid; and at no period is this more manifest than between the ages of eighteen and twenty-five, when growth becomes completed, yet the vessels and their blood do not immediately lose their habit of deposition. This view also corresponds with the fact stated by Andral, Lombard, and others, that of young persons, consumption shows itself earliest in females, in whom growth is sooner completed than in males. But throughout the whole period of childhood and of youth, tuberculous disease is very common, and under the influence of the causes already enumerated is more easily engendered than when nutrition is less active. From the tables collected in the work of Sir J. Clark it appears that more than one-fourth of those who die from birth to puberty are affected with tuberculous disease. We can under- stand why this morbid nutritive activity, this disposition to deposite tuberculous matter, should be particularly shown in women after the completion of utero-ges- Vol. II.—49 386 TUBERCULOUS DISEASE OF THE LUNG, OR tation, and in persons on the speedy healing of large suppurating wounds—cir- cumstances which, as long as they continue, are known often to suspend the progress of consumptive disease. Our limits will not permit us to go into many farther details respecting the causes of tuberculous disease or of the cachectic condition on which it depends. Sir James Clark lays much stress on abdominal plethora, or congested state of the portal system of blood-vessels, as the chief cause of this condition; and there are many facts which favour the opinion that congestions of various internal parts frequently precede the development of consumption; but it is a question whether we may not take a link higher in the chain of causes, and view defective or irre- gular action of some of the principal secreting organs, or of the capillary circu- lation in general, as the precursor of these congestions. Signs of such defective action occur in scrofulous constitutions more constantly than those of abdominal plethora, and are manifested in coldness of the extremities, blueness of the nails, flushing of the face, a dry harsh or a flabby state of the skin, relaxed throat, scanty and high-coloured urine, irregular bowels, uncertain appetite and variable strength. In many cases pulmonary consumption has been preceded by such a condition of the system, and in such instances the disease may begin very gra- dually without any very obvious exciting cause, or it may be suddenly developed by an inflammatory or febrile attack. It must, however, be confessed, that such a condition of the system is often met with without being followed by consump- tion; and not a few cases of consumption occur without appearing to be pre- ceded by any such disorder of the health. The hereditary origin of tuberculous disease is established by the concurrent testimony of almost all writers, and it may be considered as one of its most fertile sources. Sir J. Clark says that it is transmitted more often to the younger than to the elder children of a consumptive family; and he believes that a deteriorated state of the health in the parent from any cause, such as gout, severe dyspepsia, cutaneous diseases, debility from disease or from age, may give rise to the scro- fulous constitution in the offspring. The same writer has very judiciously remarked, that even in those not inheriting it, a disposition to tuberculous disease may be readily induced by bad nourishment, confinement in impure air, and neglect of cleanliness during the whole period of their growth, and more especially in early years. A child under such circumstances, although born in health and of robust parents, becomes pale and thin, with a tumid abdomen and enlarged glands, and fetid evacuations; and unless speedily removed from these unfavourable circum- stances, soon dies of some form of tuberculous disease. The same thing is observed of the lower animals: thus, the cows confined in close stables in towns, become tuberculous; and rabbits may be rendered so in the course of a few weeks, by keeping them in a close damp place, and giving them only poor food. Partly to the confinement must be ascribed the fact that many of the monkeys brought to this country die tuberculous; but the change of climate must also be considered a chief cause, for negroes who come to this country are especially liable to phthisis.* Phthisis prevails more in temperate than in hot or very cold countries. It is the cause of nearly a third of the mortality in London, and not much less in Paris; whilst in Russia and in the East Indies, it is far less prevalent. In the West Indies, however, it appears from the table of Sir James Clark to be very destructive among the negro troops, where it constitutes one-half of a large mortality; and in the East Indies a considerable number of Malays, Caffres, and Indians, fall vic- tims to the disease, which constitutes from one-eighteenth to one-seventeenth of the mortality, while among the Europeans it does not cause one in five hundred deaths. Diagnosis. Having already entered pretty fully into the signs and symptoms • Even negroes who are born in temperate climates die of phthisis in a greater proportion than whites. Their unfitness for the climate is at least one cause of this.—[Am. Ed.] PULMONARY CONSUMPTION, (Diagnosis.) 387 of tubercles of the lungs, it will not be necessary to dwell long on the subject of diagnosis. In the greater number of instances the features of the disease, together with the physical signs, are quite distinctive; but it often happens that the early stages are rendered obscure by certain complications, and it becomes difficult to distinguish, whether, in addition to the more obvious disease, tubercles are present or not These complications are chiefly bronchitis, pneumonia, and pleurisy, and the diagnosis is to be made between them combined with tubercle, and the same simple. Acute phthisis often begins with the signs of general acute bronchitis, accom- panied by much febrile irritation. But when tubercles are present, the sound on percussion is more or less impaired; in some parts of the chest the quickness of pulse is unusually great; there is more tendency to night perspirations than in simple bronchitis; and the symptoms instead of reaching an acme and then declining, with a change in the expectoration and in the character of the rhonchi, continue, and even increase whilst the patient daily loses strength and flesh. In the generality of cases, simple bronchitis prevails most in the middle and lower parts of the chest; that accompanying tubercles always extends to the upper, and often occupies these chiefly. The complication of tubercle with pneumonia, which is a very acute form of phthisis, may be generally distinguished from simple pneumonia, by its com- monly occupying both lungs and progressing from above downwards; from the less rapid increase of the consolidation, by the decidedly hectic form of the fever after the first few days; and by the early production of the signs of cavities accom- panied by copious purilaginous expectoration, and sometimes haemoptysis; none of these signs are usual in simple pneumonia. To distinguish in a case of pleuritic effusion, whether tubercles are present or not, may be a matter of great difficulty. With regard to the compressed lung of the affected side nothing can be deter- mined, and as there is no longer a standard of comparison for the sound side, absolute signs alone can be depended on, such as decided dulness, bronchial or caver- nous breathing, or pectoriloquy under the clavicle, or a permanent mucous or sub- crepitant rhonchus. In the entire absence of these, and when the respiration is clear and puerile throughout that side, and the general symptoms and the aspect of the patient is not tuberculous, it may be presumed that there are no tubercles. We have before adverted to the difficulty of distinguishing between simple chronic bronchitis and that accompanying limited or early tuberculous disease; and we must refer to the description of the physical signs for the chief means of diagnosis. Without attention to the physical signs, chronic pleurisy is very liable to be confounded with phthisis; they never fail to furnish a diagnosis in the much more complete dulness and absence of respiration in pleurisy, particularly in the lower part of the chest, on one side only; in the enlargement of this part and the smoothness of the intercostal depressions, which contrast strongly with their sunken condition in phthisis. When the effusion has been partly removed, and partial contraction of the chest taken place, although from the dilatation of the tubes there may be pectoriloquy and other signs of cavities, yet the alteration of shape affects the side more extensively than phthisis does, and a perfect dulness remains in the infenor parts, which is quite unlike the condition induced by phthisis. The diffe- rent character of the expectoration also will form another ground of distinction. Dr. Stokes thinks that tubercles are not uncommonly produced during the absorp- tion of an empyema, and mentions, as their signs, the occurrence of symptoms of new pulmonary disease, with hectic, quickened pulse, an increasing dulness and signs of irritation under the clavicle or scapular ridge. Phthisis is sometimes disguised by chronic laryngitis; the affection of the voice, character of the cough, and other symptoms directing attention exclusively to the larynx; but we have before remarked that extensive ulceration of the larynx is very commonly accompanied or succeeded by pulmonary tubercle; and on care- ful examination, the signs of this may generally be found under one or both cla- vicles by the respiration or by percussion, if not bv the voice. 388 TUBERCULOUS DISEASE OF THE LUNG, OR There is one kind of lesion which, even in its physical signs, is liable to be mistaken for tuberculous excavations; this is dilatation of the bronchi. 1 Ins may be the seat of a coarse gurgling rhonchus, cavernous breathing, and pectoriloquy; and the accompanying chronic bronchitis often causes also purulent expectora- tion. The situation, greater extent, and more stationary character of these le- sions may serve to distinguish them: they most commonly occupy the scapular, mammary, and lateral regions, and not the infra-clavian; they usually extend over a considerable space, but do not tend to spread as tuberculous cavities do. Again, if they arise from disease in the bronchi only, they do not impair the sound on percussion so much as phthisis does; and if they originate in the pleuro-pneumo- nia, the dulness is much more complete, is confined to one side, and is accompa- nied by a more marked contraction than that which occurs in phthisis. But the general symptoms should also be taken into account. There is seldom with di- lated bronchi the degree of hectic emaciation which occurs in phthisis; and when they arise from condensation of the lung, there are often osdema and general dropsy, which are not common in simple phthisis. The diagnosis of phthisis is easy enough in the advanced stages, or even in the second pe- riod before softening has taken place. The physical signs conjoined with the general symp- toms are then conclusive; but in the early stages of the disease the diagnosis is often difficult. If phthisis be regarded merely as a local disorder, the signs of it will be frequently deficient, because the local mischief is formed very slowly, and at first is so slight as to produce very in- significant obstructions to the respiration, and very little teudency to cough. If the disease of the lungs be regarded merely as a part, and as it were, a sign of a general disorder, which is usually betrayed by certain symptoms, the diagnosis is greatly facilitated. Regarding the disease in this light, the following circumstances will guide us in forming a probable and often a certain diagnosis in commencing phthisis. If the physical and other local signs are added to the symptoms referrible to the constitutional disorder, the diagnosis is of course much more unequivocal than in those cases in which the general symptoms are alone formed. 1. The diagnosis in these .cases is formed in part by way of exclusion; that is, many of the symptoms of the general tuberculous disease acquire their chief value from the absence of any apparent lesion which is capable of producing them. If they occur in young persons, espe- cially if from hereditary causes or habits of life they are exposed to phthisis, the probability of the development of this disease is of course enhanced, and the diagnosis is assured. 2. In chronic cases of phthisis, the general signs are emaciation, which is often accompa- nied by a good appetite and a tolerable digestion, and a changed colour of the skin, which seems dusky or earthy in its hue. Rounding of the extremities of the fingers, and a bluish tint of the sclerotica and the occasional flush of the cheeks have long been known as frequent symptoms of phthieis, but are less important than the colour of the skin and emaciation. There are a number of other general symptoms which are occasionally met with in com- mencing phthisis, but they are more or less irregular in their appearance, and are therefore pf value only to one who is perfectly familiar with them. 3. In acute cases the disease is generally characterized by high and continued fever, with a quick jerking pulse ; the fever continues throughout the whole twenty-four hours, but is more severe in the after period of the day than at any other time, and at night is apt to ter- minate in profuse sweating. There are sometimes chills in this stage of the disease, but this is by no means universally the case; in this respect the formative fever of tuberculous dis- eases differs from the hectic of the latter stages of it. The character of the pulse is almost peculiar; it is very quick, irritated, and more readily distinguishable by the finger than easy to describe. The fever is almost pathognomonic of acute phthisjs, if there be no decided local lesion or other obvious means of explaining it. The fever is much more similar to that observed in some varieties of inflammation of serous membranes, especially empyema, than to the ordinary hectic. And this similarity in the constitutional symptoms of the pleurisy and other inflammations of the serous membranes of the chest, is.o|ie of the points of connexion between PULMONARY CONSUMPTION, (Prognosis.) 389 these diseases; seeming to show that in these cases the moibid action of the body is very analogous if not precisely similar. 4. The last means of diagnosis by the general symptoms, of commencing phthisis, is tho existence of certain affections which are closely connected with the disease; these are the inflammations and the tuberculous diseases of other organs than the lungs, such as the small intestines and the serous membranes. When these are discovered they often explain the nature of a tuberculous disease of the lungs, and are sufficient to distinguish it from ordinary inflammations. G. Prognosis. In a disease which causes so large a proportion of the mortality of the human race, it may well be supposed that the prognosis is generally most unfavourable; until Laennec discovered sure means of detecting tuberculous le- sions, and also proved by anatomical researches that they are sometimes cured by a natural process, it was generally believed that they were quite incurable and must sooner or later prove fatal. In making these discoveries, Laennec altered the state of our knowledge, chiefly by showing those to be cases of consumption which were formerly not admitted to be such, simply because they recovered. After the diagnosis has been distinctly made by aid of thevphysical signs, and the disease proved to be tuberculous, the prognosis is to be formed chiefly through the general symptoms. The extent of the pulmonary lesion, may, indeed, only be determined by the physical signs, the dulness of percussion and respiration, the rhonchi, resonance of the voice, and signs of excavation, whether they are confined to a small space or extend to a considerable portion of both lungs; and, in the latter case, the rapid progress of the disease to a fatal termination may be at once prognosticated. But where, as is often the case, the physical signs esta- blish the presence rather than the amount of the disease, we must refer to the state of the general health, to determine the probable time during which the con- stitutional strength may struggle against the disease, and the chance, if there be any, that it may get rid of it. When the cough and dyspnoea are distressing, with copious purulent expectoration; the pulse constantly quick; the accessions of hectic severe, with or without night sweats; the loss of strength and flesh con- siderable and progressive,—no hope can be entertained with regard to the result, which will terminate unfavourably in a short time. When the dyspnoea is consi- derable, death generally takes place before the emaciation is extreme; and this is commonly the case in acute phthisis, and where the fatal termination is caused by an inflammation or hcemorrhage of the lungs supervening on the tuberculous le- sion. In such cases, oedema of the feet, face, and other parts sometimes precedes death. But in the less rapid cases, and those which run their full course, the emaciation is excessive, and nothing increases it and the weakness so much as the colliquative diarrhoea, which generally occurs in the last stage of the disease. Shortly before death, the expectoration is sometimes suppressed, and sometimes it is changed in appearance, being a dark dirty green, or a reddish purilao-e with no mixture of mucus or froth. The progress of the more prolonged cases is rarely uniform; it is marked by a series of attacks of increased symptoms, with a temporary amendment between them. This increase is generally referred to the weather, or increased exertion, and under favourable circumstances may be decidedly checked. Thus, patients often pass several years, losing ground in the winter and spring, and rallying some- what during the summer, until, at length, they sink either under an attack severer than usual, or fairly consumed by the reiterated attacks of the disease. In some cases the improvement is more decided and lasting: the fever abates; the pulse loses its frequency; the cough subsides, and the expectoration becomes mucous and nearly ceases; and, in a few instances, the disease is entirely removed, and the flesh and strength restored. The local signs that countenance the hope that such an improvement may be lasting, are, a diminution of the pectoriloquy, caver- nous breathing, and other signs of the excavations, the restoration of some vesi- cular respiration and sound on percussion to the part, whilst in the rest of the 390 TUBERCULOUS DISEASE OF THE LUNG, OR lungs the sounds are natural. There can be little hope of permanent improve- ment if there is strong hereditary predisposition, or marked symptoms of tuber- culous cachexia, or any functional or constitutional disorder which materially im- pairs the general health. Treatment. We have been led to conclude that the most important elements in the production of phthisical lesions are, a state of constitutional weakness or defective nutrition, and a local vascular irritation or congestion: these elements predominate in various proportions in different cases, and will require a corre- sponding variation in the treatment; but in almost every case, both the consti- tutional and local causes must be duly investigated and treated, or success will be only a matter of the most incalculable and irrational chance. In treating of the causes of consumption, we arranged cases in three groups: 1. Those arising from local disease; 2. Those originating from constitutional disorder, or heredi- tary predisposition, without any known previous local disease; and, 3. Those arising from local disease in subjects of hereditary or acquired scrofulous or phthisical constitution. In the last two, constitutional causes are recognised; and in the first, the local disease may act, not only by developing in the lungs lesions which tend to run a phthisical course, but also by injuring the functions gene- rally, so that here, too, a constitutional cause becomes added. In no case, there- fore, should we exclude constitutional treatment from a prominent place in the management of consumptive patients. It is where local disease has been the chief cause of the mischief, that we have the best chance of curing consumption, and the more so in proportion as the local lesions are limited, and the constitutional powers little impaired. The chief indications in the treatment of tuberculous disease are, to diminish those local irritations and congestions that lead to the formation of the indurations or tubercles; to correct the condition in the system which degrades the nutritive process, and disposes to the deposition of imperfectly organized products; to pro- mote the removal of those already deposited; and to treat troublesome symptoms and accidental complications. These indications will predominate very diffe- rently in different cases, and in the different stages of similar cases; and although all should generally be kept in view, it will be more convenient to consider the treatment in relation to the stages of the disease than to these separate indica- tions. First stage. The symptoms of the early stage, that of the indurations, arp those especially of vascular irritation and obstruction; hence this is the period at which antiphlogistic and counter-irritant remedies avail most. General blood- letting of from four to eight ounces, repeated every week or ten days, were highly recommended by Morton, Dovar, Fothergill, and Pringle, and more recently by Dr. Hosack of New York, and Dr. Cheyne of Dublin. The practice is still much pursued in this country; and if judgment be used with regard to vascular strength of the subject, it is one of the most important agents which can be em- ployed. We would, however, with Sir J. Clark, limit its use to cases in which there are marked signs of plethora, or of pulmonary inflammation, congestion, or haemorrhage; and in other cases, and subsequently, prefer moderate local bleeding by leeches below the clavicles. The latter measure should be repeated whenever an increase of pain or cough, with a bloody tinge in the sputa, dulness on percus- sion, and irregular respiration or rhonchi under the clavicles, indicate a congested state of the lung about the suspected indurations. In cases of greater debility, or where there appears to be a defect of blood in the system, blisters or other counter-irritants are more suitable than blood-letting. One of the best agents of this kind is a saturated solution of tartarized antimony, to be rubbed in below the clavicles twice a-day, until a papular or semi-pustular eruption is produced. The friction should be renewed from time to time when this eruption dies away, as the symptoms may require it. We have sometimes added hydriodate of potash to the solution, with the effect of rendering it more irritating, and perhaps of acting favourably on the constitution by being partially pulmonary consumption, (Treatment.) 391 absorbed. Issues and setons cause too much irritation of the system to be useful in this stage. A more moderate and general counter-irritation may be produced by sponging the whole chest once or twice a-day with salt and strong vinegar, or with a liniment of oil of turpentine, acetic acid, and olive oil mixed by the aid of the yelk of an egg, as recommended by Dr. Stokes, or with ammoniated liniment in various degrees of strength. The efficacy of internal sedative or antiphlogistic remedies is more doubtful; except so far as they tend to diminish the irritation of the cough and the pain. Thus digitalis, hydrocyanic acid, and colchicum may, in some cases, subdue a temporary vascular excitement, and thus give relief; but the utility of continuing them long with the view to permanently reduce the pulse, may well be questioned; for they may thus do more damage to the constitution, than give relief to the irri- tation. In case of increasing bronchial or parenchymatous inflammation, or of fever, salines, antimonials, and other means of increasing the fluid secretions, will be proper as usual. The narcotic remedies, such as opium, conium, hyoscyamus, belladonna, aco- nite, and hydrocyanic acid, are occasionally useful to allay cough and pain, espe- cially when these symptoms are associated with high nervous sensibility or a tendency to spasm; but they have no influence on the incipient phthisical lesions, or on the inflammations or irritations accompanying them; and unless given judi- ciously, they may disorder the gastric and alvine function, and thus injure the state of the constitution. But are there no remedies which will promote the removal of the induration themselves? We can answer this but doubtingly; but if we may be guided by analogy, we might be led to hope that the removal of morbid deposites, when re- cent, may be facilitated by the aid of certain medicines. Thus we see tumours of various kinds, enlarged glands, and depositions in the joints, sometimes reduced under the use of mercury, of alkalies, or of iodine; and although there are many forms of deposite on which these remedies exercise no influence, and others in which their power is very equivocal, yet the limits of their action are not so de- fined as to prove that all the kinds of induration which precede tuberculous depo- site are quite beyond their reach. The influence of these remedies in promoting the absorption of the simpler products of acute inflammation is scarcely doubted; and arising, as the lesions of phthisis occasionally do, from acute inflammation, and presenting various gradations which remove them only step by step from its products, it would be unreasonable to assert, without sufficient evidence to prove it, that they are wholly beyond the reach of such medicines. Dr. Stokes consi- ders that the strumous inflammation which constitutes incipient phthisis, may sometimes be arrested by a course of mercury producing plyalism; and he gives two or three cases to show the success of this mode of treatment. He admits, however, that its utility needs confirmation, and its exhibition must not be lightly attempted. It may, perhaps, be useful where the pulmonary lesion originates in acute inflammation, which has not proceeded to suppuration; otherwise its influ- ence is generally so injurious in scrofulous constitutions, that we cannot advise its employment. This does not apply to its occasional use as an aperient, which is generally beneficial in this, as well as in other chronic diseases, in which the abdominal secretions need its aid. Sir James Clark, on the ground of Dr. Carswell's view of the usual seat of tuberculous matter, has recommended anew the old practice of a course of emetics in the early stage of phthisis. The testimony of several English writers of the last century, Morton, Parr, Reid, Marryatt, &c, is strong in favour of the suc- cess of emetics in arresting and even curing the disease; but as we know that they did not possess the means of distinguishing phthisis in its early stages from other affections, we lose much confidence in their testimony. Nor are we disposed to trust implicitly the report of the only recent authority, Dr. Giovanni de Vittis, whom Sir J. Clark adduces: he states that in less than four years, 176 cases of phthisis were discharged from the hospital perfectly cured, 47 in the first stage, 392 TUBERCULOUS DISEASE OE THE LUNG, OR 102 in the second, and 27 in the third. But although these statements are too strong to be accepted without reserve, they are sufficient to warrant a farther cau- tious trial of this method of treatment, in cases where there is sufficient strength to bear it. Various emetics have been recommended. Dr. De Vitus gave half a grain of tartar-emetic in a table-spoonful of sweetened infusion of elder flowers, repeating the dose in fifteen minutes if necessary. This practice was pursued every morning and evening; the diet being farinaceous. Clark prefers an emetic of ipecacuanha, or sulphate of zinc, or sulphate of copper, using only a little fluid during its operation, and for this purpose warm camomile tea is best. It may be given every day or less frequently, according to the urgency of the symptoms. Several writers assert that emetics may be continued every other day, and even oftener, for months without inconvenience. Sir J. Clark says, " There can be no doubt that the physicians who employed emetics thus extensively, were fully assured of the advantages which they produced; and their patients, we may con- clude, must have been equally sensible of the benefit derived from them, other- wise it is scarcely credible that a practice so disagreeable would have been pre- scribed or persevered in." The same author supposes the action of emetics to be in a great measure mechanical, dislodging the tuberculous matter, which, accord- ing to Dr. Carswell's notion, is first deposited on the free surface of the bronchial membrane. We would rather ascribe their beneficial operation to their powerful impression on the whole vascular and secernent systems, which tends to remove local congestions and obstructions, and to render all the secretions more fluid and free. It is not probable that this unpleasant practice will be sufficiently adopted or pursued as to be extensively useful; and there are many cases in which it can- not be even attempted. We expect more from a much more manageable remedy, which we believe also to be capable of promoting the removal of phthisical lesions in their early stages, or of retarding their increase. This is iodine, in combination with dif- ferent bases. We have been in the habit of giving it in incipient cases of con- sumption for the last twelve years. Dr. Baron of Gloucester, Dr. Morton of Philadelphia, and several others, have also spoken strongly in favour of this remedy. The form which we have found to agree best is the hydriodate of pot- ash in small doses (two or three gr.) three times a-day with twenty or thirty drops of liquor potassae, in decoction of sarsaparilla, infusion of calumbo, or dis- tilled water, according to the state of the system; adding a little tincture of hen- bane, digitalis, ipecacuanha, wine, or other medicine that the predominant symp- toms may indicate. Where there is a tendency to feverish irritation, it may be given in a nitre draught; where there is vascular debility it may be combined with mild tonic infusions. In chlorotic and in exsanguine scrofulous subjects, the iodide of iron is a suitable form; when it is borne, not causing headach and fever, or increase of cough,:it rarely fails to improve the state of the general health; bnt it should always be combined with occasional local depletion, or ex- ternal counter-irritation of the chest. When iodine agrees (and by varying ita form and combination it may be generally made to agree,) it increases all the se- cretions, and seems to give increased activity to the whole capillary system. In cases of gastric irritation with pain in the stomach or heat in the throat, thirst and florrid-tipped tongue, it should be suspended, and a dose or two of hydrarg. e creta given, followed by a few small doses of castor oil or a saline aperient; and after a few days the hydriodate of potash maybe resumed, guarded by the fre- quent use of a farinaceous diluent. In the treatment of consumption and other tuberculous diseases.no single remedy is nearly so useful as iodine and its preparations. My own practice leads me to prefer the simple solu- tion of iodine or hydriodile of potass ($)i iodine and ^ij hydriodate of potash to ^vij of water.) The patient should take five drops of this solution three times daily, and if no inconvenience be felt, he may increase the doso gradually and slowly to ten drops. I do not give it in larger pulmonary consumption, (Treatment.) 393 doses, unless in some rare and exceptional cases. The hydriodate of potash may be substi- tuted for the iodine, it is more tonic, perhaps more stimulating in its effects, but less purely alterative. If the patient be anemic, the iodide of iron is a better remedy than the iodine itself. All these preparations are best fitted for commencing cases of the disease, when the patient is labouring under slight bronchial inflammation, with commencing constitutional irri- tation and emaciation, and to the more chronic cases in which the tuberculous deposite is formed very slowly with little fever. Many acute cases of phthisis, and the greater number of those which are advanced so far as the formation of cavities, arc not benefited by the iodine, at least I have had no reason to be pleased with its effects. The remedy may be combined with alteratives, tonics, and many modifications may be made in its mode of administration, such as giving it only once a-day, and from time to time it should be discontinued, and may be again resumed when the tem- porary irritation has subsided. Inhalations of various kinds have again attracted notice after being nearly disused. The most of them are certainly of benefit as means of relieving the chronic bronchitis which often attends and aggravates consumption. Iodine has also been prepared and used in this way. My own trials with it have led me to think favourably of it, under the same circumstances in which it acts well as an internal remedy. The method proposed by Sydenham of combining it with conium answers well, or it may be used in its pure state. A grain or two may be placed at the bottom of a tumbler, which should be immersed in a bowl of hot water, and the iodine inhaled by surrounding the vessel with a cloth, and breathing the vapour. If much irritation and disposition to coughing come on, the inhalations must be suspended, and if the patient is permanently irritated, the attempt should be given up. The iodine probably causes a decided local action on the bronchial membrane, and afterwards is absorbed so as to produce its ordinary constitutional effects. G. But even in the cases in which phthisical lesions are most limited and merely nascent, we must never forget that it is not these lesions alone that we hope to remove. Their very presence in the system, or the operation of the constitu- tional or local cause that produces them, may lead to the formation of more; and in our treatment of the local causes, we should ever endeavour to remove those low degrees of vascular irritation, or that unhealthy condition of the nutrient mat- ter of the blood, which, singly, or combined, occasion the deposition of tubercu- lous indurations. But the constitutional treatment is also of the utmost moment; and in this we should seek for all those circumstances and agents that may best promote the due action and balance of all the functions. The purest air, and the most suitable climate for regular and ample exercise in it; the most nutritious food that the digestive organs can easily assimilate, and that the vascular system can bear without excitement; such remedial agents as give at once tone to the system, and promote the free action of all the secreting organs, together with friction, exercise, and proper clothing to maintain the activity of the superficial circulation;—these are the means which are rationally indicated to fulfil the ob- ject of improvement of the general health. But these means must be much varied to adapt them to the wants and capacities of individual cases, and it is in the study of these, and in the power of adapting the means to them, that the ability of the practitioner is seen. Of remedial measures, those already named in relation to the local lesions and particular symptoms, may be combined or modified so as to act favourably on the functions at large. This is especially the case with iodine. Occasional mer- curial and saline aperients will be generally needed to prevent internal conges- tions, and to promote the sufficient action of the abdominal viscera; but they should not be carried to excess, and their operation should be aided by due atten- tion to diet. So also the functions of the kidneys, and the skin may in particular cases be ameliorated by the aid of medicines; but the more that can be done by clothing, diet, and regimen, the better. Clothing, in particular, should be most carefully attended to; we have in it the means of affecting, sometimes powerfully, Vol. II.—50 394 TUBERCULOUS DISEASE OF THE LUNG, OR the whole vascular system; and if so regulated as to maintain a permanently warm and supple, but not relaxed state of the whole surface and of the extremi- ties, it would prevent many of those fresh colds and exacerbations which are the great bane of phthisical invalids. In case of these aggravations, which commonly consist in an increase of bronchitis, but sometimes are pneumonic or pleuritic, the remedies for these affections must be cautiously resorted to; always limited by the reflection that we are treating a subject that may already be weak from dis- ease, in whom the restorative powers are lower than usual, and in whom the per- manent source of irritation in the lungs will preclude that complete relief that antiphlogistic measures may give in simple inflammations. In case of haemoptysis, much care is required to remove the congestion or vascular fulness which occasioned it, before attempts be made to arrest it with styptics; otherwise the congestion may pass into inflammation, which, occurring in a lung tuberculated and consolidated with haemorrhage, is particularly destruc- tive. Moderate repeated bleedings from the arm, or by cupping, and the use of tartar-emetic in small doses, not sufficient to cause vomiting, together with digi- talis and nitre, and morphia in case of nervous agitation, are the measures we have found most availing. If, in spite of this, the haemoptysis continue to any amount, the super-acetate of lead, in the doses of two or three grains, with half a grain or less of the aqueous extract of opium, should be given every two hours, or as often as the urgency of the case may require. Fluid drinks in any quan- tity, especially warm, must be carefully avoided. Slight cases of haemoptysis are sometimes effectually treated by a saline aperient, with diluted sulphuric acid; and freely opening the bowels always aids to prevent the return of haemor- rhage. Pure country air is almost indispensable to give any chance to the consump- tive. If the disease be limited and chronic, and circumstances prevent him from giving up his employment in town, he should at least sleep in the country, and take every opportunity of longer absence. But the country must be dry, and not too much exposed to the east and north: otherwise it may only change the evil from cachexia to inflammation. There is no air which is so truly an anti- dote to the poisonous effects of a town residence, as that of a dry sea coast; and the more open this is for the summer, and the milder and more sheltered for the winter, the better for the consumptive. The benefit that patients often quickly experience from the change is most striking, even in the more advanced stages of consumption. To profit fully by the influence of pure air, the patient should be as much out of doors as the weather will permit: and use as much gentle ex- ercise, both by walking and riding on horseback, as the state of the strength will allow, without inducing much fatigue. To those who bear them pretty well, sea voyages are sometimes highly beneficial; during the summer season, these may be confined to yachting about our coasts or crossing our seas; but the voy- age to India, the Cape, to Madeira, or to the Mediterranean, may, with advan- tage, be made at a later season, with the view to pass the winter in these more genial climates. Of places for winter residence abroad, Madeira, Rome, and Nice, are generally considered the choicest spots; we much prefer the former. Were there suitable accommodations for English invalids, we have reason to be- lieve that parts of the north coast of Africa, particularly Tunis, would afford a climate better suited to the consumptive than any other of the Mediterranean. Of the milder spots in our own islands, the Undercliff in the Isle of Wight, Torquay, and Hastings, and the Cove of Cork, are most favoured; but many places on the southern and western coasts, also, present many advantages in point of mildness and equality of temperature, over all inland situations. When circumstances do not permit removal to these spots, and even in them in severe weather, the patient must be kept to rooms moderately and equally warmed (from 55° 65°, according to the feelings,) and as airy and well ventilated as they can be made without risk of draughts of air. fulmonary consumption, (Treatment.) 393 The selection of the best climate for consumptive patients is often a matter of considerable difficulty. To the places recommended, we may add Hycres in France—both the mainland and the adjoining islands; St. Augustine in Florida, and several points in the West Indies, of which Santa Cruz seems the most desirable. In all, or most of these situations, consump- tion is more or less prevalent among the natives, but to a foreigner, the great advantages of a winter at them consist in the avoidance of the keen northern winters which are injurious to most but not to all consumptives, and the facilities afforded for abundant exercise in the open air. The journey and the change of scene are also decidedly curative, or at least palliative agents. But much mischief is often done by indiscriminate banishment of patients from home. None should be sent who offer the following objectionable points: 1st. Those who are strongly averse to the journey, especially if the disease be at all ad- vanced; for the moral effects which result from this species of banishment will more than counterbalance the possible advantages which might result. 2d. Patients labouring under acute phthisis with much fever should never be sent upon a journey : it is almost always mischievous to them. 3d. In the advanced stages of the disease no benefit Can accrue from' the journey, at least there are few exceptions to this, and then it is only allowable when the patient is himself strongly desirous of the attempt. 4th. There is a fourth class of phthisical patients who are positively injured by warm weather, and who can readily indicate the climate which is most fitted for them. G. The diet in the early stage of consumption should generally be of a mild and unstimulating character, consisting chiefly of milky and farinaceous food. Some- times white fish and chicken may be allowed; and a state of vascular debility, or previous habits, may make the plainer kinds of meat necessary; but this is espe- cially the period of irritation or congestion, and more mischief is likely to result from repletion than from moderation. For the same reason fermented liquors are not generally admissible at this period. Second and third stages. When the signs and symptoms announce that the tubercles are softened and cavities in the lungs formed, it will generally be neces- sary to modify the treatment in some degree, for the constitutional debility then commonly increases and the irritations may have diminished, or at least have not kept pace with the progress of the disorder. Here depletions are less needed, and worse borne; and a somewhat tonic plan of treatment, with some of the prepara- tions of bark or iron if they can be borne, and more generous diet, with meat and malt liquor, may often be adopted with advantage; still counter-irritation will prove useful in most cases, and in these stages those kinds which cause a purulent or muco-purulent secretion will generally produce most benefit. In fact, the same abatement of irritation which we have before described to accompany free purulent expectoration, will in some degree follow from this external suppuration, without the wasting and harassing effect of such a discharge from the lungs. With this exter- nal outlet as a sort of safety valve, strengthening medicines and nourishment may be borne; and there is less risk in restraining any excessive secretion which may take place from the lungs, the bowels, or the skin. Much attention is necessary to keep up the artificial discharge, whether it be by the formation of successive crops of pustules, by tartar-emetic solution or ointment, or some similar suppura- ting liniment, or by a seton or issue. If it be suddenly checked, there will in all probability be an increase of pulmonary irritation, perhaps attended by the depo- sition of more tuberculous matter. In slighter cases, or where the weakness and irritability forbids these measures, occasional blisters, or the frequent use of milder liniments, containing tartar-emetic and hydriodate of potash, or diluted nitro-muriatic acid and oil of turpentine, are often productive of some benefit. In the softened tuberculous and ulcerated stages of phthisis the constitutional powers especially need-support: and it is then, more particularly even than in the first stage, that the general measures are required ; but unless the disease be limi- 396 TUBERCULOUS DISEASE OF THE LUNG, OR ted in extent, there is, for the same reason, less hope of their success. The disease has existed longer, and passed into a stage in which it is more likely to have tainted the system. The preparations of iodine and other tonic alteratives should be used more freely; and the general health supported by all the medical and hygean circumstances that can be brought to bear on it. There are vomicae to be evacuated, and the object is to assist nature in effecting this object; in protecting the lungs from farther injury during this process, and in effecting the healing of the fistulous cavities which are left. The means already recommended to strengthen the general health, are those which most conduce to these ends; but it is necessary to advert to some topical measures which have been supposed to promote greatly these objects. These are the direct application of certain gases or vapours to the lungs themselves, by means of inhalation. The only agents to which we need advert, as having been by good authority reported to be useful are chlorine, the vapour of iodine, and that of tar. The last was recommended by Sir A. Crichton. The vapour is diffused through the patient's chamber, by heating the tar to gentle ebullition, with a little carbonate of potash to retain the irritating pyroligneous acid. From the more extensive trials of Dr. Forbes, it appears that this remedy was often injurious and seldom of marked benefit in phthisis, but in bronchial disease it proved salutary. Dr. Morton of Philadelphia, and Drs. Hufeland and Neu- mann of Berlin,are stated by Sir J. Clark to have reported more favourably. The inhalation of chlorine was first recommended by M. Gannal, and several French physicians have spoken favourable of it. Sir C. Scudamore reports that he has effected several cures by the inhalation of chlorine with the vapour of tincture of conium or some other narcotic. Sir J. Clark states, that in several instances in which he tried it, it relieved dyspnoea and apparently suspended the progress of the disease. Our own Experience of the inhalation of chlorine is not favourable; having generally found it increase the cough and other symptoms of irritation; Dr. Stokes reports to the same effect. But we should expect some benefit from it, where there is little disposition to inflammatory action, particularly when the expectoration is profuse and foetid. The vapour of iodine has also been much extolled as a means of promoting the removal of tubercles and the cicatrization of cavities; but there is not yet sufficient evidence in its favour to warrant us in recommending it The usual modes of inhaling these vapours (through tubes adapted to a bottle contain- ing hot water with a certain addition of the chlorine or iodine to it) have always appeared to us objectionable, inasmuch as the tubes are generally too small, and the effort of inhalation is irksome to most patients. It would be much easier to use a large open vessel of hot water, such as a basin or jar, and add to it, by degrees, the required quantity of liquid chlorine, or tincture of iodine; or place it in a saucer floating on the hot water; the patient might then approach his nostrils as near as he can bear without causing him to cough. This might be repeated twice a-day or oftener.- Dr. Corrigan has devised an apparatus by which the liquid chlorine or iodine can be made to drop slowly into a vessel of water kept boiling by a lamp. He found that when iodine is diffused in this mode through the apartment of the patient for some time, it could be detected in the urine. It is not unlikely that by very judicious management, the inhalation of various agents may sometimes conduce to a healthier and healing action in the interior of ulcerated lungs. But we must chiefly look to the improved state of the constitu- tion for this healthy action, and for what is of more immediate moment—a ces- sation of that disposition to deposite more tuberculous matter in other parts, which too commonly prevails during the softening and the evacuation of tuber- cles. In very many cases, alas! no means will stay the progress of consumptive dis- ease, and the utmost that we can do is to give temporary relief to the more dis- tressing symptoms; to the cough, sometimes by a leech or two over the wind- pipe, but more commonly by various narcotic remedies, such as conium, hyosya- mus, hydrocyanic acid, and particularly opiates, of which the compound camphor tincture, and Squire's solution of bimeconate of morphia in small doses, we have pulmonary consumption, (Prevention.) 397 found the best; to pains in the side, by a mustard poultice, a turpentine fomenta- tion, and if these fail, by a few leeches or a blister; to the dyspnoea, by aether and ammonia, or paregoric, or tincture of lobelia, or, according to Sir J. Clark, by extract of stramonium, half a grain in the day; to the hectic heats, by sponging with tepid vinegar; to the sweats and to excessive expectoration, by acid and tonic mixtures; to the diarrhoea, by astringents, preceded by a mercurial aperient, and accompanied by a suitable diet. In not a very small number of cases we may considerably prolong life by watchfulness and judicious measures. Con- sumption may run its course in a few weeks; but it may exist in a limited and chronic form for many years, and such cases may reward us for our attention and judicious treatment, if not by permanent recovery, at least by temporary restora- tion of a moderate share of health and strength, compatibly with the enjoyment of life, and with the fulfilment of important duties in society. Prevention of tuberculous disease. The small chance of doing good which the healing art possesses in tuberculous disease is a great reason why our attention should be directed to measures of prevention from which much benefit may rea- sonably be expected; and it is on this department of practice that our improved knowledge of the pathology may be brought to bear. The prevention or speedy removal of those inflammations and congestions which contribute to develope phthisical lesions, and of that state of strumous cachexia, or imperfect nutrition, from which they especially arise, constitute the indications for prevention which pathology suggests. To fulfil these indications is to remove or counteract the se- veral causes which we have specified as producing or increasing consumptive dis- ease, and the means of effecting this, comprehend many remedial and hygeianic details. It is only necessary here to advert to some of the more prominent. The earliest and at the same time the least doubtful cause of phthisis is heredi- tary predisposition; and when this has been fully acquired, either this or some other form of scrofulous disease generally ensues sooner or later. But it is very probable, as Sir J. Clark has suggested, that the formation of this predisposition could be in great degree prevented by attention to the health and alliances of suc- cessive generations. " If," says he, " a more healthy and natural mode of living were adopted by persons in that rank of life which gives them the power of choice, and if more consideration were bestowed on matrimonial alliances, the dis- ease which is so often entailed on their offspring might not only be prevented, but even the predisposition to it extinguished in their families, in the course of a few generations." The propriety of avoiding intermarriage with those families which have shown proofs of consumption is obvious, as nothing is more likely to increase the ten- dency. The health of mothers during utero-gestation and suckling should also be carefully guarded; and the children of consumptive families must be reared from birth to maturity with the fullest possible regard to their physical condition, and every precaution against causes of disease and derangement of the general health. Warm clothing, well-ventilated rooms, a healthy residence, plain nutritious food, but of due quantity and quality, regular and frequent but varied exercise in the open air, as far as the season will permit—that on horseback is the best; daily use of the cold bath, or free sponging, followed by friction; strict attention to the state of the excretions, and their regulation, if necessary, by diet and mild reme- dies, constitute the chief general means to be employed to fortify the constitutions of those in whom there is reason to suspect a disposition to phthisis. Frequent change of air, particularly from inland to coast and the converse, is generally be- neficial, as far as that can be practised without incurring exposure to an unhealthy or too cold an atmosphere. Occasional sea voyages are sometimes of marked benefit in generally strengthening the constitution. A residence for some years in a warm climate is indicated for those whose brothers or sisters have become consumptive in this country about a particular age; but on their return, even al- though the critical period be passed, unusual care will be necessary for some time. So, on the other hand, those who become enervated and languid during the heat 398 MALIGNANT GROWTHS IN THE LUNGS. of summer, should resort to a mountainous district or an airy coast during that period The great object is to prevent the general strength from being lowered, or the functions deranged, by any influence whatsoever, and this is generally better to effected by hygeian than by medicinal means, but we may and often must bring our aid tonics and alteratives of various kinds, as well as the different remedies that are required to improve the secretions. It is impossible to enter into any details, for very different remedies may be best suited to different individuals; but if there beany which are so more commonly than others, these are combinations of iodine and of iron, and courses of saline or saline chalybeate mineral waters. With the view to strengthen the lungs, and to render the pulmonary system less apt to suffer from cold or heat, the regular practice of freely sponging the chest and whole trunk with vinegar and water, or salt and water, followed by vigorous friction, de- serves especially to be recommended. It not only improves the tone of the respi- ratory apparatus, but diminishes the liability to bronchial affections from ex- posure to cold: these affections are the most common causes of the development of tubercles. MALIGNANT GROWTHS IN THE LUNGS. Encephaloid disease of the lung.—Scirrhus.—Melanosis and spurious Melanosis. We need say little on the subject of encephaloid, scirrhous, and melanose dis- ease of the lungs; for their occurrence is too rare to be of much practical impor- tance, and they are not known to be influenced by medicine. They may occur in a circumscribed form, or pervading a considerable extent of the pulmonary tissue; and they would then produce physical signs like those of consolidation from hepa- tisation or tuberculation of similar extent, and could be distinguished from these only by the history and general symptoms, and by the absence of the constitutional indications of tubercles. They commonly cause death, either by their encroach- ment on the function of the lungs, or from being simultaneously deposited in other organs, such as the mesentery, the liver, the ovaries, &c. But when they occupy the lung chiefly, both encephaloid and melanose deposites tend in time to soften and form ulcerous cavities as in the case of tubercle. We have seen such cavities more than once in both these forms of disease. The general appearance of encephaloid disease or medullary sarcoma, is that of a brain-white solid, of varying consistence, with a pinker hue than that of tuber- cle, occurring either in separate tumours, which are sometimes encysted, or infil- trated through the tissues of the lung, and modified by their colours. When occurring in separate tumours, it is sometimes soft and cellular; in other cases tougher, and more like the pancreas; in others, again, it becomes of fibro-carti- laginous hardness. A predominance of a loose cellular and vascular structure in it, with patches of extravasated blood, give it occasionally the appearance that has obtained for it the name of fungus haematodes. We may conjecture that the albu- minous matrix of these products is deposited in an organizable form, and vascular ramifications are certainly formed through it; but it is deficient in the cohesion and contractUe tendency of ordinary false membranes ; it does not restrain the farther effusion from the vessels, whence the tendency to growth in these produc- tions. When encephaloid matter occurs in an infiltrated form in the tissue of the lung, it sometimes presents an appearance intermediate between that of tuberculous and that of hepatised consolidations; and unless there be portions of the diseased production occurring separately, it might be taken for one or other of these lesions. MALIGNANT GROWTHS IN THE LUNGS. 399 The only form of disease which we have seen affecting the lung, which ap- proaches in any degree to scirrhus, is that which we have already described as a result of a chronic pleuro-pneumonia; there being in these cases firm adhesions to the pleura, a shrunk state of the lung, and dilatation of the bronchial tubes. The indu- ration and glistening texture which the lung so changed sometimes exhibits, espe- cially around the larger air-tubes, might lead one to suspect it to be of a scirrhous nature; but we have seen neither the tendency to cancerous ulceration, nor the simultaneous occurrence of scirrhus in other parts, which might be expected if this induration of the lung were really of a malignant kind. Dr. Corrigan seems to have lately described a similar morbid condition, which he calls, not very appro- priately, cirrhosis of the lung. We have met with several cases of melonosis, or black tubercle, affecting the lung, both exclusively, and with the same production in other parts of the system. We have seen it combined with encephaloid disease. The black matter may occur infiltrated in a natural structure, or in distinct tumours or deposites of an irregular cellular organization. We are much inclined to adopt the opinion of Andral, that the black matter is nothing but a modification of the colouring matter of the blood, in which carbon is in excess, or even in a free state. We have seen the deposites exhibit in different parts various shades of colour, from the dark cruor red of haemorrhagic engorgement to the deep jet black of perfect melanosis. The inter- mediate colours were of a bistre or sepia brown. The organized texture of mela- nose tubercles and tumours presents considerable variety, sometimes approaching to the most perfect products of acute inflammation, being soft and cellular or membranous; and sometimes having almost the totally unorganized structure of scrofulous tubercle. Probably it is only this latter form that undergoes the changes of softening and ulceration ascribed to melanosis by Laennec; and under these circumstances, such changes are to be referred to the same causes as those which operate in the kindred changes of tubercle. The presence and modification of the colouring matter of the blood seems, therefore, to be the essential pathological con- dition of this disease, as an aHered or deficient vitality of the fibrinous matter is of tuberculous affections. It is necessary to avoid confounding with melanosis the accumulations of the black pulmonary matter, which take place to a great extent in the lungs of old people, especially among the inhabitants of large towns. These are probably, as Dr. Pearson supposed, derived from the soot inhaled with the air; which, we presume, finds access to the texture of the lungs chiefly through abrasions, soft- ening, or other such lesions of the bronchial membrane, which, in a slight degree, often result from a common cold or cough. Whether from this source, or, as others have supposed, from an altered state of the colouring matter of the blood itself, we think it is plain enough, that when once deposited in any corners out of the immediate sweep of th,e circulation, such as in the angles of lobules, near old lesions, around large vessels, and in the bronchial glands, there it must lie, accumulating until death, or until it is carried off by the destruction of the tissue by some pulmonary disease. For it consists entirely of carbon; and this being totally insoluble in any animal fluid, is insusceptible of absorption, which scarcely acts on insoluble solid matter. For the same reason the carbonaceous matter of tattooed skins, and the insoluble oxide or chloride of silver in persons coloured blue from the too long internal use of nitrate of silver, are permanent, and can only be removed with the skin itself. It does not appear that this carbonaceous deposite in general interferes materially with the function of the lungs; but there are some curious cases on record, in which it has taken place so rapidly and ex- tensively as to cause chronic inflammation and consolidation of a perfectly black colour, which tends to ulceration and the formation of cavities, as in other cases of chronic consolidations. Such cases are described by Drs. Gregory, W. Thomson, and others, as occurring particularly in coal-mines, and persons labour- ing under bronchial disease whilst continually employed by the light of smoky lamps. 400 DISEASES OF THE BRONCHIAL GLANDS. The general symptoms of encaphaloid or melanotic consolidation of the lungs are those of obstructed breathing or circulation, dyspnoea, lividity, and dropsy; more commonly than those of consumption and emaciation, which belong rather to tuberculous disease. This is explained by their more rapid development, and their not so readily leading to softening and ulcerative destruction of the organ. When this process does occur, the expectorated matter may afford means of dis- tinction. We have seen, in the case of encephaloid disease, streaky red and white purilaginous liquid sputa, and, in melanosis, a considerable quantity of black matter, mixed with a muco-purulent compound. But such cases are not common, and the expectoration is more usually that of the brbnchitis or pneu- monia that may accompany the disease. DISEASES OF THE BRONCHIAL GLANDS. The bronchial glands are not unfrequently found after death in a diseased state, even when no symptoms referrible to them had been manifested during life. We do not mean the deposite of black matter like that of the lungs, for that is so constant that it can scarcely be considered to be morbid. But they are sometimes found swollen and red, or containing caseous matter, or osseous concretions. In children they are occasionally so enlarged by the deposition of tuberculous matter, as to press on the air and blood-vessels, and, according to Dr. Carswell, to produce dyspnoea and symptoms of obstructed circulation. They sometimes soften, and become evacuated by ulceration into the bronchi. Encephaloid disease, as well as ex- tensive enlargement, not of a malignant character, may also affect these glands. We suspect that encephaloid disease of the lungs generally originates in this way, and spreads afterwards along the vessels into the pulmonary tissues. We have also met with cases of dulness on percussion on the top of the sternum, with signs of obstructed circulation and respiration, with simultaneous enlarge- ment of the axillary and cervical glands, betokening a glandular tumour about the root of the lungs; and all these symptoms gradually subsided under the use of iodine and alkalies; so we conclude that the tumour was simple glandular enlarge- ment. Considerable tumours of the bronchial glands might perhaps sometimes be discovered by dulness on percussion on the upper portion of the space between the clavicles, and on the spinous processes of the upper dorsal vertebrae. The tumours generally, however, grow forwards, and we have seen them pushing out the sternum or the ribs on one side, and causing dulness at those parts, and symp- toms of displacement of the lung farther down. They also may produce signs by their pressure on the great vessels, arterial and venous, stimulating those of aortic aneurism; and we have known them compress the gieat bronchi to a fatal extent. The tuberculous disease of the bronchial glands is almost confined to children, and is in them the most frequent form of tuberculous deposite. It complicates, therefore, almost all disorders of this kind, and is the point which is in most cases first attacked. The glands do not, as a ge. neral rule, pass into softening. In the largest number of cases the tuberculous matter becomes hard and dry, and is finally converted into a calcareous deposite which is absorbed with great difficulty, and sometimes remains ever afterwards. In the smaller number of cases, softening actually occurs, and the contents of the cyst which contained the gland are evacuated through an ulcerated opening into the bronchi. influenza, (Description.) •101 There arc no positive signs of tubercles in the bronchial glands, but if they attain a tolera- ble size, sufficient to press upon the tubes and diminish their caliber, the patient frequently has attacks of spasmodic catarrh similar in many respects to those of pertussis, but less violent: if these are conjoined with the general signs of a scrofulous diathesis, the diagnosis becomes tolerably certain. The treatment is of course entirely constitutional: iodine and its various preparations, and other remedies which act as general alteratives, are the only means from which much can be expected in this form of scrofulous disease. G, INFLUENZA. Nomenclature*—Description.—History of the principal visitations.—Diagnosis.—Nature of the disease.—Source of the epidemic.—Treatment. The malady to which, from the supposed influence of the stars in its produc- tion, the name of influenza has been applied, is an epidemic affection, usually ac- companied with catarrhal symptoms, and with a depression of strength far greater than is proportionate either to the febrile excitement, or to any accompa- nying local disorder. It is the Rheuma epidemicum of Sauvages, the Catarrhus epidemicus of Swediaur, Catarrhus a contagio of Cullen, Amphimerina anginosa of Huxham, Febris remittens catarrhalis of Macbride. By the French writers it is called Folette^ Coqueluche, Petite poste, Coquette, Baraguette, Rhume epi- demique [and Grippe,] Fievre catarrliale; by the Italians, Catarro Russo; by the Spanish, Influencia Rusa; by the Germans, Huhnerzipf, der H'uhner Wenn Bletzkarr, Epidemischer Schnupfenf Russische Krankheit. Of all epidemics it is the most rapid in progress, sudden in invasion, and ex- tensive in range. The complaint usually commences like a feverish attack, with a feeling of chilliness and a sensation as of cold water running down the back; weariness and stiffness of the limbs, and pain in the neck, back, and loins, more intense than those which attend the common forms of fever. In the more severe cases there is decided rigour alternating with heat and flushing of skin; the fever has an exacerbation every evening, and lasts from two to fourteen days: pain is felt over the frontal sinuses and cheek-bones, or behind the sternum. The eyes are suffused; there is sneezing, tingling, and an acrid discharge from the nostrils; a short, frequent, harassing cough; a feeling of constriction of the chest and throat, and not unfrequently soreness, redness, and tenderness of the fauces. The inflammation of the tonsils is occasionally intermittent. The expectoration, at first scanty and difficult, consisting of thick viscid mucus, usually devoid of air- bubbles, subsequently becomes opaque, copious, and muco-purulent. Sonorous, mucous, and sibilous rhonchi may be detected by auscultation, and there is fre- quently partial crepitation, which is most apt to occur at the lower portion of the lungs. The circulating system is depressed, the pulse being usually feeble, soft, and quick in the early stages; in the decline of the disease slow and sometimes intermitting. The appetite is impaired and the taste perverted; nausea and vo- miting are often present; the tongue white and moist, covered with a creamy mu- cus, or loaded with a coating of moist yellowish fur, and presenting elevated pa- pillae of a peculiar vivid red colour at the edges: in some severe cases it is, however, little affected. In most instances the urine is scanty and high-coloured, soon be- coming thick and reddish, or assuming a whey-like appearance, and depositing a copious pink or whitish sediment. The depression of strength is extreme, occa- sionally resembling the collapse of cholera; the moral energy is subdued, and agonizing fears of death are sometimes present. The skin, at first hot and dry, soon becomes perspiring, and often exhales a peculiar, flat, musty smell; some- Vol. LL—51 402 influenza, (History.) times it assumes a bluish hue. When the lungs are not materially affected, the force of the morbid influence is in some instances directed to the bowels, pro- ducing pain and tenderness of abdomen, and diarrhoea, with mucous or dysenteric evacuations; at other times, the brain being chiefly involved, vertigo, sleepless- ness, and delirium, are prominent symptoms. In very old and debilitated sub- jects, the disorder often presents the character of suffocative catarrh. Among the most characteristic phenomena may be mentioned the persistence of cough and debility, long after the cessation of the other symptoms. The most frequent and important complications are, inflammation of the bron- chial tubes, lungs, pleura, or of the brain and its membranes, acute articular rheu- matism, neuralgia, and cutaneous eruptions. The nature of the complication occasionally depends on constitutional peculiarities, but frequently on exposure to the exciting causes of the associated diseased action, about the time of the onset of the attack of influenza. Thus, for example, exposure to damp under such cir- cumstances will occasion a liability to rheumatic complications, and fatigue or mental anxiety to erysipelas. The principal varieties of the complaint depend partly on atmospheric conditions, partly on the predispositions of the persons af- fected: they may be divided into, 1. The cerebral, characterized by vertigo, de- lirium, erysipelatous eruption on the face, sometimes swelling of the parotid glands. 2. Guttural, attended with Cynanche tonsillaris. 3. Bronchial, with difficult op- pressed respiration: this variety, when occurring in its severe form, constitutes suffocative catarrh. 4. Intestinal, with diarrhoea, mucous evacuations, and in some examples tenderness of abdomen. 5. Typhoid: this form, which rarely oc- curs except among the poor and badly nourished, is characterized by depression of pulse, extreme prostration of strength, and other symptoms of putrid or ady- namic fever. One of the most important considerations connected with the subject of influenza is the tendency of the disease to alter the condition and increase the susceptibility to disordered action of the nervous system and of the mucous mem- branes. A succession of attacks more commonly occurs in this than in any other febrile disorder; and the part to which the force of the disease has been most di- rected, remains peculiarly susceptible of derangement: thus a liability to chronic bronchitis, to intestinal irritation, and to rheumatic and neuralgic affections, often remains for years after a severe attack of the malady; and the subjects of such complications appear less tolerant of active remedies. Almost every visitation of influenza, although characterized by the predominance of some one variety, gene- rally presents examples of each, besides, in some instances, exhibiting phenomena peculiar to itself. The various features of the disorder will therefore be best ex- hibited by a review of the most remarkable examples related by authors. History. Hippocrates and other ancient authors give slight notices of catarrh resembling the disease under consideration. In latter times the epidemics of 1311, 1323, 1327, 1387, 1400, 1403, 1410, 1414, 1427, 1438, 1482, and 1505, were probably examples of the same affection. That of 1323 prevailed throughout the whole of Italy, and, according to Buoni Segni, was attributed to a pestilential wind. In 1387 the disorder prevailed at Montpellier and Romagne, and is said by Valesco to have attacked nine-tenths of the population. In 1403, according to Pasquier, a catarrhal visitation occurred at Paris, so severe as to render it necessary to suspend the assizes. The epidemic of 1410, described by Valesco, was characterized by harassing cough, which was regarded as a punishment for singing a licentious song. The visitations of 1414 and 1448 were peculiarly destructive to the aged. Although the short notices now extant of the above epidemics render it extremely probable that they were exam- ples of the disease in question, yet the first instance which we are fully authorized to refer to it, and the first accurately described by medical authors, is that which occurred in the year 1510, and proved fatal to Ann, wife of Philip of Spain. Ac- cording to Schenck, it was regarded as a new disease. The epidemic proceeding in a north-westerly direction from Malta to Sicily, Spain, Italy, France, and Britain, raged over all Europe, and scarcely missed an individual, but few died except influenza, (History.) 403 children. The complaint was attended with violent pain over the eye, and with the usual symptoms of more recent attacks. Delirium and gastrodynia were often present, and in some instances, from the seventh to the eleventh day of the attack, snatching of the tendons and syncope occurred. Diarrhoea, or sweating, were common at the decline. It was a frequent practice to apply five blisters, two to the legs, two to the arms, and one to the back of the head. Bleeding and purging are said to have been injurious. A similar disorder prevailed in the autumn of 1557, after a hot dry summer followed by cold northerly winds. The malady was in some places preceded by ill-smelling fogs, and followed by great inunda- tions. The disease took a westerly course from Asia by Constantinople to Europe, and afterwards visited America. The attendant fever, according to Mercatus, ex- hibited the character of a double tertian. This epidemic was more destructive than that of 1510; 200 persons fell victims to it at Alkmaer in Holland, and 2000 in the small town of Mantua Carpentaria. In the latter instance the mortality was attributed to the employment of bleeding; but many persons of opulence perished under the suspicion of being poisoned. A similar mortality attended the epidemic catarrh of 1580: 9000 died of the disease at Rome, according to Wierus, in con- sequence of bleeding. The course of the affection was from east and south to west and north. It raged in France after a cold dry wind, following long con- tinued warm moist weather. A prodigious number of insects covered the roads in France about the time of its appearance. In many places it was observed that animals accustomed to feed on herbs and leaves, took a dislike to their pastures. Birds of passage migrated before the usual time, and those that sleep in low val- leys repaired at night to higher districts. (Salius Diversus de Febre pestilen- tiali.) The disorder raged at Sicily in June, at Rome in July; proceeded by Venice and Constantinople to Hungary and Germany, thence to Norway, Den- mark, Sweden, and Russia, where it prevailed in December. Although the plague proved very destructive during this year at Cairo, it is remarkable that no Euro- pean country was visited by that disorder except France, which had been the first to suffer from the catarrhal epidemic. Bleeding from the nose frequently occurred during this epidemic, but the most characteristic symptoms were vigilance or somnolency, giddiness, resembling that of intoxication, and swelling of the parotid glands. Riverius and Forestus, con- trary to the observation of Wierus, speak of bleeding as an important part of the treatment. Sixty thousand persons are reported to have died at Rome in the years 1590 and 1591 of a similar epidemic, associated with severe cerebral symp- toms. Another visitation occurred suddenly in April, 1568, and was chiefly pre- valent in England, after great extremes of weather: the following summer was exceedingly hot, and a fatal epidemic fever prevailed at its close. In 1663 it is said that 60,000 persons were attacked with influenza in the Venetian states in one week. The disease was attributed by Paulini to an intense fog which came from the Adriatic. In 1669 a similar affection prevailed in Holland, and proved fatal to Sylvius de la Bb'e. In 1675 Germany was visited in September, and England in October, by a similar epidemic: the previous summer had been unu- sually warm, and followed by cold moist weather. It is worthy of notice, that the plague prevailed that year in Malta, although it did not visit that place after- wards till 1813. This epidemic was preceded in France by thick fogs. The disease is said by Peu to have been peculiarly fatal to women in the puerperal state. The influenza which prevailed throughout all Europe in 1729 and 1730 was attributed by Hoffmann to changes of weather from heat to cold, and cold to heat, greater than he had ever experienced; by Laeu it was referred to thick sul- phurous fogs. Several earthquakes occurred about the same time, and he consi- dered these, as well as the sulphurous transpiration, to be occasioned by the non- occurrence of an eruption of Vesuvius. This catarrhal fever visited every part of Europe in the course of five months, and attacked 50,000 persons at Milan, 60,000 at Rome, and the same number at Vienna. It was very fatal in Pans and London; in the latter place destroying a thousand a-week, in September, a greater 404 influenza, (History.) number of deaths than had occurred in this city in so short a time since the period of the plague. Switzerland suffered little, Italy and Spain very considerably. The disorder generally proved most severe in low marshy situations. In some places it was complicated with petechia?. Hysterical subjects when suffering from the epidemic, complained of a peculiar feeling of cold in the course of the sagittal suture. Sanguineous discharges frequently occurred at the termination of the disease, and bleeding was in many instances employed with advantage. The influences on which catarrhal epidemics depend appear to have continued in operation from the year 1732 to 1737, and they were associated with remarka- ble electrical and telluric phenomena. During the spring and autumn of 1732 the weather was unusually dry; the aurora borealis was often peculiarly vivid: volca- nic eruptions occurred in various parts of the world; south winds were attended with a dry, and those from the north with a rainy, state of the atmosphere. The disorder is said by Huxham to have ceased suddenly after the explosion of a me- teor in the air, which was accompanied with a fetid fog, and produced, for an hour, an appearance as though the north of the heavens was on fire. It was observed that the epidemic was most apt to be complicated with pectoral affections about the time of the equinoxes, and that cough was generally relieved by diarrhoea, whether occurring spontaneously or produced by purgative medi- cine. In the autumn of 1732 the disorder overran Europe and visited America. In Britain its course was southerly; it appeared at Edinburgh in November, and did not reach Cornwall till February in the following year. From New England in America it spread southward to Jamaica, Peru, and Mexico. This epidemic affected the intestinal as well as the respiratory system; sanguineous discharges from the nose, lungs, and bowels were frequent, especially when bleeding was omitted. Swelling of the parotid and salivary glands, and of the testes, was oc- casionally observed. In Edinburgh the poor and those most exposed to atmo- spheric vicissitudes suffered most. The inmates of the prison and of Heriot's hospital entirely escaped the malady, and although the interments at the Gray- friar's Burial-ground were twice the usual number in the month of January, 1733, yet the fees from the opulent classes did not exceed the common average. Be- fore the eruption of the disease, cough prevailed extensively among horses. The years 1741 and 1742 were remarkable for atmospheric vicissitudes, frequent appearances of the aurora borealis and of meteors resembling soldiers fighting in the air. Catarrhal fever visited several countries during the years 1741 and 1742; and in the spring of 1743, after five months of excessively severe weather with easterly winds, prevailed generally in Europe under the name of La grippe, a word probably derived from chrypka, the Polish word for hoarseness. Destruc- tive disease existed at the same time among horses and deer. The influenza commenced with lassitude and shivering, cold hands and feet, pains of head, limbs, and spine, inflamed eyes, loss of taste and appetite. There was a remis- sion of fever at four or five in the evening, and an exacerbation at night. The decline of the disorder was sometimes accompanied with diarrhoea, at other times with an eruption of pustules on the skin. Sauvages describes a hissing noise oc- curring in the cough of old people affected with the complaint, many of whom died on the ninth or eleventh day. This epidemic preceded the plague in some parts of Sicily. It was less fatal throughout England than in other countries; nevertheless a thousand died of it during one week in London. Epistaxis was a frequent symptom, and in young plethoric subjects bleeding was found useful, and according to Sauvages, might be repeated with advantage; but Sennertus at- tributes the destructiveness of the disease at Rome to the injudicious employment of that measure. The spring of 1762 was characterized by remarkable alternations of intense heat and cold, and by a rapid succession of wind, frost, snow, and rain; and epi- demic catarrh was general in Europe. It had however appeared during the pre- vious year in America. The disorder swept away one-third of the inhabitants of Toulon, extended northwards to Breslau, Vienna, and Hamburgh, and in a month influenza, (History.) 405 passed from London to Edinburgh. This epidemic was singularly capricious in its course and severity, destroying a hundred daily at Breslau, yet sparing Paris and the greater part of France; it was exceedingly mild in many parts of Eng- land, especially London, the suburbs of which escaped, but in Norwich was more fatal than the visitation of 1743. It prevailed among the sailors in the Mediterranean in July, during the prevalence of hot weather with easterly winds. Those who were severely attacked usually had either head symptoms, or haras- sing cough. These symptoms sometimes alternated with each other, but scarcely ever existed together. At the end of the second week at Edinburgh, some of those affected complained of pains of the thigh, others had maniacal attacks. A large proportion of the inhabitants of Europe suffered from the complaint; but scarcely any died, except the old, the asthmatic, and the consumptive. Relapses were frequent, and those who neglected themselves had a tedious cough with some degree of fever, which occasionally was intermittent, and yielded to bark. The autumn of 1775 appears to have been remarkable, both in France and Bri- tain, for thick noisome fogs, so prolonged as to obscure the sun for many weeks. In France the weather was cold and rainy, in Scotland unusually dry. The com- mencement of the year was very cold, then followed snow, abundant rain, and sudden changes of temperature. These vicissitudes occurred later in England than on the Continent, in correspondence with the later appearance of the epi- demic. Disease prevailed at the same time among dogs and horses: meat sus- pended in the air by means of a kite, near Glasgow, quickly became tainted. Dr. Fothergill, with laudable zeal, engaged in a correspondence with various practitioners on the subject of the epidemic, and much valuable information was thus obtained respecting the local peculiarities of the complaint. This visitation was mild in its character, especially in England; and most of the deaths which occurred were attributed by Dr. Macbride to the omission of bleeding. More men than women suffered, and, with the exception of Dr. Ash of Birmingham, most observers agree, that those who were most exposed to the weather, were most liable to the attack. Sir George Baker remarks, that girls' schools fre- quently escaped, whilst boys' schools were often severely affected. The com- plaint was attended with pain in the loins and sides, and occasionally with cramps; there was frequently itching of the skin; in some instances an eruption of pustules, in others erysipelatous redness; and Dr. Heberden saw two cases in which there was a rash resembling scarlatina. Suppuration of the parotid glands occasionally occurred, and a tendency to somnolency was sometimes present. Dr. Thompson of Worcester in some instances observed an alternation of delirium, stupor, and cough. Dr. Haygarth in one case remarked the follow- ing symptoms in succession,—diarrhoea, delirium, cough, and an exanthematous eruption; subsequently the cough returned, and continued as the prominent symp- tom till the disease subsided. The average duration of the complaint was five or six days. Dr. Fothergill mentions that those patients soon recovered, who, within thirty-six hours after the onset of the disease, had a free discharge from the nose, copious expectoration, perspiration, or bilious evacuations. Sir George Baker notices a milky appearance of the urine as an indication of recovery. The decline of the disease was attended with a febrile condition, which was often in- termittent. This state on the Continent was relieved by bark, but in England that medicine only aggravated the fever, and purgatives were found requisite. Several peculiarities of a local character deserve to be noticed. In many places bleeding was found useful, but Dr. Ash of Birmingham mentions that none died in the workhouse of that town except those that were bled. In some dis- tricts the disorder was partial, in others general. Thus, for example, at Exe- ter, of 173 persons in the hospital only two children escaped; and at Chester all the inmates of the house of industry, amounting in number to 175, suffered from the malady. At York, the inhabitants of which are peculiarly prone to constipa- tion, the disease was usually combined with diarrhoea. At Aberdeen the atten- dant fever never assumed the intermittent character. Dr. Fothergill observes 406 influenza, (History.) that the blood taken from patients under the complaint was uniformly sizy; the size being rarely cup-like, but resembling a flat cake of yellowish tallow, floating on deep yellow serum: this observation, however, is not confirmed by other ob- servers. The epidemic is said to have ceased suddenly on the setting in of a frost. The influenza which raged in England in the spring of 1782 appears to have travelled from the east. It was termed Bletzkarr, from the suddenness of its in- vasion. In September, 1780, the crew of the Atlas, East Indiaman, suffered from the malady on their course from Malacca to Canton. Although no instances of the disease had occurred at the former place, they found, on arriving at Canton, that it had raged there associated with bilious complaints, which attended it also in Octo- ber, 1781, on the Coromandal coast and in Bengal. In November, 1781, the epi- demic attacked the army besieging Negapatam; it prevailed at Astrachan, Tobol- ski, and Moscow, in December; Petersburg!! in January, 1782; and Strasbourg in February; spreading through Denmark and Holland (where it received the desig- nation of Morbus Russicus) in March, it arrived in England at the end of AprU, making its first appearance at Newcastle-on-Tyne. This epidemic attacked three-fourths of the population. It was observed to visit towns before villages, and villages sooner than detached houses. It took three weeks to pass from Edin- burgh to Musselburgh, which lies five miles to the south-east. The most promi- nent symptoms were, loss of smell and taste, feeling of contusion in the limbs, darting pain and sense of constriction in the forehead and temples, and sometimes of the whole face, with soreness under the muscles of the cheek-bones. This last symptom sometimes occurred without catarrh, at other times preceded it. Lan- guor, dejection, and depression of spirits, were always present in a high degree, and even in the milder cases the countenance was much altered. There was con- siderable constriction of chest, dyspnoea, and generally cough, which produced much pain behind the sternum, and aggravated the suffering in the frontal sinuses. In some instances pain in the chest and sides are constituted the only symptom. When the catarrh was slight, the disorder had more the appearance of an attack of fever, at first intermittent, and afterwards marked by a quotidian exacerbation like continued fever, and attended with cough, and pain of chest and head: in these cases bark was found useful. Dr. Haygarth considered the disorder contagious. In the plethoric, delirium frequently occurred, particularly at night. Bleeding was not generally found expedient. As in other visitations of influenza, six weeks was the average continuance in each place, and those most exposed to the weather suffered most from its influence. As respects the relation of this epidemic to meteorological conditions, we may mention, that the summer of 1781 was excessively hot and dry, no rain falling in England from the middle of June to the middle of September; the autumn was cold and damp, and the winter changeable. The spring of 1782 was remark- ably late, the hedges in some parts of England not being full blown till June. In May the weather throughout Europe was singularly disturbed, gloomy, cold, and humid. Dr. Darwin observes that the sun was for many weeks obscured by a dry fog, and appeared red as through a common mist. In Bedfordshire, according to Dr. Hamilton, the temperature of the 2'2d of May was one degree lower than that of the 22d of the previous December. On the 2d of January the thermome- ter at St. Petersburgh rose during the night from five degrees below to thirty above zero, and in the morning, in that city alone. 40,000 persons were affected with influenza. For three months previously to the occurrence of the epidemic, in the midland counties of England, scarcely a day had passed without rain; and the outbreak of the disorder was preceded by thunder-storms presenting remark- able phenomena :—" The lightning consisting of balls, which struck against each other, and threw out sparks; and although the thunder was distant, houses were burnt, trees shattered, and several persons killed." It must however be acknow- ledged, that remarkable variations of temperature during the prevalence of the influenza, (History.) 407 disorder did not appear materially to influence the severity or frequency of the attacks. The influenza of 1803, which was nearly as extensive as that of 1775, advanced in a northerly direction. Several solitary cases occurred previously, but the disease did not prevail as an epidemic in England till February, when it.appeared in Sussex; it entered Nottingham in March, Yorkshire in April, and Durham in May. France and Holland suffered before England. Northeasterly winds, thick, foetid, acrid fogs, vivid appearances of the aurora borealis, and sudden atmospheric changes, had been previously observed, and in some countries shocks of earth- quakes* were experienced. In England the fields were covered with immense numbers of insects, and disease prevailed among horses, cows, sheep, swine, dogs, and cats. In France the disorder was often followed by ophthalmia, and in America by dysentery; many children who were the subjects of the complaint had dilated pupils, itching of the nose, and anus, and mucous evacuations contain- ing worms. Pneumonia was also a frequent complication, and bleeding was often found necessary. In some subjects dimness of vision attended the complaint, and remained even after the recovery of strength. One patient, for four days, saw objects three times multiplied. In this epidemic those who lived in sheltered situations, as in prisons and infirmaries, frequently remained free from the disease. The boarders in schools often escaped, provided they were not exposed to the north. One of the most striking instances of the influence of exposure is related by Dr. M'Can of Armagh, who mentions, that of 400 soldiers in barracks only eight were affected, while a large proportion of those billeted in the country suffered se- verely. Many interesting particulars of this epidemic are recorded in the account published by the London Medical Society. Dr. Fothergill, who wrote an excellent account of this visitation, considered the malady contagious. In September, 1830, the disease again appeared at Manilla; it attacked some parts of Britain in the spring of 1831, but did not reach others till the autumn. Remarkably thick fogs, and great variations of weather, had been observed for some months previous to its appearance. This epidemic was widely diffused, prevailing both in the East and in America. In Warsaw, as well as in many parts of Britain, it preceded the epidemic cholera. The characteristic symptoms were, tenderness of the scalp, and cramps of the legs and arms. Towards the subsi- dence of the epidemic, diarrhoea, and dysentery occurred, and formed a transition to cholera. Cough and debility continued long afterwards. In 1833 the epidemic cholera was followed by influenza, which made its first appearance at Java, and attacked more than the influenza of 1831. It was more acute, and left less cough than the ordinary visitations of the malady. The dis- tinguishing symptom was severe headach. Those who died generally had cere- bral symptoms at an early period. According to Dr. Fife, of New-castle, bleed- ing was generally found injurious. The influenza, as it occurred in England in 1836-7, is fully described in the Trans, of Prov. Med. Assoc, vol. vi. that society having made laudable efforts to obtain information respecting the complaint, from all parts of the country. The weather prior to the occurrence of the disorder had been extremely unset- tled. From the 22d to the 25th of December, 1836, there was a fall of tempera- ture of twenty-five degrees, and a quantity of snow followed, perhaps unexampled in this country. Snow fell also in Palermo, Lisbon and Canton. On the 2d of January a thaw set in, and thick fogs prevailed during the month; the general outbreak of the disorder occurred at the commencement of the thaw: easterly winds prevailed, and the aurora borealis was frequently visible: a great many dead flies were found on the surface of ponds. It is remarkable that the malady existed simultaneously at Sidney and the Cape of Good Hope, and on the shores of the Baltic. Half the population were attacked in London, Hamburo-, and Copenhagen. The symptoms for the most part corresponded with those described at the commencement of this article as generally characterizing influenza, particularly 408 influenza, (History.) feverishness, pain and weight of forehead, tingling and acrid discharge from the nostrils, soreness of the fauces, hoarseness, cough, dyspnoea, far exceeding the degree of attendant inflammation, and great general depression. In some parts of the country, particularly at Salisbury and Aylesbury, rheumatism, neuralgia, and rheumatic neuralgia, were frequent complications. In some cases inflamma- tion of the membranes of the brain occurred, in others inflammation of the spinal cord. Pneumonia was a frequent accompaniment, and when it was relieved by bleeding, the original disorder pursued its usual course. The head was in some patients attacked with pain, resembling neuralgia of the branches of the fifth pair of nerves. The pain was remittent, never distinctly intermittent, and sometimes yielded to arsenic. Spontaneous ptyalism occasionally occurred. Dr. Fife and a few other practitioners mention, as an occasional occurrence, enlargement of the parotid glands. From an interesting statement by Dr. Clendinaing (Med. Gaz., vol. xix.) it appears that of 157 complicated cases (constituting three-fifths of those recorded by that accurate physician,) 36 had pneumonia, 52 bronchitis, 25 phthisis, 25 fever, 5 pleuritis, and 14 suffered from other affections. Of 40 severe cases related by Dr. Macleod, 3 had laryngitis, 3 pleuritis, 4 otitis with purulent discharge, 4 inflammation of the fauces, 2 swelling of the parotid and sub-maxillary glands, 1 inflammation of the conjunctiva, and 3 had erysipelas on the subsidence of the other symptoms. The membranes of the eyes were less frequently affected in this epidemic than in that of 1833. Some patients were seized with sudden insensibility; many were affected with agonizing fears of death. Syncope was produced by the removal of a small quantity of blood, and in some instances occurred spontaneously. A state of collapse, resembhng that of cholera, was occasionally observed. Relapses were frequent, requiring more active treatment than the primary attack, and often attended with violent pain between the umbilicus and symphysis pubis. It was observed that children suffered much less severely than adults, excepting during the period of dentition. The victims to the disease among elderly persons had been for the most part previously subjects of bronchitis, or disease of the heart; and, among the middle- aged, of phthisis. The fatality of the complaint was also considerable among those affected with asthma or pertussis, or who had just recovered from eruptive diseases. The deaths, as far as could be ascertained, were about two per cent. on the number attacked, a proportion corresponding with that deduced by Oza- nam from a calculation of the mortality of all the recorded instances of epidemic catarrh. During the epidemic of 1836 it was generally thought, that free expo- sure to the weather lessened the liability to the disease. We may deduce from the preceding account that, since medical records have become available, influenza has prevailed on an average once in ten vears, and has proved the most destructive of epidemics. There is also reason to believe, that a modified condition of the atmosphere may remain for vears after the pre- valence of the disease, and occasion a liability to affections of a similar character, to which the term influenzoid might be applied. For eight years after the pre- valence of influenza at Lyons, this was found to be the case, 1300 deaths out of 10,096 occurring during that period, being attributed to catarrhal or mucous fevers. We are inclined to believe, that a similar condition has existed in this country since the epidemic of 1833, affections of the bronchi and fauces having been unusually prevalent, associated with severe muscular pains and unusual depression of strength. If this be the case, the subject is one of great importance, and well deserves special investigation. Diagnosis. Bronchitis is perhaps the only disease with which influenza can easily be confounded. The former affection, however, is generally induced by atmospheric changes, and attacks the predisposed; the latter has comparatively little reference to changes of weather, affects all individuals nearly equally, and is attended with more local pain and general debility than is proportionate to the severity of the catarrhal symptoms. Nature of the disease. Uncomplicated influenza rarely destroys life, and the influenza, (Sources.) 409 appearances deteeted in the bodies of those who have died while suffering from the malady, have been usually the relics of some associated disease. In the few cases of death which have occurred from simple influenza, the following are the chief appearances which have been observed:—The mucous membrane of the larynx and bronchi has been found of a deep red colour, flakes of lymph have been sometimes observed on the chordae vocales and in the ventricles, and the trachea has been injected and covered with glassy-looking mucus; the lungs sur- charged with serous and mucous fluid, and having portions of their lower lobes engorged and sometimes consolidated. The danger, in extreme cases of influenza, appears to arise from an excess of mucus preventing the due arterialization of the blood. The difficulty and rapidity of respiration are, however, out of all proportion to the quantity of secretion, or even to the amotint of inflammation, and the dyspnoea is sometimes intermittent; and this circumstance cannot easily be explained except by supposing that the cause of the disease must operate, by producing an impression on the vital energy of the lungs, analogous to that occasioned by cutting the nervus vagus; and we may reasonably conjecture that influenza depends on an influence exerted on the nervous system, especially on that part of it having most relation to the bronchial mucous membrane, tending to elicit any latent predisposition to disease, and modified in its character by varieties of constitution as well as by peculiarities of climate and other external conditions. This opinion derives support from the liability, so frequent in this complaint, to derangement in a great variety of organs, as well as from the occasional occur- rence of inflammation of the spinal chord, and of inflammation or other affections of the brain. The effects of such a shock thus communicated to the nervous system may be expected to develope themselves in the weakest organ, and to vary according to collateral circumstances. Thus, in the same epidemic, one patient will suffer from meningitis, another from enteritis, a third from rheumatic affections. If a sudden increase of temperature succeed to frost or snow, pneu- monia will frequently be found associated with the complaint, whilst exposure to fatigue and mental anxiety will increase the liability to erysipelatous complica- tions. Sources of the epidemic. In entering on this inquiry, it is necessary to recall some of the most prominent circumstances which have attended the progress of the disorder: and although most of the accounts which have been given abound in discrepancies, partly arising from real diversity in the phenomena, partly from the preconceived opinions of those who have written on the subject, we shall still be able to select several particulars in which nearly all observers concur. The course of influenza is singularly analogous to that of epidemic cholera. It almost invariably travels in a westerly direction, and from the south towards the north. In proceeding from the east, it passes through Russia and the north of Germany to England, and then turns round through France and Spain to Italy. When arising in the south, its course is from Italy through Spain, France, Bri- tain, and the Netherlands. The average period during which the disease rages in any place is generally six weeks. When specific inquiries have been made to ascertain the truth in this respect, as in Cheshire in the epidemic of 1782, and throughout England in that of 1836, the results have confirmed this statement, which rests on the concurrent testimony of a very large majority of authors: a partial outbreak of the epidemic has, however, frequently occurred a week or more previously to its general prevalence in an affected place. This circumstance was frequently remarked in the visitation of 1836, particularly at Stratford-on- Avon, Chester, and Southampton. There are circumstances recorded making it appear probable that the atmo- sphere of a district in which catarrhal fever has recently prevailed is sometimes so modified as to be capable of producing the disease in visiters some weeks after it has ceased to rage among the inhabitants. For example, in 1782, a family ar- Vol. II.—52 410 influenza, (Sources.) riving in London from the West Indies, two months after the cessation of influ- enza, became affected with the disease; and at Liverpool in 1837, the crews of ships arriving from America were often attacked two months after the inhabitants of the place had become proof against the epidemic influence. Some visitations have most severely affected persons of the sanguine, and others those of the phlegmatic temperament; in some instances those most exposed to the weather have suffered most, in others the reverse has been the case; and it is agreed that no constitution or condition is at present known capable of securing immunity from this all-pervading malady. One of the correspondents of the London Medical Society (Mem. Lond. Med. Soc, vol. vi.) mentions that no case of the disorder occurred in a work-house near Reigate, where 200 were employed in the manufacture of blankets; and he seems inclined to attribute their escape to the free use of oil in the preparation of the blankets; but we need not have recourse to such an explanation, since many other instances occurred during the epidemic, in which persons living in sheltered habitations remained free from the malady. Probably the most remarkable and inexplicable case of exemption which has been recorded, is that mentioned by Mr. Greenhow, of 300 women engaged in coal dredging in the sea at Newcastle. We now proceed to inquire how far the different theories regarding the origin and extension of the epidemic can be reconciled with acknowledged facts; and we shall particularly notice among the alleged causes of its origin or extension, conta- gion, atmospherical vicissitudes, the diffusion of foreign substances in the atmo- sphere, and electrical conditions. Cullen designated the disease Catarrhus contagiosus, and many other authors have attributed its prevalence to this cause: but epidemics into which contagion enters as an important element, for the most part advance slowly, attack masses in succession, and affect different classes of the community at different times. The diffusion of influenza over a whole country is occasionally so rapid as to be abso- lutely inexplicable on the doctrine of contagion, which is also inadequate to explain its frequent extension among the lower animals, having no communication with one another. The theory of contagion is also incapable of explaining the occur- rence of the disease in ships at sea, of which several remarkable instances occurred in the epidemic of 1782: for example, in the Atlas, East Indiaman, between Ma- lacca and Canton; in the ship of Admiral Kempenfelt, whilst cruizing between Brest and the Lizard, and in the fleet of Lord Howe off the coast of Holland, these vessels in every instance having put to sea some weeks before influenza appeared at the ports from which they sailed. On the other hand it must be acknowledged, that the disease occasionally attacks the members of a family in succession, after the manner of a contagious malady. It is also true that, in many instances, when an individual affected with the disease comes from a distance to any place, the inhabitants of the house he visits are often the first attacked. This was particu- larly observed at Norwich and St. Alban s in 17S2. (Dr. Hamilton, in Mem. of Med. Soc.) Dr. Haygarth obtained specific information regarding the same epi- demic as it occurred in ten of the towns of Cheshire; and in seven instances of the ten the first cases presented themselves in houses at which travellers had arrived from affected places. A similar observation was made in the last visitation. (Trans, of Med. Prov. Assoc.) Such evidence is too forcible to be altogether disregarded, and we therefore incline to the opinion, that this disease may be occa- sionally propagated by personal intercourse. At the same time we should consider this mode of communication incidental and occasional, not essential, and should place influenza very low in the scale of contagiousness. Another cause which has been assigned for the production of this remarkable disorder is great atmospheric vicissitudes of temperature or humidity, and the pre- valence of particular winds. We have been careful to relate the most important phenomena having reference to this inquiry; and at first sight there appears to be some evidence in favour of the theoiy of sudden changes of temperature, north- easterly winds, thick fogs, and other indications of an unsettled state of atmosphere INFLUENZA, (SoWCesS) 411 having been present in numerous instances. The comparative mildness of the complaint in sheltered dwellings has been frequently noticed, especially in the epidemic of 1803 : and a remarkable circumstance is mentioned by Dr. Carrick, rather favourable to the explanation under review. On Clifton Hill is a range of building called Richmond Terrace, forming three sides of a parallelogram, respec- tively fronting east, south, and west During the prevalence of influenza in 1803 scarcely an individual residing in the side fronting the east escaped the disorder, whilst a majority, both of persons and families living on the south side, remained entirely free from the malady. We may add that the disease has prevailed most frequently in severe weather. Of 56 epidemic seizures in Europe, 22 have been in winter, 12 in spring, 11 in autumn, and 5 in summer. There is, however, too much evidence of an opposite character to allow us to be satisfied with this expla- nation. The disorder has prevailed in every climate, at almost every season, and during every variety of wind and weather. In 1580 it raged during a sultry autumn; in 1830 at Manilla in the month of September, during a temperature of from 78 to 92 degrees; and in 1836 it existed at the same time in Cape Town and London, the season being mid-summer in the one place and mid-winter in the other. Vicissitudes of temperature, damp weather, and melting snow have often existed to a great extent without inducing influenza, although they have a decided ten- dency to produce catarrhal, bronchial, and pneumonic affections, and when pre- sent during the prevalence of influenza to superinduce such complaints as compli- cations. The theory which refers the cause of the malady to the diffusion of some noxious matter through the air demands consideration. It may not be irrelevant to observe, that spots upon linen and other articles, resembling those occurring from leprosy, have been noticed during the prevalence of cholera and plague, and that such appearances give a plausible aspect to the idea that some tangible mate- rial is engaged in the production of such epidemics. It cannot be denied, that minute substances diffused through the atmosphere occasionally produces effects in some respects analogous to influenza. Cases are related (Rust's Mag. and Lond. Med. Gaz.) in which urgent dyspnoea, spasmodic cough, dryness of fauces, quickness of pulse, and great debility, were produced by inhaling the powder of ipecacuanha; in one of these cases the symptoms were aggravated by bleeding. The production of hay-asthma by the odoriferous particles of the vernal grass, may be adduced as additional evidence of the possibility of such an occurrence. If, however, the epidemic could be referred to such a cause, the uniformity in the period of its continuance in any place it visits would lead to the impression, that the cause must be liable to gradual development and decline, and therefore be organized. The observations of Ehrenberg have proved the abundant prevalence of animalcules in our atmosphere, and it is not improbable that vegetable germs may also abound in it The supposition is allowable, that such organized matter, if existing, may suffer modification, more or less extensive in quantity or condition under the influence of magnetical or other changes, which may alter the relation of the atmosphere to living beings, and by engendering or diffusing some peculiar virus become a source of disease. Such an idea is however purely speculative. Facts approaching nearer to the character of evidence may be adduced in favour of the opinion, that mineral impregnations adequate to produce analogous disorder may exist in the atmosphere. It is difficult to suppose, that the same mineral dete- rioration could arise in every variety of soil; but the difficulty may be slightly dimi- nished by assuming a volcanic- origin. Berzelius, after inhaling a small quantity of seleniuretted hydrogen lost the sense of smell, and suffered from catarrh, suffused eyes, and cough, for many days. Dr. Prott has ingeniously remarked, that some combination of selenium may be diffused through the atmosphere and produce epi- demics. (Bridgewaler Treatise, p. 357.) This substance is often associated with sulphur in volcanic emanations, and there appears to have been a connexion between the acrid dry fogs, which often preceded or accompanied influenza, and volcanic eruptions, especially in the year 1782. Even the grosser kinds of volcanic matter 412 influenza, (Treatment.) may be thrown to a considerable extent. In January, 1835, for example, dust was carried in the opposite direction to the wind, and therefore evidently in a counter- current, from Coseguina in Nicaragua to Chiapa, a distance of 1200 miles; and it is easy to suppose, that gaseous emanations may spread still more widely through the air. At the same time it must be allowed, that the systematic duration of the complaint for a certain number of weeks, and the similarity of its violence in all parts of the world, is unfavourable to this hypothesis. The electrical theory remains to be noticed. M. Weber was so firmly con- vinced of the dependence of the complaint on a negatively electrical state of the atmosphere, as to recommend for a preventive, socks made of non-conducting ma- terials, such as oiled silk, or paper covered with sealing-wax. Dense isolated clouds in a state of negative electricity have been occasionally observed at the commencement of epidemics. Influenza -has often been preceded by violent storms, and in the years 1775 and 1803 meat exposed to the atmosphere was ra- pidly tainted; circumstances rather favourable to the assumption of a connexion of the epidemic influence with electrical conditions. It is true that this theory is not at first sight consistent with the systematic duration of the complaint, and that the observations of Volta did not detect any electrical changes in the atmosphere of affected places. Still the science of electricity is not sufficiently advanced to enable us to decide against this view; and the singular exemption of the coal- dredgers at Newcastle, exposed continually to a conducting medium from stand- ing in the sea, is favourable to the modification of the electrical hypothesis enter- tained by Dr. Schweich, who appears to attribute the disease to a condition of atmosphere favourable to the production of accumulated electricity in the animal body. (Die Influenza, fyc.) The uniformity of the course of influenza from east to west, thence turning round to the south, may be conceived to intimate some connexion with magnetic cur- rents ; and it is not improbable that magnetical conditions may have some effect in predisposing the system to the morbid influence, or in modifying the causes on which the malady may essentially depend. Treatment. Notwithstanding the general analogy presented by different visi- tations of influenza, there is yet so great a variety in the prominent symptoms of any visitation, that our experience of one is an insufficient guide to the treatment of another. Indeed in any single epidemic the derangements of health produced in different subjects are so diversified, and our knowledge of the organic changes on which they depend is so incomplete, that we cannot reduce the plan of treat- ment to a systematic form. An attempt to divide the disease into different stages and to fix the appropriate treatment for each, would lead to unnecessary refine- ment, rather than conduce to practical utility; and it will probably be sufficient to speak of the management adapted to the complaint at its commencement in its progress, and in its decline. In the slighter manifestations of the disorder we must confine our treatment to the mildest measures. A careful regulation of the diet may be alone sufficient. When the employment of remedies is expedient, we believe that too much importance cannot well be attached to the use of mercury followed by an aperient at the onset of the malady. In a considerable proportion of cases, a dose of calomel combined with compound extract of colocynth, followed by a saline purgative, will be found of signal utility, obviating congestion, diminish- ing the liability to local inflammation, and rendering the subsequent affection milder and more transient. In many instances a single dose of the remedy seems to accomplish the object; in others it may be once or twice repeated on alternate days with advantage. Even when some degree of intestinal irritation is present, mercury in a milder form may usually be administered. Under such circum- stances, mercurial pill combined with an anodyne extract, as that of hemlock or henbane, may be employed, and for subsequent use castor oil will be the most suitable aperient. In a few cases without the previous adoption of this plan, and in nearly all after its employment, more especially if the skin is hot and the pulse frequent, it will influenza, (Treatment.) 413 be desirable to confine the patient to bed, and administer mild diaphoretics. Perhaps the most appropriate remedy of this class is acetate of ammonia, which may be combined with ipecacuanha if a mild expectorant is required; and if there be much attendant irritation of the bronchial tubes, with antimonial wine. In cases accompanied with any degree of crepitating rhonchus, a few leeches may usually be applied with advantage. The complication of pneumonia is that which most frequently renders bleeding expedient, but as in the pneumonia of typhus, this measure must be employed with caution. The state of the pulse materially assists in determining the question. Ozanam mentions, that of fifty-two epidemic catarrhs which have prevailed in Europe, bleeding was found useful in thirty-nine, hurtful in ten, and useless in three. In every visitation of influenza there are in- stances in which this measure may be requisite; but as the disease appeared in Britain, with the exception of the epidemics of 1775 and 1803, the cases requiring its employment have been comparatively rare; and it may probably be admitted as a general rule, that inflammation associated with influenza should be treated less actively than when uncombined. This rule applies even to the complication of pleuritis and of pericarditis. When pain of the frontal sinuses, or cerebral symptoms, are distressing, a few leeches applied to the Schneiderian membrane often give material relief When convulsive cough is present, hydrocyanic acid is a suitable remedy. Ipecacuanha combined with oxymel of squills may be ad- ministered if the cough is unattended with expectoration. If, as commonly oc- curs in those who are subject to asthma, there is congestion of the bronchial mucous membrane characterized by sonorous and sibilous rhonchi, aetherial tinc- ture of lobelia inflata may be administered according to the recommendation of Dr. Llakiston. Having found this remedy useful in chronic bronchitis, he was induced to try it in influenza, the dose being from ten minims to half a drachm diluted with two ounces of water. He considers it a narcotic, acting on the or- gans of circulation through the nervous system, and controlling the quantity of blood sent to the lungs. Alkalies may be combined with the lobelia if the bron- chial secretion be tenacious and difficult of expectoration. In cases partaking of the character of suffocative catarrh, mustard poultices should be applied, and senega with ammonia and paregoric, or, in some instances, the Lobelia inflata. Ammonia is peculiarly adapted to cases of profuse bronchial secretion, associated with depression of nervous energy. In some extreme cases, acetate of lead has proved singularly efficacious in checking inordinate secretion from the bronchial tubes. When there is remarkable slowness of the pulse, either spontaneous or produced by treatment, brandy, may be given with advantage, and the cordial plan may be continued so long as it improves the pulse without increasing the cough. In the decline of the affection, in cases which have materially involved the bronchi, copaiba will be found useful in improving the secretion and correcting the morbid condition of the mucous membrane; and where a more stimulating expectorant is requisite, as in the old, and in cases which have assumed any degree of the suffocative character, ammo- niacum and squill may be preferred. In the later periods of such affections, opium is a useful auxiliary; but notwithstanding the sanction of some eminent practi- tioners, we believe its premature use to be hazardous, calculated to check secre- tion, and often to induce inflammation. If restlessness at night be distressing, and tincture of henbane prove inefficacious, morphia may be given with advantage. Should bilious diarrhoea occur, mucilaginous drinks, sometimes combined with lau- danum, are indicated, and emetics if there is nausea or vomiting. In these cases the state of the tongue affords us much assistance in determining on the plan of treatment. If it be covered with a thick fur, especially if the bowels are confined, purgatives are requisite, but if it be preternaturally red and the epigastrium be tender, demulcents, counter-irritants, and even leeches to the epigastrium should be employed. When a febrile condition continues, associated with much debility, and espe- 414 asphyxia, (Preliminary Observations.) cially, if presenting phenomena of an intermittent character, quinine, and Battley's solution of the yellow bark are eligible remedies. Sequelse. We have no conclusive evidence that phthisis can be absolutely pro- duced by influenza, but it is indisputable that previously existing tubercular dis- ease may be called into activity by it. Chronic bronchitis and asthmatic affections, are frequent consequences of the malady, and are often found very obstinate. It is remarkable that the severity of the sequelae bears no proportion to the violence of the attack of influenza. Thus after the mild visitation of the year 1762, a pecu- liarly severe and fatal dysentery prevailed. It should not be forgotten that influenza, perhaps through the medium of a shock communicated to the nervous system, often leaves a state requiring consi- derable and prolonged attention. Even when no particular disease is superin- duced by the attack, the mind and body do not for a considerable time recover their ordinary energy: fatigue is easily produced; there is increased liability to bronchial affections, perhaps a morbid condition of the membrane of the nostrils; greater susceptibility of the mucous membrane of the intestines to irritating medi- cines, or to injudicious diet, and of the skin to atmospheric vicissitudes; and if the patient have been previously subject to neuralgic or rheumatic affections, or to cutaneous eruptions, they will be easily reproduced. In such instances, simplicity of diet, cool rooms, change of air, diminished amount of intellectual labour, the shower bath, and the general adoption of a mildly tonic plan, will be requisite. ASPHYXIA. Preliminary observations.—Causes.—Phenomena.—Anatomical characters.—Nature.—Treat- ment.—Strangulation.—Anatomical characters.—Treatment.—Submersion.—Anatomical characters.—Treatment. The literal meaning of this term (according to its derivation from *, priv. and e-^t/gjj, pulse) is a loss or suppression of the pulse, indicative of a failure in the action of the heart, constituting what is now known as Syncope. It is, however, uni- versally employed at present to designate the cessation of the function of respira- tion (or rather, of its essential part, the aeration of the blood,) and the consequent suspension of the heart's action. Preliminary observations. In order to have a clear idea of the pathological condition thus indicated,—of its causes, nature, and results,—it is necessary to take a brief survey of the character of the respiratory process, and of its connexion with the other vital functions, especially those of circulation and nutrition. This process essentially consists in the interchange of ingredients between the blood and the atmosphere, when brought within the sphere of each other's action in the organs adapted to the purpose. There is, on the one hand, an extrication of carbonic acid from the circulating fluid; and, on the other, an absorption of oxy- gen from the atmosphere. Although these are not the only changes which take place in the process of aeration, they are the most important to the present in- quiry, from their immediate necessity to the continued well-being of the animal. The nutritive fluid, by its circulation through the capillaries of the system, under- goes great alterations both in its physical constitution and vital properties. It gives up to the tissues with which it is brought in contact some of its most im- portant elements; and, at the same time, it is made the vehicle of the removal asphyxia, (Preliminary Observations.) 415 from these tissues of ingredients which are no longer in the state of combination that fits them for their offices in the animal economy. To separate these ingre- dients from the general current of the circulation, and to carry them out of the system, is the object of the excretory organs; and it is very evident that the im- portance of their respective functions will vary with the amount of the ingredient which they have to separate, and the deleterious influence which its retention will exert on the welfare of the system at large. Of all these injurious ingredients, carbonic acid is without doubt the most abundantly introduced into the nutritive fluid; it is also most deleterious in its effects on the system, if allowed to accumulate; and we accordingly find the pro- visions for its removal surpassing in importance that made for any other excre- tion. The two largest glands in the body appear to have for their chief object the separation of carbon from the blood; but this operation is subservient in each case to other purposes. By the liver this element is combined with others into a fluid excretion, which has important uses in the digestive function; whilst by the lungs (which may be certainly regarded as organs of a glandular character) it is excreted in a gaseous form, and thus made subservient, according to the laws of the mutual diffusion of gases, to the introduction of oxygen into the sys- tem, and the consequent maintenance of the animal temperature as well as of the stimulating properties of the blood. It is evident, then, that any circumstances which check the excretion of car- bonic acid by the lungs, will have an immediately injurious effect upon the sys- tem at large, by causing the accumulation in the fluid upon which it is dependent for the performance of its vital actions, of an agent that so seriously injures its vivifying properties. But this is not the only mode in which the cessation of this function is injurious. The exclusion of a constant supply of oxygen from the blood, even though the removal of the carbonic acid were provided for by other means, deprives it of its due power of nourishing and exciting to action the tissues and organs to which it is afterwards distributed; for it would appear that this element is, throughout animated nature, a stimulant as necessary to the energy of its operations, as caloric is to all, and light to many of these. Farther, we shall hereafter see reason to believe that any obstruction to the due aeration of the blood has an immediately injurious effect upon the circulation, by causing a re- tardation or even an entire cessation of its movement through the capillaries of the lungs; and, in consequence, a dangerous accumulation of blood in the venous system, with a proportional deficiency in the arterial. We observe, accordingly, that a provision for these changes is more universally found to exist in living beings than for any other function, save the ingestion of aliment, and the perpetuation of the race. Even in plants a true respiration analo- gous to that of animals is constantly going on, although its effects are sometimes obscured by the converse change which is subservient to a different purpose. (Principles of general and comparative Physiology, p. 294.) In the lower ani- mals the process is carried on by means which render it equally independent of any active movements adapted expressly to the purpose. In proportion to the energy and variety of the nutritive processes, however, does the necessity arrive for a more powerful and constant respiration; and we find in the warm- blooded Vertebrata the highest activity of this function provided for by the vast extension of the aerating surface, and by the means adapted to renew both the blood and the air in contact with it. The arrangement of the circulating appa- ratus is such, that all the blood which has been returned from the system is made to pass through the lungs, before being again transmitted through the aorta —a provision which is not made for any other gland, the portal circulation pre- senting the nearest approach to it. And, on the other side, the nervous and mus- cular systems are adapted to keep up, without the intervention of the will of the individual, a constant series of movements, by which the air that has been viti- ated is replaced by a pure supply. Although these arrangements will be fully explained in the physiological division of this work, it is necessary here to advert 416 asphyxia, (Preliminary Observations.) to the mode in which these constant changes are maintained, in order that the operation of various causes in the production of asphyxia may be rightly under- stood. The periodic movements of the heart, by which the blood is propelled into the capillaries both of the system and of the lungs, result, there is good reason to believe, from the simple contractility of its muscular structure, excited by the direct application of a stimulus. Experiment seems to have sufficiently demon- strated that, although they may be influenced by particular conditions of the nervous system, they are not dependent upon any constant influence transmitted through it, as was formerly supposed. Like other muscular structure, the parietes of the heart may be excited to contraction by stimuli of various kinds; but that which is employed in the living body is the contact of blood with the membrane lining its cavities. So long as the fibre retains its vital properties, will this stimulus excite it to contraction; but if it be deficient, and not replaced by any other, no movement will take place. In those cases in which the movements of the heart have continued for many hours after it has been removed from the body, it is probable that the admission of air to the interior of its cavities has acted as the stimulus. Over-distention of the muscular tissue appears to suspend for a time its contractility; and this effect may even be produced by the accumulation of blood in excessive quantity, which prevents the fluid from exercising its usual stimulant influence. On the other handr the movements of the respiratory muscles are entirely de- pendent upon the influence of the nervous system^ Their ordinary actions are of the class denominated by Dr. M» Hall excito-motor, and were spoken of by Whytt and other authors as sympathetic. They result from a stimulus origina- ting in the extremities of the nerves usually denominated sensory, but which may be more properly called afferent; and this, being conveyed to the spinal cord, occasions the propagation along the motor or efferent nerves of an influence which excites the muscles to action. The afferent or excitor nerves most con- cerned in producing the lespiratory movements are the pneumonic portion of the par vagum, and those which supply the surface of the face and body. The impres- sion of the external air on the skin (itself in some degree a respiratory organ) seems to be the stimulus which acts through the latter; and it is in this manner that the first inspiration of the infant is excited. The presence of venous blood in the lungs has usually been considered as the stimulus which acts through the par vagum; but Dr. M. Hall contends, with some apparent justice, that it is the evolution of carbonic acid which is to be regarded in this light. However this may be, it is admitted on all hands that, after the function is once actively established, the impression of the besoin de respirer conveyed by the pneumogastric is the principal source of the continuance of the movements. From the recent experi- ments of Dr. J. Reid (Edin. Med. and Surg. Journ., April, 1839,) it appears that, although they will continue after section of these nerves, they are much diminished in frequency. The great interchange of filaments which has been proved to take place between the pneumogastric and the sympathetic, joined to certain " residual phenomena" brought to light by experiment, leaves little doubt that the latter system of nerves also is concerned in the maintenance of the respi- ratory movements, its function being perhaps supplementary to that of the pneu- mogastric. We may suppose, also, without much improbability, that the besoin de respirer may be produced by impressions transmitted from other parts of the system as well as the lungs, when imperfectly arterialized blood is transmitted through its capillaries; just as the sense of hunger seems to depend, not only upon the emptiness of the stomach, but upon the demand for nutrition existing in the body at large. It will be observed that the two most powerful excitors of these actions, the pneumogastric and the fifth pair, terminate in the medulla oblongata; and that the motor nerves by which the most important of them are called into play arise in their neighbourhood. Hence respiration may continue when the portions of the nervous centres, both above and below this division, AsPHYxiA, (Causes.) 417 have been removed, which has caused it to be regarded as the peculiar seat of life.* A little consideration will show, however, that it is so only by furnishing the mechanical conditions requisite for the real organic function of respiration, to which the inspiratory and expiratory movements are bat superadded actions pro- perly forming part of the animal functions. We are now prepared to consider the causes which may operate in the production of asphyxia. Causes. The variety of conditions required for the healthy performance of the function we have been considering, involves a similar diversity in the causes which may produce its suspension. These may, however, be classed under two general divisions: theirs* comprehending those which mechanically prevent the contact of the aeriform medium surrounding the animal with the membrane lining the lungs; and the second including those which affect the chemical processes to which this contact is subservient. I. This division embraces a great variety of causes, which must be separately considered. 1. Those which suspend the respiratory movements, by interrupting the nervous circle through whose agency they are maintained. Thus, section of the eighth pair of nerves on each side may induce asphyxia, though slowly, by suspending the transmission to the medulla oblongata of the stimulus originating in the lungs; If no other excitor nerves existed, there can be little doubt that this operation would suspend the usual respiratory movements as completely as section of the moter nerves themselves, though they might still be performed by an effort of the will 5 but the other excitors, which have been already specified, have sufficient power to maintain these actions, although with far less than the normal energy and regu-i larity. The asphyxia of new-born infants arises from the want of a sufficient im- pression upon these superadded excitors, by which the first inspiration is occasioned} as is shown by the effect of the stimulus of cold air on the face, or of the smart stroke of the palm on the body, in producing this essential movement. The nervous chain may be also interrupted at the point of communication between the afferent and efferent nerves, namely the spinal cord. Any want of integrity in the portion of this central organ which is included between its connexions with these nerves, will obviously impede the transmission of the necessary influence, a$ completely as lesion of the nerves themselves. This is by no means unfrequently exemplified in the effects of the disease or accidents to which this part is subject Thus, fracture or dislocation of the upper part of the cervical vertebrae may pro- duce compression or laceration of the cord above the origin of the phrenic nerve. In this case all the respiratory movements of the trunk are immediately suspended, except those produced by the spinal accessory nerve, which are by no means alone sufficient to maintain the constant exchange of air which is required ; and death, therefore, very rapidly supervenes. If the affected part of the cord be below the origin of the phrenic nerve, but above that of the intercostals, life may be pro- longed for some time; but a slow asphyxia appears to take place, since death generally occurs at an interval of from three to seven days. (Sir A. Cooper, on Dislocations, fyc.) The same effect will result from want of functional activity in this portion of the nervous centres, although no disease or injury may have directly affected it. Thus, in the ordinary apoplectic coma, as in profound sleep, the functions of the medulla oblongata being but little impaired, the respiratory movements continue almost as usual; but if, by compression or other deleterious- influence, it should become less able to respond to the stimulus communicated to it by the excitor nerves, the movements will cease more or less gradually, and the aeration of the blood will be consequently prevented. A similar condition may result from the operation of narcotic poisons, by which the functional activity of the * In the class Tunicatd there is but a single ganglion, and this seems almost entirely de- voted to the maintenance of the respiratory movements; so that Nature may be regarded as here presenting the physiologist with an anticipation of the above experiment. (See the author's Prize Thesis on the Nervous System of the Invertebrate, p. 51 A—Author Vol. II.—53 418 asphyxia, (Causes.) Vhole nervous system, but more especially of its central organs, is depressed, and the respiratory movements in consequence suspended for want of the maintaining power. Section of the motor nerves will of course produce a corresponding effect. If the phrenic be divided, respiration may be carried on for a short time by the intercostals, but not in a degree sufficient for the prolongation of life. If the intercostals be divided, the animal will respire with difficulty and imperfectly, as when the spinal cord is injured above their origin; and slow asphyxia is usually the result There is a difference among different species, however, as to the degree in which the movements of the diaphragm and those of the thorax are respectively concerned in producing the ingress of air. In birds it is entirely dependent upon the elevation of the ribs, no complete diaphragm existing in that class; and paralysis of the intercostal muscles, by the division of the spinal cord above their nerves, consequently produces immediate asphyxia. In fishes, on the other hand, the respiratory movements can only be affected by injuries of the me- dulla oblongata, as all the nerves concerned in them arise from that division of the spinal axis. 2. The next group of causes to be enumerated is composed of those which pre- vent the dilatation of the thoracic cavity by mechanical compression of the exte- rior of the body. Instances are by no means rare in which persons engaged in excavating are suddenly overwhelmed by a fall of earth which closely envelopes the body, leaving the head free. If not speedily relieved from such a situation, the sufferer dies of asphyxia; since the descent of the diaphragm is prevented by the compression of the abdomen, as well as the ascent of the ribs by the restraint to which the thorax is subjected; and the first shock expels the contents of the lungs, and reduces the cavity to its smallest dimensions. A curious case is mentioned by Dr. Roget (Cyc. ofPrac. Med., vol. i. p. 177.,) in which a similar result was very near occurring to a pugilist, of whose body a cast was being taken in one piece. As soon as the plaster began to set, he felt deprived of the power of respiration; and, to add to his misfortune, was cut off from the means of expressing his dis- tress. His situation, however, was perceived just in time to save his life. The due expansion of the thoracic cavity may also be prevented by accumulation of fluid or the growth of tumours in the abdomen, by which the descent of the dia- phragm is impeded; but though a very distressing amount of dyspnoea often results from this cause, it is not likely ever to produce absolute asphyxia. Any disease which occasions a very painful condition of the contents of the abdomen, such as acute peritonitis, will offer a similar impediment to the movements of the diaphragm; as will inflammation of the pleura or pericardium, or rheumatism of the external muscles, to those of the thorax. 3. Asphyxia may take place from disorder of the mechanism of respiration, without the existence of any force externally compressing the thorax, or of any direct impediments to the entrance of air into the lungs. These organs may be prevented from dilating by an accumulation of fluid in the pleural sacs ; or by the admission of air into the thoracic cavity, either through its parietes, or through the lungs. If an aperture be made into the cavity on one side, so that air rushes in at each inspiratory movement, the expansion of the lung on that side will be di- minished or entirely prevented in proportion to the size of the aperture. If air can enter more readily than through the trachea, an entire collapse of the lungs will take place; and if such apertures be made on both sides, asphyxia necessarily results. But if they are too small to admit the very ready passage of air, the vacuum produced by the inspiratory movement will be more easily filled by the distention of the lungs; so that a sufficient amount of change takes place for the maintenance of life. Sudden death by asphyxia not unfrequently occurs from a communication being opened by disease between the air-passages and the pleural cavity, so as to check the dilatation of the lung of that side, whilst the function of the other is impeded by tubercular deposition, hepatisation, or some other morbid alteration of its structure. 4. The next group of causes is a very numerous one; and those which it in- asphyxia, (Causes.) 419 eludes, although operating upon the respiratory process in the same manner, an^ very different amongst themselves. It is composed of those which interfere with the admission of air into the air-cells (where alone it is brought into relation with the blood,) either by altogether preventing its entrance into the passages, or by obstructing its movement through them. The entrance of air into the trachea will of course be prevented by any means which produce occlusion of the orifices that lead to it—the mouth and nostrils. If these be obstructed by any solid sub- stance applied closely upon them, death is said to take place by suffocation. If the face be immersed in water, that air can gain no admittance to these openings, asphyxia is said to be produced by submersion. It is obviously immaterial whether the whole body be covered with water or not; many drunkards have been drowned (so to speak) in a puddle, from which they had not sense enough to withdraw their faces; and many infants have been prevented from making the first inspiration by the immersion of the mouth and nostrils in the pool formed by the maternal discharges, or by the occlusion of these entrances by their own membranes. Air may gain admittance to the mouth and nasal passages, and yet be prevented from passing into the trachea, by meeting with some obstruction in the larynx. The rima glottidis may be closed by the oedema resulting from acute Inflammation, or by the thickening which is produced by more chronic disease; or it may be constricted by the spasmodic affection which so often accompanies these states, and which sometimes occurs independently of them, from irritation of the nervous system by other causes; or it may be closed in consequence of para- lysis of the dilating muscles, as Dr. H. Ley believed to occur in laryngismus stridu- lus.* Obstacles to the admission of air into the lungs may also exist in the trachea; the aperture of which may be closed by external pressure, as in strangulations, or its lining membrane may be so much tumefied by disease as nearly to prevent the passage of air. The accumulation of secretions, too, which the patient has not strength to expectorate, may occasion asphyxia; and the same result sometimes occurs in croup, from the obstruction presented by the formation of a false mem- brane, which is often of considerable thickness. The pressure of tumours upon the trachea will often produce asphyxia, which has been the immediate cause of death in many cases of aneurism, and in some of bronchocele. In such cases this con- dition gradually supervenes; and the difficulty of respiration is indicated by the * The pathological explanation of this disease given by Dr. Ley was founded upon the sup- position, that the dilators of the rima glottidis are supplied by the recurrent laryngeal nerve, whilst the constrictors of that opening are stimulated by the superior laryngeal branch. He thence inferred that, if the functions of the former nerve were impeded by the pressure of en- larged glands or other causes, and the muscles which it supplies be consequently paralyzed, the constrictor muscles would close the rima glottidis for want of opposition. The more re. cent experiments of Dr. J. Rcid (Edin. Med. and Surg. Journ.,vol. xlix.,) however, have shown that the superior laryngeal is almost entirely a sensory nerve, and that the recurrent is al- most exclusively motor, supplying both constrictor and dilator muscles. He states that " se- vere dyspncea amounting to suffocation may arise both from irritation and compression of the inferior laryngeal nerves, or the trunks of the pneumogastrics. For when both or even one recurrent nerve was irritated, the arytenoid cartilages were approximated, so as in some cases to shut completely the superior aperture of the glottis." (p. 149.) When the recurrents are cut or compressed, the arytenoid cartilages are no longer separated during inspiration ; and their movements become so completely passive, that they are carried inwards by the current of entering air, which they consequently impede, whilst they are separated again by the expi- ratory blast. " We shall leave it," continues Dr. R., "to those who have had frequent oppor- tunities of seeing this disease to determine which of these two causes, irritation or paralysis, will best explain its phenomena. There appears, however, to be little doubt that the crowing respiration and dyspnoea, which accompany some cases of hysteria, depend upon a spasmodic closure of the glottis, produced by some irritation of the recurrent nerves.—Author. 420 asphyxia, (Causes.) flavor of the countenance and the dilatation of the nostrils, for a long time previous to the termination of life. Sometimes, however, an aneurism or abscess will burst into the trachea, and occasion immediate death by suddenly obstructing the access of air to the lungs. A frequent cause of asphyxia is the presence of foreign bodies within the air-passages, or even in the pharynx. In the former case they may oc- casion speedy death, even though not of sufficient size to produce material obstruc- tion to the passage of air by the irritation they excite; during a fit of coughing they may be driven up against the rima glottidis, which they may mechanically obstruct; or they may occasion spasmodic closure of this orifice by reflex excite- ment of the laryngeal nerves. The increased secretion also, which results from the irritation, adds to the mechanical impediment; so that, from a combination of these causes, death by asphyxia often supervenes where at first no material ob- struction to respiration appeared to exist. The lodgment of large masses of solid matter in the oesophagus, as when an attempt is made to swallow hard substances which are too bulky for its caliber, will sometimes produce immediate asphyxia, as if by strangulation; or, if a partial obstruction only be created, the difficulty may be fatally aggravated by the spasmodic action which is excited, as in the last case. These are the most frequent cases of obstruction to the entrance of air through the larynx and trachea. The bronchial tubes also may be similarly af- fected ; but the amount of impediment thus created in the respiratory process will depend upon the proportion of the pulmonary structure which the particular tube supplies. A foreign body obstructing one of the passages into which the trachea primarily divides, will of course impede, more or less completely, the respiratory action of the corresponding lung, and may thus induce slow asphyxia, which will be aggravated by the spasmodic actions to which the irritation of its presence gives rise. But if it should find its way to one of the smaller passages, no immediately fatal result would probably occur; though diseased action would probably be ex- cited in its neighbourhood, which might ultimately terminate life. Several in- stances are on record in which such an occurrence has seemed to be the remote cause of death. A fatal result may, however, be speedily occasioned by causes which affect the bronchial tubes only, if it involve them universally or nearly so. Thus it may take place from the accumulation of secretions or fluid effusions, which prevent the entrance of air to the air-cells, even though it freely pass through the trachea. This is very apt to occur as a consequence of a congested state of the pulmonary vessels brought on by other causes; and it aggravates this very condition, by the new obstacle it opposes to the respiratory process, and to the movement of blood through the capillaries. Such a state may be artificially in- duced by section of the pneumogastric nerves j but it also supervenes, to a greater or less extent, on many pulmonary diseases. Perhaps we may include, under this class of causes, spasmodic constriction of the bronchial tubes, which seems to be an impediment to respiration in some forms of asthma: the existence of such a state is, however, uncertain; and no experimental proof has yet been given of the ppvyer of nervous irritation to produce it. It is, however, the only feasible mode of accounting for some of the phenomena of this disease. 5. Supposing the air necessary for respiration to have obtained free admission through the teachea and bronchial tubes, asphyxia may still take place from the lungs themselves being in an unfit state to allow the due action between their gaseous contents and the blood. Various morbid alterations of their structure, which it is needless to specify, may thus prove fatal, and this, either rapidly or slowly, according to the progress of the disease. Thus pulmonary apoplexy, a pneumona of a few hours' duration, and a deposition of tubercular matter which has been proceeding for years, may occasion death in the same manner. It is thought by some that, independently of any change of structure, the lungs may be functionally unfit for the aeration of the blood, through a disordered supply of the " nervous influence " which is required for the process; but sound physiology does not warrant us in the belief that any such influence is necessary: nor is there any solid reason to believe that this function can be affected by any cause that asphyxia, (Phenomena.) 421 does not produce a change in the physical conditions which are evidently essential to its performance. Having thus taken a general review of the principal causes which operate by physical means in the production of asphyxia, we may consider, ii. The causes which affect the chemical processes, to which the physical con- ditions are only subservient. These may be briefly dismissed. Of the several gases which may be introduced into the lungs, there are but a small number ca- pable of producing simple asphyxia. Most of them have an immediate deleteri- ous action on the system, quite independent of their negative properties, which consist in their want of power to afford oxygen to be absorbed or to remove the carbonic acid that is to be excreted. Hydrogen and azote are almost the only gases which can be regarded as simple asphyxiating agents. Both these may be breathed for some little time with impunity, even by man; and cold-blooded ani- mals will exist in them for several hours or even days. By their physical proper- ties they are enabled to remove the carbonic acid from the blood nearly as energe- tically as common air can do; but as they afford no oxygen, the animal must sooner or later perish for want of this stimulus. Oxygen breathed alone, how- ever, is very deleterious to the system, which it over-stimulates. Other gases act as true poisons on the system, when introduced into it through the lungs; and their effects, therefore, are of a complex nature. Phenomena. These vary, to a certain degree, with the cause of the suspended aeration of the blood; nevertheless, there are some which are universally witnessed, and to these our principal attention will be directed. They may be best observed when the axphyxia is gradually produced, as by a partial obstruction of the air- passages; when it suddenly comes on, they succeed one another so rapidly as not to admit of accurate observation. They may be divided into three stages. The first commences with an increase of that natural besoin de respirer, which prompts to the ordinary acts of inspiration; and this increases until it amounts to a sensa- tion of extreme distress. In respondence to this extraordinary stimulus, active and powerful inspiratory movements are involuntarily performed; and muscles are excited to contraction, which do not partake in the ordinary duty. Other instinc- tive movements, more remotely conducive to the relief of the sufferings experienced by the individual, are sometimes performed by him at this time. The distress, which soon amounts, if not relieved, to intense agony, is of short duration; though it lasts longer if the aeration of the blood continue to a slight degree, than if the process be entirely suspended. It gives place to vertigo and a feeling of stupidity, which soon increases to absolute insensibility, which may be regarded as charac- terizing the second stage. The respiratory movements now become irregular and convulsive; and the other instinctive movements assume a similar character, the whole frame now partaking in them. Lividity of the countenanoe may sometimes be observed at the end of the first stage; it rapidly increases in the second, and especially affects the lips, which are often of a deep purple. The veins also be- come turgid; and the eyes are injected, and seem as if ready to start from their sockets. At this time the heart is found to be pulsating languidly, and the pulsa- tion at the wrist is almost imperceptible. Very shortly all the animal functions are suspended; no farther muscular movements are performed, nor are any capable of being excited. The sphincters give way; and the animal, if previously erect falls completely powerless. This is the third stage. The heart continues for a time to contract feebly; but the aeration of the blood is entirely suspended, and sufficient fluid is not propelled by it into the aorta to produce sensible pulsation of the arte- rial trunks. The general surface now partakes of the livid tint which first showed itself in the face; the hands and feet presenting a violet hue, and patches of a simi- lar colour existing in other parts of the skin. The organic functions do not entirely cease until the circulation of the blood has been completely suspended; and even after somatic death must be regarded as having taken place, the temperature of the body is very slowly dissipated, and the post mortem rigidity of the muscles tardily supervenes. In fact recovery may take place even after the heart has ceased to act, if the proper means be employed. 422 asphyxia, (Phenomena.) %The relative intensity of these phenomena will be affected by the cause to which ey owe their origin; as will also, in some degree at least the order in which they present themselves. The preceding description applies especially to those cases in which the deprivation of air is sudden and almost complete, as when due to an obstruction existing in the air-passages. It is in these that the inspiratory efforts are most laborious, and the sense of distress the greatest Where, however, the cause be such as puts a stop to the muscular movements concerned in respiration, the fatal termination more rapidly comes on, and there is less of general distur- bance. When the asphyxia is more gradually induced, on the contrary, the suf- ferings are often most distressingly prolonged. Thus, where it supervenes as a consequence of pulmonary disease, the dilated nostrils and livid cheek often indi- cate for a protracted period the existence of deficient aeration, whilst the patient's complaints of dyspnoea but too truly correspond with these symptoms. The feel- ing of distress is often referred to the lower part of the sternal region; and we have known counter-irritants applied to the spot with the view of relieving it when the real malady was situated in the larynx. It is a point therefore, of considerable practical importance, not to be hastily led to infer from local sensations the cause of the difficulty of respiration; this it may frequently exercise the skill of the phy- sician to detect. It is when asphyxia slowly supervenes as a result of disease, that the greatest irregularity in the order of the symptoms is observable. A very high degree of lividity often shows itself long before the stage of insensibility has come on; and the latter is often preceded by symptoms of irregular action of the brain, such as vertigo, tinnitus aurium, flashings of light before the eyes, and various spasmodic actions. The subsequent convulsive movements are less violent; and the lividity of the face never acquires so deep a tint although the discolouration is more general over the body. In these cases the action of the heart usually ceases soon after the respiratory movements have come to a stand; and this is the mode in which life very commonly terminates. The time which is necessary to destroy life by asphyxia varies much, not only in different animals but in different states of the constitution of the same. Thus, warm-blooded animals are much sooner asphyxiated than reptiles or invertebrata; and, on the other hand, an hybernating mammiferous animal supports life for many months with an amount of respiration sufficiently low to produce speedy asphyxia if it were in a state of activity. And among mammalia and birds there are many species which are adapted, by peculiarities of conformation, to sustain a depriva- tion of air for much more than the average period. Excluding these, it may be generally stated, that if a warm-blooded animal in a state of activity be totally de- prived of respiratory power, its muscular movements (with the exception of the contraction of the heart) will cease within five minutes, often within three; and that the circulation generally fails within about ten minutes. Many persons, how- ever, are capable of sustaining a deprivation of air for three, four, or even five minutes, without insensibility or any other injury; but this power, which seems possessed to the greatest degree by the divers of Ceylon, is only to be acquired by habit. The period during which remedial means may be successful in restoring the activity of the vital and animal functions, is not however, restricted to this. Cases are not unfrequent of the revival of drowned persons after a submersion of half an hour; and more than one has been credibly recorded in which above three- quarters of an hour had elapsed. It is not improbable, however, that in some of these cases a state of syncope had come on at the moment of immersion, through the influence of fear or other mental emotion, concussion of the brain, &c; and that, the circulation being thus enfeebled, the deprivation of air had not the same injurious effect as when this function was in full activity, just as in the case of an hybernating animal. Such a state has been denominated syncopal asphyxia. The reanimation of still-born infants has been successfully attempted when nearly half an hour had intervened between birth and the employment of resuscitating means; and when probably a much longer time had elapsed from the period of the suspension of the circulation. asphyxia, (Anatomical Characters.) 423 Anatomical characters. In cases where death has resulted from simple as-* phyxia rapidly induced, the external appearances found on subsequent examina- tion are usually very characteristic. The general lividity of the surface is not unlike that which is observed on the depending parts in other cases, but may be distinguished from it by not being confined to these situations. Morever, it is often farther characterized by the presence of deeper spots, resembling those of ecchymosis. These are most commonly seen in the face and neck of persons who have been hung or strangled; and, on the other hand, they are usually ab- sent in cases of drowning; but they are occasionally seen under other circum- stances. The appearance seems to be the result of congestion of blood in the vessels of the skin, from which, indeed, the fluid appears sometimes extravasated; numerous points being observable when a section is made into the substance of that tissue. The features usually retain the expression of distress, and the eyes, as already noticed, continue prominent; the pupils are dilated, as in coma. The accumulation of blood in the right side of the heart, and in the vessels, connected with it, namely, the systemic veins and the pulmonary artery, and the comparatively empty state of the left cavities, as well as of the pulmonary veins and systemic arteries, are the appearances most characteristic of asphyxia; and they are constant when this state has been completely developed. They are best marked, however, where it has slowly terminated life; especially when some de- gree of aeration has taken place up to its close, and the action of the heart has ceased within a short time. The coronary veins may often be observed to exhi- bit an extraordinary turgescence. Not only may the venous congestion be no- ticed in the vena cava and larger trunks, but it is very perceptible in all organs which are largely supplied with blood. Thus, the liver and spleen are in a state of engorgement; and the blood may be forced out in large drops by slight com- pression of their parenchymatous tissue. The intestinal membranes, too, are observed to be excessively congested, especially in the most depending parts; and ecchymosed spots are not unfrequently seen on the mucous membrane of the sto- mach after strangulation, constituting a variety of pseudo-morbid appearance, which the inspector will do right to bear in mind. This tendency to congestion in the venous system, which so constantly accompanies deficient respiration, has a most important influence on the condition of various organs in the later stages of chronic diseases of the thorax; and it readily explains the derangements which they are liable to exhibit. Even the heart not unfrequently suffers from the same cause; a permanent distention of its right ventricle, with hypertrophy of its walls, being a frequent concomitant of obstructed respiration; of which particular in- stances will be hereafter given. The blood is usually found fluid, or but imperfectly coagulated, if the asphyxia have been rapid; and this corresponds with what is observed after other kinds of sudden death. Where it has more slowly supervened, the blood coagulates as usual. The veins and sinuses of the head of course partake of the general venous con- gestion; and, in well-marked cases, an unusual number of red points are seen on slicing the brain. The distention is greatest where the previous struggle has been most severe, or where there has been a peculiar obstruction to the return of the blood from the head, as in hanging or strangulation. There is seldom, however, any morbid effusion; but an apoplectic extravasation is sometimes found, though rarely as a consequence of simple asphyxia. In cases where there has been but little general disturbance, the vessels of the brain and its membranes are found to be in their natural state. The venous congestion is usually well marked in the root of the tongue, which often appears as if injected, the papillae being remarkably prominent. It extends also to the mucous membrane of the larynx and epiglottis, of the trachea and bronchi, which is deeply coloured by vascular turgescence, and which becomes darker as it is traced into the smaller ramifications of the bronchi. The mucus which covers its surface is generally mixed with a frothy serous exudation, 424 asphyxia, (Pathology.) Usually exhibiting a sanguinolent tinge. This effusion, which is often very abundant where the obstruction to the respiration has gradually operated, seems to result from the congested state of the vessels, and not to be an altered form of the natural secretion, as some have supposed. The fibrous tissue which unites the cartilaginous rings of the trachea and bronchi is also injected with blood. The lungs themselves, if not previously diseased, aie greatly distended, and ex- pand so as to meet over the pericardium. When exposed to view, they present a dark brown, sometimes almost blackish, hue externally; but their parenchyma exhibits a redder tint when cut into. The engorgement is here in the arterial system; but it is occasioned by the accumulation of venous blood, of which large dark, thick drops flow out when incisions are made in the substance, and slight pressure employed. Pathology of Asphyxia. There can scarcely be a more remarkable illustra- tion of that important truth that morbid anatomy furnishes but one class of the facts upon which the science of pathology must be erected, than that presented to us in the inquiry which we have now to make into the nature of the morbid ac- tion which results from the derangement of the respiratory function, and the mode in which this occasions death. There is no dispute as to the leading facts sup- plied by anatomical examination; but in the interpretation of those facts there is much scope for discussion. No satisfactory conclusion can be attained, unless a clear conception be first formed of the physiological or normal action of the organs whose deranged function is the subject of investigation. We particularly refer to that of the capillary vessels of the lungs, the duties of which must, it is obvious, be the first deranged by any cause which obstructs the access of air to the respiratory membrane. It is in these vessels that the character of the blood is altered from the venous to the arterial; and to be subservient to this change is their peculiar function, just as the secretion of fluid is the function of the capillaries of glands, and nutrition that of the capillaries of the system in general. That the movement of the blood through them is principally dependent, in their usual condition, upon the action of the heart, does not admit of a doubt; but it seems equally certain that for the continuance of this movement, the continuance of the changes to which it is subservient is essential; and that not even the powerful contractions of the heart can force the blood into the pulmonary veins, when these changes are suspended. The condition here assigned to the maintenance of the capillary circulation does not apply to that of the lungs alone. It cor- responds with that which we find by observation and experiment to hold good in reference to the capillaries of the whole system. We need not imagine that any mechanical propulsory power exists in them, in order to understand how such an influence on the movement of the blood through their canals may be exercised by their parietes; since it is easy to conceive that new attractions and repulsions between the solid and fluid particles may be created by the processes to which they are subject. This is not the place to discuss such a question, however; the correctness of the view just stated, in its application to this particular topic, will, we think, appear from the facts to be presently adduced; and a fuller elucidation of it will be found in the physiological division of this work. If its validity be assumed, it will follow that the first effect of impeded respiration will be a retarda- tion or cessation of the passage of blood through the capillaries of the lungs; and that this impediment will be the cause of all the other phenomena which are observed in the progress of the complaint, and finally of its termination in death. Before proceeding to develope this view in detail, however, it will be desirable to glance at the principal theories which have been offered as explanations of the same facts, and to inquire briefly into their value. It would be scarcely necessary to mention the doctrine propounded by Haller, since it received a most complete refutation from Goodwyn, were it not that he assigned the true situation for the commencement of the morbid changes, although he misunderstood their nature. In his opinion, the stagnation of the blood com- menced in the capillaries of the lungs, and thence affected the whole venous sys- asphyxia, (Pathology.) 425 tem; but he imagined this stagnation to arise from a mechanical impediment, produced by the cessation of the motions of the lungs themselves. It is a suffi- cient reply to this doctrine, that all the phenomena of asphyxia are as completely developed in an animal which is made to breathe azote, as in one which has been drowned or strangled; and it was pointed out by Goodwyn, that after the fullest expiration, the air-cells do not return to the state in which they were in the new born child, but are sufficiently distended to permit the blood to circulate freely through them. In fact, as will be subsequently shown, any excess of distention is unfavourable to the passage of fluid through their capillaries. The theory of Goodwyn himself was, that whilst venous blood furnishes to the right cavities of the heart the stimulus which excites them to contract, the fibre of the left side requires a more powerful stimulus,—that of arterial blood; and in default of this, ceases to perform its functions in maintaining the systemic circulation, no longer contracting upon the blood returned to it from the lungs, when this has not been arterialized. This hypothesis, however ingenious, is inconsistent with several observed facts. Were it correct, the pulmonary veins and left auricle ought to be found loaded with blood, which is not the case. Moreover, the left side of the heart continues to contract upon blood which may almost be called venous, in hybernating animals, whose respiration is so trifling; and Bichat proved ex- perimentally that venous blood might be injected into the left cavities of the heart, with the effect of exciting, not depressing, their action. He also ascer- tained that venous blood is propelled into the systemic circulation of an animal undergoing asphyxia; so that the doctrine of Goodwyn may be regarded as com- pletely disproved. We do not mean to assert, however, that venous blood is as effectual as arterial in stimulating the left side of the heart; but that it is suffi- ciently powerful for the maintenance of the actions of that portion of the organ so long as it is supplied, is evident from the fact that its chief cavity and the vessels connected with it are never found to contain more than a comparatively small quantity of blood. The theory of Bichat is the one which, until recently, has gained the most general assent; and there can be no doubt that it is partly based on truth. That it does not accord with all the facts of the case, however, and cannot, therefore, be regarded as a satisfactory explanation, will presently appear. He ascribed the cessation of the circulation to diminished irritability of the heart, resulting, as he supposed, from the deleterious effect of its penetration by venous blood upon its vital properties, an effect which he proved this fluid to exert on the excitability of the nervous system. Thi3 doctrine, as well as that of Legallois (who sup- posed the irritability of the heart to be destroyed by the circulation of venous blood in the spinal cord,) is open to the same objection as that already brought against the theory of Goodwyn; which is one that will apply to any theory which primarily refers the cessation of the circulation to want of power in the heart; namely, the empty state of its left cavities, and the renewal of its action, after it has entirely ceased, by a cause which does not immediately affect it. Bichat, indeed, foresaw these objections. Of the second he attempted to dispose by as- serting that artificial respiration never renews the action of the heart when it has entirely ceased—a statement opposed by well-ascertained facts. Of the first, he has given no satisfactory explanation. Moreover, his opinion that the circula- tion of venous blood through muscles is destructive of their irritability, is contra- dicted by the experiments of Dr. Kay (Treatise on Asphyxia, p. 50,) who found that the exhausted irritability of muscles was restored when venous blood was made to circulate through them, but remained extinct if no fluid was transmitted. Some of Dr. Edwards experiments also lead to a similar conclusion; namely, that venous blood, though less powerful than arterial in maintaining the vital proper- ties of muscles, is by no means rapidly destructive of them. That the first impediment to the circulation of the blood in asphyxia is occa- sioned by an obstruction to its passage through the pulmonary capillaries, might be inferred simply from the progressive accumulation of the fluid in the system Vol. IT.—54 426 asphyxia, (Pathology.) of vessels, of which those channels form as it were the outlet; a phenomenon constantly observed in this condition, and more or less rapidly induced as the aerating process is more or less completely suspended. It hag been maintained by some that the blood flows freely into the pulmonary veins, and is thence car- ried into the general current of the circulation, until its deleterious action has been exercised on the nervous centres; and that, from a sort of paralysis of the capillaries of the lungs, the flow of blood through them is then impeded. But this view is inconsistent with the fact of every day occurrence, that a great de- gree of venous congestion may occur long before the blood in the arteries has become sufficiently loaded with carbon and deficient in oxygen, to produce insen- sibility by its action on the brain. Moreover, the doctrine that " nervous influ- ence " is essential to the flow of blood through the capillaries of the lungs, or of any other part, is a mere assumption, unsupported by physiological facts. On the contrary the recommencement of the circulation through the capillaries of the lungs, when oxygen is brought in relation with them, before any alteration has taken place in the character of the blood in the vessels of the brain, sufficiently proves that it is in them and them alone that we are to look for the primary cause of obstruction, and the cause of the recommencement of the circulation. What, then, is the nature of their influence on the movement of the blood through them? That it is not mechanical is sufficiently proved by observation; for no regularly alternating contractions and dilatations have ever been seen by the microscope in these vessels; and the only mode in which a change in their caliber would seem to influence the current is by such relaxation as may give it free passage, or such contraction as may impede it. The latter state is the one which would seem pri- marily to result from the application of any stimulus, as is shown both by micro- scopic examination and by the experiments of Wedemeyer, who found that stimulating liquids injected into the arteries of living animals were much longer than mild liquids in finding their way into the veins. The state of relaxation is that which paralysis or want of tonic action would seem to produce; and it is therefore impossible to attribute to either of these causes the cessation of the movement of blood in the pulmonary capillaries, which is consequent upon sus- pended respiration. A more valid and consistent explanation may be found in the cessation of those changes to which the passage of the blood through the capillaries of the lungs is subservient. How the movement of the fluid is dependent on their continuance, it may not perhaps be easy to explain; but the fact seems well established by direct evidence, and coincides with what we know of the laws of vital action in general. In the lower animals, as in plants and in acardiac foetuses, the circula- tion is almost entirely independent of any central propulsive organs, and is chiefly maintained by powers originating in the capillary vessels; and even where a dis- tinct and powerful heart is developed, we find that the distribution of blood to different organs is governed more by the relative activity of the processes taking place in them than by any other cause. Any circumstance which peculiarly excites the nutritive or secretory actions of a texture or gland will occasion a determination of blood towards it, which is quite independent of any alteration in the heart's ac- tion; and on the other hand, any depression of their natural actions will produce a corresponding diminution in the amount of blood transmitted through them, with which the heart has no concern. The fact, then, seems to be, that any impedi- ment to the arterialization of the blood in the pulmonary capillaries will of itself impede its motion through them; and this in proportion to the completeness of the obstruction. It is quite true that when the access of air to the lun«rs is sud- denly and completely checked, the circulation through them continues for some lit- tle time; and that blood of a partly venous character is transmitted into the systemic arteries. But it is to be recollected that a considerable quantity of air is contained in the air-cells of the lungs; and that it is not until this has been so far deprived of its oxygen and loaded with carbonic acid, as to be unfit to effect any change on the blood, that we should expect the movement to be entirely checked. More- asphyxia, (Pathology.) 427 over, the alteration in the character of the whole mass of the circulating fluid is effected gradually, as might be inferred from the small proportion transmitted by the heart at each contraction; so that, if a small stream be drawn from the caro- tid artery of an animal undergoing asphyxia, it will be seen to become progress sively darker, from the commencement of the suspension of the respiratory move- ments to the cessation of the heart's action. If, then, an interruption of the chemical changes effected in the pulmonary capillaries be the cause of the stag- nation of the blood in them, a renewal of those actions ought also to renew the movement; and this it has been experimentally demonstrated to effect, in a suffi- cient number of cases, and under a great variety of circumstances, provided that the suspension have not been so prolonged as to occasion a loss of the vital pro- perties of the organism. To these cases we shall presently return. We may consider it sufficiently proved, then, that the stagnation of blood in the capillaries of the lungs is the primary effect of suspended aeration; and we have now to inquire into the mode in which this disturbance of the current of the circulation affects other organs, especially the heart and nervous system. It is very evident that the accumulation of blood in the right ventricle must soon be- come a mechanical impediment to its contraction; and the distention at last appears to impair or even destroy its irritability, just as in the case of the bladder. There is no doubt, however, that the permeation of its texture by venous blood will affect its contractility; but that it is still able to propel its contents, if the distention be slightly relieved, is shown by the recommencement df its action when the renewed movement of the blood in the capillaries of the lungs diminishes the engorgement of the pulmonary arteries, and by the effect of more direct evacua- tion, as will be presently noticed. The left side of the heart, on the other hand, gradually ceases to act from an opposite cause—«-the deficiency of blood. It has been proved by the experiments of Drs. Williams and Kay that its contractility is retained until after the pulmonary veins have ceased to return sufficient blood to excite its action. When rabbits were asphyxiated by tying the trachea, it was found that the flow of blood from a divided artery almost ceased at the end of the third minute, and was entirely suspended at the fifth; yet " the left heart contracted spontaneously for a very considerable period longer." And when the left auricle was examined undeT similar circumstances, it was found that after a period of three or four minutes very little blood was returned by the pulmonary veins, though the heart still acted vigorously. " In general," says Dr. Kay, " the phenomena of the cessation of motion in the left heart in asphyxia are these:—a smaller quantity of blood is received into its cavities, and expelled for a time vigorously into the arteries; the ventricle mean while diminishes in size, as the quantity of blood supplied becomes less, until at length, although sponta- neous contraction still occur in its fibres, no blood issues from a divided artery, and the ventricle by contraction has obliterated its cavity; after this, blood slowly accumulates in the auricle from the large vessels of the lungs; and its contractility continues for a very considerable period." (Edin. Med. and Surg. Journ. vol. xxix. p. 46; and Treatise on Asphyxia, p. 135.) So long as the contrac- tility of the left ventricle is retained, although its movements may have entirely ceased, it may be excited to renewed action by a supply of the necessary stimu- lus; and thus it may be revivified, and the general circulation restored, by artificial respiration which, by unloading the right cavities, and filling the left, furnishes the required conditions. There is no difficulty, then, in understanding how the entire circulation may be brought to a stand by a cause acting immediately upon the capillaries of the lungs. We have next to inquire into the mode in which those phenomena are produced whieh indicate an affection of the nervous centres;—namely, the vertigo, delirium, spasms, and insensibility which mark the later stages of as- phyxia. These have been usually attributed, and with much show of reason, to the circulation of imperfectly arterialized blood through the vessels of the brain and spinal cord. In most vertebrated animals we find a provision for sending to 428 asphyxia, (Pathology.) i the head the most highly-aerated portion of the general mass of nutritious fluid. The provisions for this purpose are most apparent in the class of reptiles; but they are also peculiarly manifest in the embryo state of birds and mammalia. It is evident, then, that of all organs of the body, the nervous centres are the most dependent upon a constant supply of pure arterial blood, for the due per- formance of their functions. But the quantity, as well as the quality, of the circulating fluid seems to have an important influence. The brain is well known to receive a proportion of the whole'amount of blood, far beyond that to which its relative bulk would entitle it; and any interruption to the supply is found to have an immediately injurious effect upon its functional activity. Thus, Sir A. Cooper has shown, that if the carotid arteries be tied, and the vertebrals be com- pressed, a state resembling syncope immediately supervenes. We may reason- ably infer, then, that the insensibility of asphyxia may arise from the concurrent action of both these causes—deficient supply, and depravation of quality. The deleterious influence of the circulation of venous blood through the cerebral arte- ries was proved by an experiment of Bichat. He injected venous blood from the heart of one dog into the carotid of another, and insensibility was the result; but, on the other hand, it has been shown by Dr. Kay that large quantities of venous blood might be injected into the carotid arteries without producing more than muscular debility and lassitude, provided the injection be made slowly and cau- tiously, so as not to produce mechanical injury of the cerebral matter, by disten- tion of the vessels. In one of his experiments (op. cit., p. 195) an accidental circumstance occasioned the employment of considerable force; the animal strug- gled and its limbs quivered, but it seemed to recover for a time, though it re- mained feeble. It afterwards exhibited symptoms of lesion of the brain, and died at the end of ten days, from the effects of an abscess in one of the hemispheres. There is no difficulty, then, in accounting for the immediate insensibility produced by Bichat's injections. From the results of Dr. Kay's experiments it may be in- ferred, that " though venous is a much less stimulating fluid than arterial blood, it may circulate through the cerebral mass without producing by its contact with the brain a sudden suspension of the functions of the nervous system. I conceive that it must be regarded as a fluid capable of only slightly nourishing and stimu- lating the nervous system. Its presence in the vessels of the brain, even for a short time, occasions languor and feebleness; and if its circulation were prolonged, we may imagine that sensation and voluntary motion would become still farther impaired; but it does not destroy life by contact with the brain, and in asphyxia small quantities of it are transmitted, and for a short period only, to the cerebral structure." (Op, cit. p. 198.) The sudden insensibility of asphyxia is, there- fore, to be in part attributed to the rapid diminution in the amount of the blood sent to the brain; and a state by no means dissimilar is often witnessed in cases of haemorrhage, in which deficiency of the nutritious fluid is the only cause in operation: neither change alone would produce the train of phenomena formerly described; this results from a combination of both. We have already observed a similar combination of influences in the suspension of the heart's action; and our attention is thus forcibly directed to the fact that when any link in the chain of vital phenomena is broken, and the equilibrium of the whole disturbed, the de- rangements which ensue are so various and complicated, that it is difficult to as- sign to each its peculiar agency in finally producing the fatal termination. It is obvious, that the state of deep coma, once induced, will hasten death in those cases in which a small amount of respiration was previously going on, by the suspension of the muscular movements necessary to it. But even after this has supervened, and the animal life of the being has ceased to manifest itself, the organic life may be maintained for a considerable period; its duration depending upon the intimacy of the connexion between the two classes of functions at the time. Thus, although the destruction of the brain and spinal cord (by which a state corresponding with profound coma is induced) occasions speedy death under common circumstances, Dr. M. Hall has shown that it may be performed in an asphyxia, (Pathology.) 429 hybernating animal, without extinguishing the heart's action, for many hours. Again, this connexion cannot be said to be established in the new-born animal until the first respiration has taken place; and before this has occurred, life may be prolonged for a considerable time under submersion in warm fluid. Thus, Burton found that greyhound puppies appeared to have suffered little, after being immersed in warm milk for half an hour; and Legallois found the mean duration of life in full-grown foetuses of rabbits, immersed in water, to be twenty-eight minutes. After the animal has respired for a short time, however, this power of resisting the want of air diminishes very rapidly; and in those species which ge- nerate a large amount of heat soon after birth, such as the guinea-pig, this power is scarcely greater in the new-born animal than in the adult. These different conditions, natural to the lower animals, find a parallel, to a certain degree, in peculiar states of the human economy induced by disease, especially those in which syncope partakes. When the causes of asphyxia were being enumerated, it was pointed out that it is the natural tendency of many internal diseases, as well as of various exter- nal agencies, to induce this condition. We may now go farther, and state what will to many appear startling, that in a very large proportion of deaths, natural as well as violent gradual as well as sudden, the event is either immediately or re- motely attributable to this cause. It must be remembered that, so long as the circulation is maintained, the life of the system must be regarded as continuing, even though the animal functions should have ceased to manifest themselves; and if the causes which can operate in suspending this movement be considered, they will be found to act in one of three ways; either by destroying the moving powers, which have their seat in the heart and capillary vessels: by occasioning an obstruction in some part of the channel, which shall affect the whole current, and not a part of it merely: or by withdrawing the vital fluid itself. In the first of these cases, death is said to take place by syncope; and the same term includes the last also. Few causes but asphyxia can operate in the second mode, since no stagnation of blood in any other organ than the lungs can suspend the ge- neral current of the circulation, and a similar effort could only be produced by a complete obstruction of the aorta or pulmonary artery. It is therefore desirable to review briefly the principal morbid conditions which terminate in death through the medium of asphyxia, as well as to notice others which the continuance of imperfect respiration would be liable to produce. Of the former, one of the most common is the state denominated coma or stu- por, which results from some change in the healthy condition of the brain and spinal cord. When this is profound, it suspends the respiratory movements, as formerly mentioned, by interrupting the channel through which the stimulus con- veyed by the afferent nerves acts in producing them. All diseases and injuries which terminate in coma, do in reality, therefore, occasion death by asphyxia. This principle is a very important one, since it leads us to take means for the maintenance of respiration when the cause of the stupor is temporary only;—an indication which has been successfully acted upon. Thus, Sir B. Brodie found that animals rendered insensible by narcotic poisons might have their lives pre- served by artificial respiration, kept up until the functions of the brain were re- stored; and the same expedient has been practised with success on the human subject. Although it would be evidently useless where the coma is a result of permanent organic lesion, it is by no means impossible that it might be success- ful in some cases of insensibility with convulsions in children, resulting from some temporary cause, which might subside if the circulation could be carried on for a sufficient length of time, especially if life were enough prolonged to allow of the operation of remedial agents. It must not be supposed, however, that all causes acting through the nervous centres produce death through the medium of asphyxia: since there are many which rather occasion syncope, depressing the general vitality of the system, destroying the contractility of the heart, and the peculiar properties of the capillaries, as by a sudden and general shock, which 430 asphyxia, (Pathology.) seems diffused through the nervous trunks to every part. It is in this manner that concussion, and other violent mechanical injuries to the brain, occasion the immediate cessation of the movement of the blood, which is not prolonged for an instant beyond the cessation of the movements of respiration. There is a form of apoplexy, the apoplexia fulminans of old authors, denominated by French writers apoplexie foudroyante, in which the effusion of blood acts instan- taneously in the same manner as a mechanical shock; whilst the mode in which this disease ordinarily becomes fatal is by suspending the respiratory movements alone. It seems probable that when death results from exposure to cold, it is at last by asphyxia induced by coma. It does not appear very clear, however, to what the coma is to be attributed; nor is it certain that the injurious influence of cold as a sedative to all vital actions is not directly exerted in checking the circu- lation, by depressing the powers of the heart and capillaries. The connexion of obstructed circulation through the lungs with diminished sensibility of the ner- vous centres, should not be forgotten in the consideration of the phenomena of fever. It is well known that in typhoid states of this disease, in which coma is threatened, dyspnoea is a very frequent occurrence, and that this is accompanied by a considerable effusion of fluid into the parenchyma of the lungs, without any decided symptoms of active disease in these organs. The continuance of this state will of course favour the complete production of coma; but a sound patho- logy will teach us to direct our remedial means rather towards the head than the chest. The diseases which have a tendency to produce asphyxia by directly prevent- ing the access of air to the blood have already been pretty fully indicated: but it must be remarked, that when these are very chronic in their form, they do not pro- duce death by asphyxia simply, but by such a general wasting of the powers which move the blood, that it may be said to partake of the nature of syncope. It is in cases of violent and sudden death that the distinctions above made are most easily recognised; the termination of protracted disease, if observantly watched, will generally present phenomena partaking of all the forms which may separately manifest themselves in particular cases. The intimate dependence of all the or- ganic functions with one another, and the degree in which every one may be in- fluenced by the nervous system, often cause them to be affected by disorder of any one, in a manner which at first sight appears anomalous, but which a little consideration will generally elucidate. We have hitherto considered asphyxia only in its fully developed form, and examined only its fatal termination. It must not be forgotten that imperfect respi- ration has a tendency to produce various diseases, although it may not be suffi- cient for the immediate extinction of life. The recent experiments of Dr. J. Reid (Edin. Med. and Surg. Journ., April, 1839) have shown that when the number of inspiratory movements is greatly diminished by section of the pneumogastrics, the sanguineous engorgement of the lungs which is thereby produced is very apt to pass into the state of inflammation; and that the various stages of pneumonia, and even gangrene, are very commonly witnessed in animals which have lived sufficiently long after the operation for these changes to take place. The most constant result of this engorgement is an effusion of serous fluid into the air-cells and passages, which, of course, adds to the difficulty of respiration. It may, then, be reasonably surmised that there is a tendency to similar morbid changes in other cases of obstructed respiration; and this has been noticed in a variety of instances. Thus, when foreign bodies have remained impacted in the air-tubes, but have not pro- duced immediate suffocation, inflammation of the lungs is very apt to supervene: and bronchocele not unfrequently proves fatal in a similar manner, whilst the real obstruction is still inconsiderable and does not excite attention as the cause of the disease. The permanent congestion of the pulmonary arteries, and the de- mand for increased propelling force, will often occasion hypertrophy and dilata- tion of the right ventricle; and the same congestion, extending to the systemic veins, may be the cause of many diseases in remote organs, especially the pain, asphyxia, (Treatment.) 431 liver, intestines, and kidneys. Dropsical effusions, also, are very liable to occur from the same cause. It is perhaps during the progress of phthisis that we most frequently observe these consequences of partial asphyxia. The bronchitis which so commonly accompanies chronic tubercular disease of the lungs may be not improbably regarded as taking its origin in the congestion of the mucous mem- brane of the air-passages, which has been mentioned as a constant result of ob- structed respiration; and the attacks of active inflammation of the lungs them- selves, which are so liable to supervene whenever deposition of tubercular mat- ter has taken place, may, without doubt be in part attributed to a similar predis- position. The diarrhoea which so commonly occurs in the later stages of the complaint may be accounted for in a similar manner. It is often found on post mortem examination that no morbid change has taken place in the mucous membrane of the alimentary canal or in the intestinal glands; and its functional disorder may be attributed to the irritable state induced by the congestion which has affected it during life, and which has been mentioned as often so remarka- ble a feature in the appearances found after death from asphyxia. Even where ulceration of the intestinal glands, and softening of the mucous membrane, are found to have taken place, they may be regarded as having had their origin in the disturbance of the circulation so often alluded to. Treatment. The ideas which are entertained of the nature of asphyxia must necessarily have an important bearing upon the principles of treatment. Those which will be here stated have been for the most part fully sanctioned by expe- rience ; and will, at the same time, be found to harmonize well with the theore- tical views formerly stated. It is rarely that this condition comes under the no- tice of the physician in any other form than as secondary to other diseases; but as he should not be ignorant of the share it has in various kinds of violent death, we shall presently consider the principal forms under which it may present itself, and the treatment specially adapted to each. The first object in the treatment of asphyxia will evidently be to remove its cause; since, as long as this continues to operate, no permanent relief can be pro- cured by any means whatever. This precept will apply not only to the removal of direct or mechanical obstructions, but to the abatement of all sources of inter- ference with any of the operations naturally concerned in the function, and espe- cially those of the nervous system. When the derangement has not advanced so far as to occasion cessation of the respiratory movements, it will usually be found that this measure will restore the due action of the whole train in a very short time, provided that no organic lesion, such as extravasation in the brain, has taken place. But where these have been suspended, more active means become necessary. It will be remembered, that not only is there a suspension of activity under such circumstances, but an absolute diminution of the vitality or irritability of all the organs concerned, occasioned by the previously insufficient supply of blood, and by the want of oxygenation in that which has been last transmitted. The indications of treatment, therefore, are two; the renewal of the respiratory actions, and the excitement of the low irritability of the system by unusual sti- muli. The first is effected by artificial respiration, which is undoubtedly the most powerful means in our possession of restoring suspended animation under such circumstances. Its success, however, will mainly depend upon the care and judg- ment with which it is employed. As little time as possible should be lost in putting this measure into execution; but whatever interval should from necessity occur, may be advantageously employed in other ways to be presently noticed. Until more appropriate means are available, the natural movements of respiration may be in some degree imitated, by compressing the chest and abdomen, so as to di- minish the cavity of the thorax, and to expel from the lungs as much as possible of their contents, and then allowing them to recover their former dimensions by their natural elasticity. Although but a poor substitute for the natural process, even this trifling assistance may be of the utmost benefit, if given at the critical time when the heart's action is nearly suspended, and the vital powers rapidly 432 asphyxia, (Treatment.) sinking. Where no bellows can be procured, the insufflation of the chest from the mouth of another is the best measure that can be adopted. It would, in feet, be preferable, on account of the higher temperature at which the air is thus intro- duced, and the security which is afforded against the employment of an injurious degree of force, were it not for the partial carbonization and abstraction of oxy- gen which this air has undergone. The insufflation is performed by applying the mouth of the operator to the mouth or to one of the nostrils of the patient, closing the other apertures, and making a forcible expiration, so as to dilate the chest which is then to be emptied again by gentle pressure. The insertion of a short tube into the nostril, if of sufficient bore, will much facilitate the operation. It will be desirable that an assistant should at the same time gently press the larynx backwards and a little downwards upon the vertebrae, so as to oppose the pas- sage of air through the oesophagus into the alimentary canal When a pair of bellows is employed, the air should be injected through one nostril, whilst the mouth and the other nostril are closed: the latter is then to be opened for the ex- piration of the air,* and the process repeated about fifteen times in the minute With regard to the amount of air to be thus introduced at each stroke, there is some difference of opinion. Goodwyn, although he estimated the quantity natu- rally taken in at each inspiration to be no more than twelve cubic inches, recom- mended that a hundred cubic inches should be thrown in by the bellows, for the dislodgement of the impure air from the air-cells and smaller bronchial tubes, which he thought could not be otherwise effected. There is no doubt however, that if this principle were followed, irreparable injury would result from it to the texture of the lungs; indeed, there is reason to believe that many individuals have been sacrificed by injudicious insufflation who might otherwise have recovered. Leroy discovered that brisk inflation of air into the trachea killed rabbits, foxes, goats, sheep, and other animals, even when the force employed was that of an expiration from the human being; and the recent experiments of Dr. Southwood Smith (Philosophy of Health, vol. ii. p. 75,) have shown, that though a mode- rate inspiration favours the passage of the blood through the lungs, great disten- tion of their cavity checks almost entirely the circulation of fluid through them, by the mechanical compression of the vessels. According to Leroy, the quantity injected ought to be the same as that naturally inspired; and this is the safest rule. A few repetitions of the process will soon produce an entire exchange of the air contained in the lungs, by the tendency to mutual diffusion of which all gases partake; and it is better that no risk should be run of doing mischief where the organs concerned are of so delicate a conformation. Moreover, the insuffla- tion of too large a quantity of air will diminish rather than increase the deve- lopment of caloric; and this is the explanation of the results which have led to the belief, that artificial respiration has no power of maintaining animal heat. The respiratory movements may also be excited by galvanic action on the muscles, in the method proposed by Leroy and approved by Magendie (Journ. de Physiologie, torn. ix.;) and there can be no doubt that the penetration of a fresh atmosphere into the air-cells will be more facilitated by such a process, than by insufflation. This method requires little skill for its employment and is unattended with any danger; and it is thereby superior to that of Dr. Ure, which can only be carried into effect by a person possessed of considerable anatomical knowledge. Leroy introduced acupuncture needles a short way into the fibres of the diaphragm on each side, in such a direction that they might be easily connected with the oppo- site poles of a galvanic battery. When the galvanic circle was completed, the dia- phragm contracted and enlarged the cavity of the thorax: when it was interrupted, the weight of the abdominal viscera, assisted by gentle pressure on the surface, * The bellows constructed under the direction of the Royal Humane Society is provided with an additional valve for this purpose, which prevents the necessity of the alternate closure and unclosure of the nostril.—Author. asphyxia, (Treatment.) 433 caused its return; and thus alternate movements of inspiration and expiration were produced, and maintained until the natural movements supervened. A small galvanic apparatus only is sufficient for this purpose. The second indication for treatment is the exhibition of various stimulating agents, both internally and externally. Amongst the most powerful and useful of these is warmth; but some judgment is required in its application. If the circula- tion have ceased, and the temperature of the body be much lowered, no attempt should be made to raise it suddenly; since experiment shows that when such attempts are made on animals in a state of torpor, they are often fatal. Warmth may be gradually communicated by means of a warm bath, or by warm applications, especially to the region of the stomach; but no fluid of a temperature above 98° or 100° should be employed. Rubefacients also may be applied to the skin with advantage, and friction employed, when it has in some degree recovered its sensi- bility ; but they are previously useless. Warm stimulating fluids in moderate quantity should be injected into the stomach or rectum, and stimulating vapours applied to the nostril. When not only the respiratory movements but the actions of the heart have ceased, the case becomes much more serious, but it is not entirely hopeless. It has been already stated that artificial respiration has proved successful in renew- ing the circulation by unloading the right cavities of the heart and transmitting the necessary stimulus to the left. But this is unfortunately not often the case; and it is therefore to be considered what auxiliaries can be employed. Slight shocks of electricity, or a current of galvanism, transmitted through the regions of the heart, would appear the most likely means of re-exciting its contractions. Another method has been pointed out, however, which is well deserving of trial. Professor Coleman found that after animals had been asphyxiated, and the right auricle had lost its irritability, the detraction of a small quantity of blood from one of its veins occasioned it in few minutes to respond to the application of a stimu- lus (Wilson on the blood, p. 131.) A similar fact was observed by Dr. J. Reid in experimenting upon the action of certain poisons. A slight incision into the auri- cle itself appeared most effectual; but the opening of the jugular vein generally produced the same effect. This measure is likely to be useful in more ways than one, since it will relieve the congestion of the cerebral veins, and thus promote the recovery of the sensibility. It is not a step, however, to be indiscriminately adopted. The inquiries of Mr. King (Safety-valve Function of the Heart, in Guy's Hospital Reports, vol. ii.,) leave us no difficulty in understanding how an ab- straction of blood from the jugular vein may relieve the distention, not only of the right auricle, but of the ventricle, since the tricuspid valve does not close so as to prevent regurgitation, when the accumulation of blood is considerable. The effect of an electric or galvanic stimulus should be first tried; and if it fail, the experi- ment should be repeated after the abstraction of a little blood from the jugular vein as low in the neck as possible. Attempts at resuscitation should not be abandoned as hopeless until many hours have elapsed, unless evident indications of death present themselves; nor should the employment of remedial means be discontinued at too early a stage of recovery. The condition of the patient, even after the natural movements of respiration have recommenced, and the circulation has been renewed, is very precarious, and requires watchful attention for a considerable time. Many lives have been sacri- ficed by too early neglect. The object of the preceding sketch has been rather to give a general view of the whole subject of asphyxia, and especially to exhibit the connexion of this patho- logical state with other morbid conditions of the system, than to pursue any department of it into details. We shall now inquire how far it is concerned in two of the most common forms of violent death,—strangulation and submersion : these, however, will be here con- sidered simply in a pathological view; their juridical relations will be fully treated of in the division of this series appropriated to forensic medicine. One form of Vol. II.—55 434 asphyxia, (Strangulation.) asphyxia which has been but slightly adverted to in this article, the Asphyxia neona- torum, will be more fully treated of among the diseases peculiar to infants. We shall now consider the phenomena attending certain forms of violent death, in the production of which asphyxia is principally or solely concerned. Strangulation. By this term is understood forcible compression of the neck by a ligature, to such an extent as to impede or prevent respiration. Suspension is, therefore, but one variety of strangulation, the peculiarity of which consists in the traction of the ligature being produced by the weight of the body. In the simplest form of suspension the phenomena are precisely the same as those of ordi- nary strangulation; this takes place where the body is lifted from the ground by traction of the cord, and where no violent jerk is given to the neck. But this seldom happens; for in most cases of suspension the body has been made to fall more or less violently, so as to occasion other injury besides the simple compres- sion of the neck in which strangulation properly consists. We shall first then, consider the phenomena of death by strangulation simply; and afterwards those which often attend death by suspension. If the compression of the neck affected only the trachea, it is obvious that death would be produced by asphyxia solely; and in this manner it has been occasion- ally brought about,—some firm substance, like the cushion of a tourniquet, having been applied upon the windpipe. A mode in which infanticide has been some- times perpetrated—the firm and continued pressure of the thumb upon the trachea —operates in precisely the same manner, although hardly referrible to the head of strangulation, from the absence of ligature. On the other hand, it is easy to conceive that a ligature may be applied around the neck in such a manner as to make injurious pressure on the jugular veins, so as to occasion death by cerebral congestion, or by apoplexy simply, without materially obstructing the respiration. And again, it is sufficiently evident that, in most cases of strangulation, both these circumstances will operate in producing the fatal result. Accordingly it is found, by examination of the bodies of those who have died by strangulation, that in a few cases the signs of asphyxia alone are present; in some those of apoplexy alone are very decided; and in a large proportion the appearances indicate that both states have existed. Out of 102 cases colleoted by Remer (Annates rf'Hygiene, torn. iv. p. 179,) unequivocal signs of apoplexy were found in nine; the appear- ances resulting from pure asphyxia in six ; a combination of the two in sixty-eight; and in the remaining nineteen the proximate cause of death was not substantiated. More recently Dr. Casper (Wochenschrift fur die gesammte Heilkunde, January, 1837,) has given a similar collection of the results he has obtained, of which the following is a summary. Out of 106 cases, death appears to have taken place by apoplexy in nine; by simple asphyxia in fourteen; by both conditions in sixty-two; from neither in five; and the number of unexamined bodies was sixteen. In several of the cases attributed by Remer to apoplexy, there seems to have been (although not distinctly stated by him) an extravasation of blood in the brain, as well as congestion of the cerebral vessels : in those related by Casper, on the other hand, the congestion alone seems to have been too much relied on as a sign of apoplexy, since it is to be recollected that distention of the veins of the brain occurs in asphyxia. It can scarcely be doubted that these variations depend principally on the mode in which the ligature is applied to the neck ; and a series of experiments upon his own person was performed by Dr, Fleischmann (Annules d'Hygiene, torn. viii. p. 432,) with the view of elucidating this question. Although not entirely satisfactory, they afford some important results, of which we shall give an abstract. 1. If the neck be encircled with a ligature placed between the chin and the os hyoides, so as to rest upon the sides and angles of the lower jaw, the principal vessels are but slightly compressed, and the cord may be drawn tightly with- out any material impediment being offered to the respiratory actions. After a short time, however, a flushing of the face and a prominence of the eyes are per- ceived ; the head becomes unusually hot; a sensation of weight is perceived in its asphyxia, (Strangulation.) 435 interior, which increases to great oppression almost amounting to insensibility; and a noise in the ears suddenly commences. When this symptom developes itself, M. Fl. remarks, it is high time to give up the experiment, as a few moments longer would be fatal. The compression may, however, be borne for as much as two minutes with impunity. There is evidently a tendency to the production of apoplectic congestion; but the vessels are not sufficiently compressed for this con- dition to be immediately induced. The account given of these sensations by per- sons who have recovered after suicidal, accidental, or experimental suspension (instances of the last being by no means unfrequent,) does not materially differ from that just quoted. A peculiar feeling of a pleasurable nature is first expe- rienced; then imperfection of the sight, with flashings of bluish light; and these are rapidly followed by insensibility. 2. Similar consequences will follow the applica- tion of the ligature upon the larynx; but here the respiration is more impeded. Scarcely half a minute expires before the noise in the ears, and a sensation in the brain which it is difficult to describe, give warning that the experiment must be discontinued. It is obvious that, in this position of the cord, the vessels are no longer protected by the angles of the jaw, and will therefore be more completely compressed, so that death will result from the concurrent effect of apoplexy and asphyxia. 3. If, on the other hand, the ligature be placed between the os hyoides and the thyroid cartilage, or upon the os hyoides, and rests upon the angle of the jaw or the mastoid processes, the vessels will be almost entirely protected from compression, and the respiratory acts will alone be affected. Occlusion of the rima glottidis is produced by the depression of the epiglottis, which is forced down by the displacement of the mass of flesh that forms the root of the tongue. In this case death will be almost purely owing to asphyxia. 4. Lastly, if the cord be applied over the trachea, the passage of air will be completely checked, and asphyxia will soon result; the event will be less rapid if the ligature cross the cricoid carti- lage. The vessels will, of course, be also compressed when the cord is thus fixed; and the signs of apoplexy will be found more or less coexistent with those of asphyxia. It is to be recollected, in making such distinctions, that congestion of the cephalic veins is an ordinary appearance in cases of simple asphyxia; so that it might seem unfair to consider it of an apoplectic character in any instance in which there is not actual extravasation. But the value assigned to it will depend upon its amount when compared with that of other portions of the venous system, and upon the comparative state of the right and left sides of the heart. If the pulmonary arteries, the right cavities of the heart, and the great veins leading to it be all gorged with dark blood, whilst the left cavities and their vessels are flaccid, it is evident that the congestion of the brain is only a part of the general result of the cessation of the respiratory function. But ifj as sometimes happens, no such general congestion is found, and the right side of the heart is not peculiarly distended, whilst the veins and sinuses of the brain are loaded, we may regard the latter as an apoplectic condi- tion not immediately dependent open obstructed respiration, though aggravated by it if it co-exist. And here it is necessary to remark, that although in cases of apoplexy with gradually increasing coma, asphyxia seems to be generally the proxi- mate cause of death, there are many instances in which the fatal result occurs too rapidly for it to be thus accounted for, and in which it seems rather due to a sud- den violent impression transmitted through the nerves to every part of the system, destroying the vitality of the whole at once, and putting an immediate stop to the motion of the blood. It is this kind of impression which is produced by concus- sion of the brain, by blows on the episgastrium, by a violent electric shock, and other similar causes which check at the same time the action of the heart and that of the capillaries, producing death by syncope. It is well known that in the lower animals the circulation will continue after the gradual removal of the whole of the brain and spinal cord: whilst sudden violent and extensive injuries of these cen- tres, such as crushing the brain, or breaking down the spinal cord, entirely check it This fact appears to indicate the actual propagation of an anti-vital influence (if 436 asphyxia, (Anatomical Characters.) we may be allowed the term) along the nerves in cases of this nature, since the mere suspension of the function of the nervous centres cannot prove similarly fatal. In this manner only can we account for the suddenness of death in the apoplexia fulminans; and the same view seems appUcable to several cases of death by hang- ing, in which the appearances are very different from those of the more common forms of apoplexy or of asphyxia, as will presently be pointed out The obstruction to the passage of air through the air-tubes, and the pressure upon the blood-vessels of the neck, are not the only causes of death by suspen- sion, although it is probable that they are alone in operation when the cord has been tightened simply by the weight of the body. When greater violence has been used, it is not unfrequently found that the vertebral column has been injured, so as to compress or lacerate the spinal cord. This injury may be of several kinds, but it is generally confined to the first and second cervical vertebrae. Some- times the odontoid process has been displaced from the atlas, with rupture or laceration of the ligaments which confine it, and has been forced against the spinal cord. In other instances it has been separated from its own vertebra; and these displacements of the atlas upon the dentatus may happen in various ways. Again the first two vertebrae have been separated from the rest of the column, by rupture of the intervertebral substance, and of the spinal ligaments. Other frac- tures of these vertebrae have been seen; and in all, the spinal cord was more or less injured. But even where no evident displacement is found, there is often an appearance of straining of the ligaments; and in such cases the spinal cord must have received a severe shock, which will obviously aid the other causes of death, if not itself competent to produce it. Anatomical characters. From what has been stated as to the operation of several causes, singly or combined, in producing death by strangulation, we shall be led to expect a considerable variety in the morbid appearances afterwards found; and, indeed, it is almost only from the observation and comparison of these appearances, that our knowledge of the action of these causes is derived, since the means of observing them during life are so restricted. The description given by the older writers of the signs of death by strangulation will only apply with strictness to a limited number of cases. Indeed, it may almost be asserted, that some of the appearances mentioned are incompatible with each other, and that the description must have been drawn up by combining observations made upon several dissimilar cases. The following have been specified:—" Lividity and swelling of the face, especially of the lips, which appear distorted. The eyelids are swollen and of a bluish colour; the eyes red, projecting forwards, and sometimes forced out of the orbitar cavities; the tongue enlarged, livid, and com- pressed between the teeth, or frequently protruded. A sanguineous froth about the lips and nostrils, A deep and acchymosed impression around the neck, in- dicating the course of the cord, the skin being sometimes excoriated; laceration of the muscles and ligaments in the hyoideal region; laceration or contusion of the larynx, or of the upper part of the trachea. There are also commonly cir- cumscribed ecchymosed patches, varying in extent, about the upper part of the ^^' ^nd *6 upper and lower extremities, with a deep livid discolouration of the hands. The fingers are generally much contracted or firmlv clenched. The urine, the faeces, and the seminal fluid, are sometimes involuntarily expelled at the moment of death. The bodv is, ceteris paribus, a much longer time than usual in parting with its heat." (Taylor's Medical Jurisprudence, vol. i. p. 165.) Some of these signs may be observed on the bodies of most persons who have come by their deaths in the mode in question; but it must be also admitted that they may all be absent. This is especially the case where the general shock to the nervous system appears to have been the proximate cause of death. They are usually most developed where death has supervened slowlv, and has been due either to asphyxia produced by the direct obstruction of the'windpipe, or to gradually increasing coma resulting from the accumulation of blood by pressure on the vessels of the neck. In cither of these cases we find the mode of death asphyxia, (Anatomical Characters.) 437 indicated internally by the general venous congestion, already described as indi- cative of asphyxia, with more or less peculiar turgidity of the vessels of the brain. It will be desirable to examine separately each of the principal external signs, with the view of determining the circumstances under which they should be respectively relied on, or their absence made a ground of hesitation. The lividity of the face, lips, and eyelids, and the prominence and brilliancy of the eyes, are not unfrequently absent, at least for some time after death. It is somewhat remarkable that the appearance of the countenance is usually least altered in suicides; its traits being frequently those of undisturbed placidity. These signs are, on the contrary, more constantly observed on the bodies of those who have been executed; and they are still more developed where strangulation, as commonly understood, has been murderously performed. On an instance of this kind the graphic description given by Shakspeare was founded. (Henry VI. Pt. ii. Act 3. Scene 2.) It is frequently observed, however, that although the face presents no lividity, and the lips and eyelids no tumefaction, soon after the body has been cut down these appearances present themselves after an inter- val of some hours, especially if the ligature be allowed to remain about the neck. This was pointed out by M. Esquirol (Arch. Gen. de Med. Jan. 1823,) who was the first to draw attention to the uncertainty of these appearances in cases of hanging. Although, however, their absence cannot support a negative inference, their presence may be held as a proper foundation for a positive presumption; that is, if a body be found hanging, or with a ligature tightly drawn round the neck, and these signs are present, the presumption is very strong in favour of death having taken place by strangulation. For they cannot be produced by sus- pension after death from other causes, even if this be effected immediately upon the extinction of life. This has been established by the experiments of Orfila. Sometimes lividity and tumefaction of the face will appear after an interval of some hours, even when the ligature has been removed, as was the case in some of the instances mentioned by Esquirol; more recently this has been noticed by Fleischmann (op. cit., p. 436,) who attributes it to the change of position of the body, causing the blood (remaining fluid as it does) to run towards the head, which is often in the removal the most depending part. In the case of the no- torious Burke, it is stated by Mr. Watson (Treatise on Homicide, p. 136,) that by changing the position of the body after the cord had been removed, the con- gestion of the vessels of the head and face could be made to appear and disappear at pleasure. As a general fact it may be stated, that the more slowly death supervenes, whether from asphyxia or from apoplectic coma, the more decidedly will these signs be presented; and that, on the contrary, they are likely to be absent whenever death results from the sudden shock sustained by the nervous system, or from complete obstruction to the entrance of air into the lungs. The protrusion of the tongue has been considered by most writers (after Bel- loc) as dependent upon the position of the ligature. If this press above the os hyoides, it is stated that the tongue will be drawn backwards into the mouth; but if below the cricoid cartilage, the laryngeal apparatus will be drawn upwards, and the tongue protruded. But it must be remembered, that this protrusion of the tongue may be found in the bodies of those who have died of asphyxia from other causes, or of other diseases. Moreover, M. Devergie states (Traite de Med Legale, torn. ii. p. 384,) that he has found the tongue protruded between the teeth, when the ligature has been applied even above the os hyoides; and that the same effect may be produced on the dead body; whilst he has occasionally found it within the mouth, when the ligature has been on the larynx or below it. According to Fleischmann, this change, like the former one, is mostly produced by the gradual approach of death; and is likely to be absent where death has been almost or altogether immediate. Farther inquiry is certainly needed on this point; but in the mean time it may be safely stated, that, if a body were found with the tongue protruding between the teeth, and bearing their impressions, and 438 Aan.ociA, (Anatomical Characters.) other indications of strangulation were present, little hesitation need be felt in at- tributing death to this cause. The next point to be considered is a very important one—the mark of the liga- ture upon the neck. A good deal of confusion will be found in the statements of medico-legal writers on this subject, arising principally from the vague and con- tradictory significations which have been attached to the term ecchymosis. By true ecchymosis is to be understood an infiltration of blood into the internal sub- stance of the skin and sub-cutaneous cellular tissue, so that thin laminae of these textures shall be found penetrated with it. This can only be substantiated by dissection; and from neglecting this mode of examination many observers have mistaken for ecchymosis the external discolouration which is often entirely inde- pendent of it. Thus we may account for the great diversity in the proportions given by different observers, of the instances in which ecchymosis was found on the neck after death by strangulation. Remer declares that nine-tenths of his cases presented it; whilst Klein relates fifteen cases which came under his own observation, and Esquirol twelve under like circumstances, in none of which was this lesion observed. Devergie has collected fifty-two cases in which the state of the neck was particularly observed, and in only three of these did true ecchymo- sis exist; and Dr. Casper (loc. cit.) states, that out of seventy-one cases, twenty- one were accompanied by true eechymosis. Of the cases collected by Remer, many were probably furnished by persons who were unacquainted with the cha- racters of true ecchymosis; and it is not surprising, therefore, that he should es- timate the proportion so high. The discrepancy between the accounts of Klein, Esquirol, Devergie, and Casper, is however, at first sight, more striking. Still, it would probably be reconciled had we more precise information as to the mode of death in each class of cases; for it is observed that ecchymosis rarely or never occurs after suicidal hanging, where for the most part the body has not fallen vio- lently upon the cord, whilst it is much more frequent on the necks of those who have been murdered or executed. The following curious case is related by Dr. Casper. A young man in a fit of drunkenness hung himself with a stout cord. He was cut down in about half an hour afterwards; and attempts were made at resuscitation. The cord had merely produced a slight superficial mark on the neck, destitute of any appearance of ecchymosis. Signs of returning animation began to manifest themselves; the efforts of the medical attendants were con- tinued for several hours, but the traces of vital reaction disappeared. To the astonishment of all present, when life was about to become extinct, the mark on the neck became deeply ecchymosed; this was verified by an examination made the next day. This case is an illustration of the physiological fact, that to pro- duce true ecchymosis there must be a continuance, for a certain time, of the vital processes to which it is due; and that, where death is verv suddenly occasioned by violence of any description, all marks of that violence may be absent. This has been repeatedly observed in cases of death from concussion of the brain, blows on the epigastrium, &c. When ecchymosed spots are found on the neck, their correspondence with the indentation of the ligature should be carefully ex- amined; since it not unfrequently happens that they result from violence pre- viously inflicted, which the suspension has only been intended to conceal. Where a true ecchymosis is found in the line of the cord, little doubt can be entertained of the strangulation having taken place during life; since all experimental re- searches yet performed agree in a negative result as to the possibility of any true ecchymosis being produced by the application of a ligature after death, even although but a short time has elapsed. Experiments are yet wanting, however, as to the possibility of producing a true ecchymosis by suspension immediately after death; such a point is obviously very difficult of decision, and at the same time of the utmost consequence in a medico-legal view. In one instance related by Dr. Casper, the mark produced by the application of the ligature was so de- cided, that an individual not acquainted with the circumstances would have sup- asphyxia, (Anatomical Characters.) 439 posed from it that the deceased had been hanged while living. But the subject had died of typhus; and although the experiment was tried an hour after death, marks of cadaveric lividity had already shown themselves; so that the tissues must have been in a state peculiarly favourable to the production of this appear- ance. Still, however, there was no infiltration of blood in the skin or cellular texture. The mark which is most constantly left on the neck after death by strangula- tion, is a line of slight brownish-yellow discolouration, along which the skin has the dryness and hardness of parchment. This is seldom absent where a cord has been applied; but where strangulation has been effected by a handkerchief or other soft material, the pressure may be diffused over so large a surface that even this may not be produced. The Thugs of Hindostan, who use their tur- bans for this purpose, are said to accomplish their work so dexterously, as to leave no external mark whatever of the mode in which they have destroyed life. Where an indentation has been produced by the ligature, its lips have a violet tinge, especially when the ligature has not been removed; and with this the pale- ness, which the skin of the depression presents on first being exposed, strongly contrasts. It is not until after it has been for some little time subjected to the contact of air, that the discolouration and hardening of the skin are perceived. This character was first pointed out by M. Esquirol, who regarded it as indica- tive of strangulation during life; but from the experiments of M. Devergie and Dr. Casper it appears, that it is of little or no value as a single proof, since it may be produced by suspension after death. All that is required appears to be a sufficient force in the application of the ligature, and its subsequent removal. But the violet tinge of the lips of the depression cannot be so completely imitated by post mortem strangulation; and even though it may show itself on the upper side, it is scarcely perceptible on the lower. Whenever this is very decided, therefore, and is presented by both lips of the furrow, it is a tolerably positive indication of strangulation during life. We must not expect to find such a mark, however, all around the neck. It will be most decided where there have been any resisting points beneath the ligature. In case of death by suspension, we should not expect to find it at any great distance from the larynx, or os hyoides. Where strangulation has been practised, however, the circle'will be more com- plete; and by a careful examination, we may thus be enabled to pronounce that the subject has been strangled first, and then hung—a mode in which attempts have often been made to conceal the first crime, by exciting suspicion of suicide. Sometimes when the ligature has been hard (a piece of new cord, for example,) and roughly applied, slight excoriations are produced by it, the epidermis and corpus mucosum being rubbed off. The degree of vascularity of the true skin at these spots will generally indicate whether or not the violence has been in- flicted during life; and this may even be detected after the desiccation of the skin by holding it between the eye and the light But it must be remembered that the same cause which prevents ecchymosis may prevent any vital reaction of this kind, so that a negative inference must not be drawn from its absence. Another change is produced by the forcible application of a ligature, to which also M. Esquirol was the first to direct attention. If the skin of the furrow be carefully dissected off, leaving all the cellular substance behind, a whitish silvery line will be perceived, marking its course along this tissue. This appearance seems to result from the condensation of the tissue, occasioned by the forcing of its fluid and fatty matter into the surrounding substance. If desiccation has pro- ceeded far, the mark will not have a glistening, but a white and dry aspect. This also is principally observed on the front of the neck, and sometimes over the sterno-mastoid muscles. A very important branch of this inquiry is that which relates to the possibility of an impression like that of a strangulating ligature being made during parturi- tion, by the twisting of the umbilical cord round the neck of the child, and the traction to which it will be subject if not preternaturally long. Medical jurists 440 asphyxia, (Anatomical Characters.) and accoucheurs seem pretty fully agreed as to the improbability of such an occurrence; and most authors deny its possibility. Klein, for example, states, that although he has examined a considerable number of infants who came into the world with the cord twisted round the neck, he has never detected any traces of it, either in the form of actual ecchymosis or of any impression whatever. The importance of this question to the medical jurist is evident, from the fre- quency of attempts to conceal the commission of infanticide by strangulation, by twisting the cord around the neck, so that death may be referred to natural causes. This contrivance may often be detected by collateral evidence, although we may admit the possibility of an impression being produced on the neck in this manner; thus, foreign matters, such as bits of straw, fine gravel, &c, have been found on the inside of the folds of the cord; or the child has been proved to have breathed freely. That an impression may be thus produced, however, and that the child may die from this kind of strangulation, and may still have breathed, is proved by the collection of cases recently published by M. Taufflieb. (Annales d,Hygiene, torn. xiv. p. 340.) In one of these the infant had lived for a quarter of an hour, and its lungs were crepitating and floated in water; but it had evidently died of apoplexy, for which the twisting of the umbilical cord sufficiently accounted. In this case the mark was a narrow red line encircling the neck, without any extravasation or depression. In another there was a livid mark, and the skin had assumed the parchment character, which was sensible to the touch as well as to the sight. M. Carus relates a case in which sugillalion resulted from the same cause; but whether true ecchymosis is to be thence un- derstood, we are unable to say. It has been supposed that the margin of the os uteri might, in a case of protracted labour, occasion a similar impression by con- tracting on the neck; but we are not aware that any positive example of such an occurrence has ever been produced. Additional marks of violence about the neck, such as rupture of the muscles in the hyoideal region, fracture of the os hyoides or of the cartilages of the larynx, are of rare occurrence. When such are found, they afford a strong indication that the strangulation has not been suicidal, since very few instances have been recorded in which any of these have resulted from self-inflicted violence. It may not be possible to say, however, that these injuries were inflicted during life, and that they are to be relied on as proving that death was due to the suspension or strangulation which produced them. For, if inflicted immediately after death from other causes, the appearance they present may very much resemble that which they would assume if they had been suffered at the termination of life, so that they do not forbid the idea of the subject having been murdered first, and suspended or strangled afterwards. Another indication of death by strangulation has been pointed out by M. Amussat,—namely, rupture of the inner and middle coats of the common carotid arteries. This, however, has been only twice no- ticed; once by M. Amussat, and once by M. Devergie. It is not improbable that it may not be of unfrequent occurrence, escaping observation from its peculiarity; but we have no evidence that it may not be produced by post mortem strangula- tion. The ecchymosed patches which have been described as common on the upper part of the body in persons who have been strangled, are seldom any thing more than spots of peculiarly deep lividity, which occur after all the varieties of death by asphyxia. Where decided ecchymosis is found, we should be led to attribute it to external violence. The contraction of the fingers cannot be much relied on; as, although pretty general in death by strangulation, it is almost equally common in other kinds of violent death. The state of the genital organs has been much attended to, as a character of strangulation. Erection of the penis not unfrequently occurs, and it is often fol- lowed by emissio seminis. It is not very easy to say in what proportion of cases this takes place. Erection may occur at the moment of suspension, and may subside afterwards, so that no traces shall he found of its having taken place. In Dr. Casper's memoir already referred to, it is stated that this change took place asphyxia, (Anatomical Characters.) 141 at the moment of suspension in every one of the fourteen negroes who were exe- cuted together; but that in only nine were any marks of it found an hour after death. M. Devergie has recently attempted to show, that where no appearance of erection is found, there is a general congestion of the vessels of the genital or- gans, which does not subside for some time, and which contrasts strongly with the usual pallor of these parts after most kinds of death. (Annales d'Hygiene, torn. xxi. p. 174.) The membrane of the urethra he has found highly injected, especially towards the extremity of the penis. No sufficient evidence has yet been brought, however, to prove that a corresponding state is generally produced in the genital organs of the female; it has been detected in a few instances by Remer and Casper. Emission of the seminal or prostatic fluids is more fre- quently perceived to have taken place; but it is liable to occur from other causes, such as injuries of the spinal cord by direct violence. Casper met with this emission in nineteen out of seventy-seven cases,—not much oftener, therefore, than one in four; but others have observed it more frequently. Care must of course be taken, not to mistake it for a discharge from the urethra itself. Dever- gie has recently maintained (loc. cit.,) that some effusion of semen into the ure- thral canal almost constantly takes place, although it may not be ejected from it; and he calls in the aid of the microscope to detect the animalcules characteristic of this fluid. He states that, soon after an ordinary emission during life, all traces of it disappear from the urethra; but that if it be soon followed by death, an ap- preciable quantity will remain there. This view is obviously deserving of con- siderable attention; and in no case of doubt should the test be overlooked. But there are several objections to exclusive reliance upon it, some of which have been acutely pointed out by M. Orfila (op. cit., p. 471,) and we can only use it in conjunction with the facts supplied by other observations. Lastly, evacuation of the faeces is a comparatively rare occurrence; Casper observed it only four times in 106 cases. With regard to the internal appearances, little need be added to what has been already stated. They will generally be those of asphyxia, together with a pecu- liar degree of congestion in the veins of the head. But this may be altogether absent, or it may be the only morbid appearance, in which case we should attri- bute death to apoplexy alone. In some cases no morbid appearance whatever can be detected. Extravasations of blood beneath the mucous membrane of the sto- mach and intestines are more common in this than in other kinds of asphyxia. From the details we have thought it right to give on this difficult subject, it will be evident that no single signs can be regarded as sufficiently diagnostic of death from strangulation, for us to rely upon either their presence or absence in doubtful cases. Our decision must be founded upon the balance of several; and it will be rarely that a full investigation will leave much room for doubt. We shall, how- ever, bring such a case under review, since it will serve to prove that death by hanging may take place, leaving scarcely any of the signs which have been usually regarded as characteristic of it A man aged about thirty-six or forty years, ro- bust and plethoric, was found hanging on a tree in a forest. He had employed for the purpose of suicide a narrow leather thong, and had disposed of it in such a manner that anteriorly it pressed between the larynx and os hyoides, and then di- rected itself upwards and backwards. The furrow produced by it was a quarter of an inch deep in front, rather less on the left side, and almost imperceptible on the right, where there was a knot beneath the ear by which an impression was left. The furrow was somewhat rough to the touch, and its colour was a deep yellow. No ecchymosis was found in any part of its course, or in its neighbour- hood. The countenance presented no appreciable change; it was calm and pale, without disfigurement. The appearance of the eyes was in all respects natural; there was no sanguineous injection; and their globes were not prominent. There was no protrusion or lividity of the tongue; the vessels of the brain, lungs, and su- perior extremities contained fluid blood, but they were by no means gorged; this blood preserved its fluidity for fourteen days after death;—a moderate quantity Vol. II.—56 442 asphyxia, (Submersion.) was found in the right ventricle; the left was nearly empty. The lungs were in a state of flaccidity very remarkable; they were so sunk in the thoracic cavity, that they did not even cover the heart laterally. (Orfila, Traile de Med. Leg., torn. ii. p. 409.) The treatment of cases of strangulation is to be conducted on the general prin- ciples already stated, with such modifications as the peculiarity of the case may seem to require; bleeding to a small amount, especially from the jugular vein, is evidently indicated where there is much turgescence of the vessels of the head; but it should never be carried far at first, though it maybe subsequently necessary to abstract a larger amount when the circulation is re-established. When the face is pale, however, and the general appearances are not those of venous congestion, such a step is highly improper; and the administration of stimulants is rather indi- cated. It will be seldom that any measures can be successful after the lapse of a few minutes, unless there be some peculiarity in the circumstances of the suspen- sion. It has happened more than once that ossification of the larynx has prevented the occlusion of the air-passages, and that the position of the ligature has been such as not seriously to impede the circulation, so that recovery has taken place after a whole night's suspension. Submersion. Although death cannot, in strictness, be said to take place by submersion, unless the whole body be covered by fluid, the distinction is of little practical importance; and the term may be conveniently applied to all those cases in which the entrance of air into the lungs is prevented by the immersion of the mouth and nostrils in water or other liquid. With our present knowledge of physiology, especially in regard to the vital importance of the function of respira- tion, it seems extraordinary that any difficulty should ever have been felt in ac- counting for the occurrence of death under such circumstances. So little, however, was the subject of asphyxia formerly understood, that the fatal termination was attributed to the injurious effect of the contact of water with the surface of the body. In order to show that an animal could live under water, provided that the continuance of its respiration were ensured, M. Gauteron made the following ex- periment :—Having fixed a long tube into an opening in the trachea of a dog, he forcibly retained the animal at some depth under water, keeping the end of the tube above the surface. In this situation the animal remained upwards of a quar- ter of an hour, respiring freely through the tubes, and at the termination of the experiment, it was found to have sustained no injury. This may almost be re- garded as a useless cruelty, when it is remembered that a similar experiment has been prepared for us by Nature, who has adapted the elephant to remain for an almost indefinite time under water, by the prolongation of the air-tube through its extended proboscis. Various other hypothesis have been advanced to account for death by submersion, some of them almost equally absurd with that just men- tioned. Of these it will be desirable to advert to a few, which are founded more or less upon observed facts. Among the older writers we find death ascribed to the ingestion of water into the stomach—almost as unphilosophical a cause as it is possible to imagine. Many cases of drowning occur in which no water passes down the oesophagus; and its entrance appears to depend on certain accidental circumstances which will be explained hereafter. Even if it were constantly found, it would be ridiculous to attribute death to it; since it is well known that a much larger quantity than is ever seen in the stomach of a drowned person may be ingested without any dele- terious effect. By many physiologists, the introduction of water into the air-passages has been conceived to be the proximate cause of death. With our present knowledge, however, it must at once be evident that this can only be injurious by preventing the entrance of air into the air-cells; and that it cannot, therefore, be more preju- dical than the external obstruction. Other fluids may be more deleterious; but water, if so introduced in the healthy state, is gradually absorbed. Goodwyn injected two ounces, by small quantities into the trachea of a cat; the animal asphyxia, (Submersion.) 443 seemed to breathe with some difficulty, but did not seriously suffer, and was at last strangled. Similar experiments were tried by Gardanne and Vernier upon dogs and rabbits; they injected four times more than is ever found in the lungs of these animals when drowned; and they found that the dyspnoea gradually passed off, and that perfect recovery took place. It is quite possible, however, that when respiration is suspended, and before absorption can take place, the introduc- tion of any considerable quantity of water into the lungs may contribute to stag- nate the pulmonary circulation; since it has been found by Dr. Southwood Smith that, if water be injected into the air-passages so as to completely fill them, it is almost impossible to force any liquid through the pulmonary artery. Others have ascribed death by drowning to a collapsed state of the lungs, by which it is supposed that an impediment is offered to the passage of blood through them. Though it frequently happens that a large quantity of air is expelled during sub- mersion, and that this being replaced by none, the lungs are found to contain little air after death, such is by no means invariably the case; and we cannot, therefore, attribute death to this cause. Even supposing it were constant, it would require to be proved that this collapse offers any sufficient impediment to the passage of blood, which we have no reason whatever for believing. That it aids in producing the stagnation when it does take place, may, however, be rea- sonably admitted; since it is known that a much-contracted state of the lungs is as unfavourable as over-distention to free circulation through them. Congestion of the cerebral vessels, also, has been alleged by some to be the proximate cause of death by drowning. It is quite true that this state is found to exist after death in a large proportion of those who have thus perished; but it by no means follows that it is the immediate cause of the fatal result. We have already seen that it is one of the usual phenomena of asphyxia, and that it is a consequence of that stagnation of blood in the lungs which operates so inju- riously on the vital functions in general; whilst, on the other hand, this conges- tion, supposing it to arise from some different cause, could only occasion death by itself producing asphyxia. The supposition is therefore untenable as a general explantion; although, as we shall presently see, it is applicable to particular cases. We can have no hestitation in regarding asphyxia, occasioned by the obstruc- tion to the admission of air into the lungs, as the principal cause of death in the greater number of instances in which it is produced by submersion. Still, as in the case of death by suspension, there are several collateral causes, the operation of which must be borne in mind, both as explaining the variations that we meet with in the post mortem appearances, and as having an important bearing on the me- dico-legal inquiries which are often founded on such occurrences. It is to Mac- quer that we are indebted for the first approach to a true view of this subject. He described death by drowning to the deleterious alteration which the air con- tained in the lungs undergoes when not renewed by the actions of respiration. That such an alteration takes place was proved by the experiments of Berger, who states that the air expelled from the lungs of a drowning animal will be found to have lost fifteen or sixteen per cent, of its oxygen, having thus acquired about the same degree of contamination as an atmosphere in which respiration is car- ried on until asphyxia is induced. Although Macquer was evidently right in the main, his theory stops short at the important question, how the non-renewal of the air affects the movement of the blood and the other vital functions. Having already discussed this question in full, as part of the general subject of asphyxia, we need not here return to it. Death by submersion may be regarded as taking place in one of four modes. First, We shall suppose that an individual in the full possession of his intellec- tual faculties falls into deep water; he descends to a depth proportional to the height from which he fell, and then rises to the surface in consequence of his specific lightness, assisted by the buoyancy of the air which is entangled in his clothes. If he knows how to swim, he may keep himself there, until, his mus- 444 asphyxia, (Submersion.) cular power being weakened, he is incapable of the exertion: and he is then simi- larly circumstanced with one who cannot thus sustain himself. Although, if com- pared in ordinary situations, the human body is, bulk for bulk, considerably lighter than water, the ease is altered when it is thus immersed in the fluid. The sudden shock, affecting the whole surface, occasions a general contraction of all the parts susceptible of it, but more especially produces a diminution in the bulk of the trunk. Of this any one may satisfy himself in the cold bath. Even when unaf- fected by mental emotion, he will find it almost impossible to take in a full inspi- ration; for the contraction of the abdominal muscles prevents the descent of the diaphragm; and the effect is increased by the pressure of the circumambient fluid, so that the abdomen becomes almost flattened. There is no doubt that this altera- tion is increased by the influence of agitation and terror; and this is exercised principally on the first respiratory movements which take place when the indi- vidual rises to the surface. A part of the air which the lungs contained is ex- pelled; and it commonly happens that the attempt to replace it by inspiration causes the introduction of water along with air into the trachea. The former excites the tendency to cough; and in this effort a still larger proportion of the air is expelled, and the bulk of the chest is thus diminished. In the irregular struggles which follow, the individual sometimes sinks, sometimes rises to the surface; and every time that his face meets the air an inspiratory movement is attempted, usually with the same consequences as at first, so that the air at first contained in the lungs is gradually diminished in quantity, and partly replaced by water. At the same time the fluid is generally introduced by these efforts into the stomach. During this period the usual phenomena of asphyxia are being deve- loped. The circulation through the lungs is gradually checked, and a state of gene- ral venous congestion is induced. This will more particularly affect the internal organs in consequence of the influence of cold upon the external surface; and the functions of the brain will be speedily suspended under the combined influence of this cause and of the diminished supply of arterial blood. All movement then ceases; the asphyxia becomes complete; and the body sinks to the bottom of the water. Some bubbles of air are usually then expelled by the external pressure, which is no longer resisted by muscular effort. Secondly, A state of syncope may supervene at the moment of immersion, by the influence of various causes,—such as the violent shock to the nervous system occasioned by the contact of cold water with the whole surface, or the sympathy of the corporeal structure with the agitation of the mind. In such cases the indi- vidual generally rises once to the surface, and then sinks without farther struggle. Some physiologists are disposed to consider this mode of death as hypothetical merely, and are not willing to appeal to it in elucidation of the remarkable facts already adverted to respecting the length of time during which submersion may be occasionally borne; but we cannot but consider their incredulity as the result of a want of fair consideration of known facts. In the first place there can be no doubt, from the accounts of various persons who have recovered, that syncope not unfrequently comes on at the moment of immersion; and the same inference may be drawn from the occasional absence of any signs of asphvxia or cerebral congestion, joined with the want of those indications of grasping movements, which we expect to find on the hands of those who have been drowned within reach of any objects that can be laid hold of. That we cannot produce it, in the same manner at least, by experiments on animals, is not to be wondered at; since they are not susceptible of the influences upon the nervous system just described. But the same condition may be induced by blows on the head; and an animal suffering from concussion is in precisely the same state, as far as its organic func- tions are concerned, with a human being in a state of profound syncope from mental emotion. Now it is found, that an animal in this condition may be sub- mersed for a much longer time than one in a state of vital activity, without its ultimate recovery being prevented; and this is readily accounted for when it is remembered, that the circulating system is here primarily affected, and the func asphyxia, (Submersion*) 445 tions of the nervous system already almost suspended, so that the small amount of aeration afforded by the air contained in the lungs is sufficient for the mainte- nance of life. This may be illustrated by the case of the hybernating animal already alluded to, which may be regarded as almost in a state of syncope; its circulation being very feeble, and its respiratory movements scarcely perceptible. It may be said to live more slowly than when in a state of activity; and just in proportion to the slowness of its life, is its power of supporting the deprivation of air. The same may be said of the whole class of reptiles when compared with that of birds. There is no physiological difficulty, then, in accounting for the preservation of vitality by a human being after an immersion of half an hour, or even of three-quarters; and that this occasionally takes place there is evidence which we have no right to doubt. Mr. Taylor, however, in his recent excellent work on medical jurisprudence, withholds his assent, on the ground that we have no proof, in any of these cases, of the individual not having occasionally respired at the surface, during the time when he was supposed to be submersed. He has overlooked, however, the following case, which, though involving a shorter du- ration, is one which establishes the condition of syncopal asphyxia beyond a doubt; it is related by Marc (Manuel d'Autopsie Cadaverique Medico-Legale, p. 165,) on the authority of Plater. A woman convicted of infanticide was con- demned to be drowned. This punishment was inflicted in Germany by the now obsolete Caroline Law, according to which the criminal was enclosed in a sack with a cock and a cat, and sunk to the bottom of the water. In this instance the woman, after being submerged for a quarter of an hour, was drawn up and spontaneously recovered her senses. She stated that she had become insensible at the moment of immersion. This form of death will be most common among persons of susceptible nervous system; and therefore more frequent in the fe- male than the male sex. Thirdly, A state of syncope may supervene under the influence of mental emo- tion, when the individual has been immersed for some little time, and death may thus result in part from asphyxia and in part from syncope. Fourthly, Death may result from some primary disturbance in the functions of the brain; produced by the direct operation of external causes. Thus, a per- son falling into the water in a state of drunkenness, or in the midst of a violent struggle, will have already become the subject of congestion of the brain, which, when aggravated by external cold and pressure, and by the impediment soon of- fered to the pulmonary circulation, may be regarded as the proximate cause of death. This is still more decidedly the case when the head strikes some hard substance in its fall, in which an apoplectic effusion is the consequence; and we then find no signs of asphyxia referrible to the submersion. As already stated, however, it is most common to find marks of cerebral congestion accompanied by the appearances which ordinarily indicate asphyxia. We shall now consider in some detail the anatomical characters usually re- garded as characteristic of death by drowning, the circumstances under which they are respectively produced, and the degree of importance to be attached to each. 1. In cases where death has resulted from simple asphyxia, a livid tint may sometimes be observed in the face, though this is frequently pale; discolourations are more commonly found on the hands and feet, and on other parts of the body. The appearance of the surface, however, will greatly depend upon the duration of the immersion, and upon the length of time during which the body has been sub- sequently exposed to the air; this will be detailed subsequently as being common to all the modes of death above described. The eyes are generally half open, and the pupils dilated. The mouth and nostrils are covered with a mucous froth; the tongue pushed forward against the incisor teeth, but not usually protruding exter- nally. A mucous froth, rarely sanguinolent, covers the lining membrane of the larynx, trachea and bronchi; the membrane itself is sometimes deepened in colour. Water is occasionally found in the air-passages. Sometimes it exists only in the 446 asphyxia, (Submersion.) trachea and the primary divisions of the bronchi, not exceeding half a spoonful in quantity; whilst in other instances it fills the air-tubes to their ultimate ramifica- tions. Any substances suspended in it, such as mud or vegetable matter, may afford important indications of the locality at which the submersion took place. The lungs are usually gorged with dark fluid blood, and are sometimes so dis- tended as to meet when the anterior mediastinum is cut through. The circulating system presents the condition described as produced by asphyxia. The stomach often contains water. Sometimes a small quantity of dark or even bloody urine is found in the bladder. 2. When syncope has been the cause of death, on the other hand, extremely little alteration from its natural condition is found in any part of the body. The whole surface is pale. The trachea sometimes contains a little water, but no froth; the lungs are sometimes collapsed, and never preternaturally distended. 3. In the third class of cases above described, the signs mentioned as charac- teristic of the first are observable, but in a less decided form. The right cavities of the heart, and the vessels connected with them, are fuller than those on the left side; but the latter are not entirely empty. The lungs are moderately distended with blood; but little froth exists in the trachea, and little or no water. Fluid is often found to have entered the stomach. These are, perhaps, the most common ap- pearances, it being rare to find cases in which all those first described present themselves. 4. Death from an unequivocally apoplectic condition is extremely rare in cases of drowning: it will of course be recognised by the appearances characteristic of that state: it not unfrequently happens, however, that the congestion of the cerebral vessels is greater than that which would simply result from asphyxia. We shall now inquire into the value of the chief of these signs, considered sepa- rately, as indications of death by drowning. The aspect of the surface depends much upon the length of time during which the body has been immersed, and upon the interval which elapses between its removal from the water and the inspection of it. If it have remained in the water only a few hours after death, and be examined soon after its removal, but little dis- colouration will commonly be found, unless the phenomena of asphyxia have been developed to an extraordinary degree. A body which has been immersed in water, however, undergoes very rapid decomposition when removed from it; and the longer the immersion, the more rapid the decomposition. A very few hours will thus effect such a change in the aspect of a body which has been some weeks immersed, that it would scarcely be recognised again. This change takes place the most rapidly in a high temperature; so that a body which has been withdrawn from the water, with scarcely any discolouration of the skin or tumefaction of the face, will in summer very soon appear livid and bloated, and the features extremely distorted. The discolouration takes place most rapidly in the parts most freely exposed to the contact of air; and it is not observed on cutaneous surfaces which have been in close opposition with each other, or with their coverings. The skin becomes at first of a livid brown colour, which gradually passes into a deep green. According to Orfila, the progress of this change enables us to distinguish it from that occasioned by decomposition under other circumstances. In general, the first part of the trunk which is so affected is the skin of the abdomen; but in submerged bodies, it is the integuments of the thorax. Discolouration of the sur- face will take place, however, without exposure to air, provided the immersion have been sufficiently protracted ; but as it is not confined to bodies that have suf- fered death by drowning, this is not the place to enter into a description of these changes, which have been minutely detailed by M. Devergie (Ann. d1Hygiene, torn. ii. 5; and Med. Leg., torn, ii.,) whose opportunities of observation are very great. It is right to state, however, that the accuracy of his descriptions is dis- puted by M. Orfila. (Ann. rf'Hygiene, torn. vi.; and Exhumations Juridiques, torn, ii.) An external sign which was formerly much relied on, is the presence of exco- asphyxia, (Submersion.) 447 riations on the fingers, and of sand or dirt under the nails. This may obviously be of great importance in a juridical investigation; but as our present view of the subject is simply pathological, we may pass over it with a slight notice. It can only occur in those cases in which there has been a long struggle for life; and its absence, therefore, is no proof that drowning has not been the cause of death in either of three out of the four modes above specified. Moreover, the local con- ditions of the spot where the drowning has occurred, may prevent any such marks from being formed. Where they are discovered, however, they may afford very important evidence as to the fact of submersion having been the cause of death. The presence of mucous froth in the mouth and around its orifices, is an indi- cation into the value of which it is right that we should carefully inquire. This froth is formed in the air-passages, and resembles a lather of soap; its appearance externally can only result from one of two causes;—either it has been formed in such quantity as to fill the bronchial tubes, the trachea, and the mouth, and then to escape from its cavity; or, having been produced to a less amount, it has been forced outwards by the extrication of gas in the lungs, which results from putrefaction. This change takes place most rapidly in summer; and hence it is far more common to find the mouth filled with froth, and the air-passages free from it, at this season than in winter, when it rarely occurs. As its formation takes place originally in the air-passages, we may regard it as occurring under the same conditions with the mucous froth in the trachea,—a sign of considerable value, although several medical jurists have denied that any weight can be attached to it. The experi- ments of Orfila and Piorry, confirmed by those of Mr. Taylor, have now satis- factorily established that mucous froth can only be formed in the air-passages when the animal rises frequently to the surface to respire. It appears to be pro- duced by the agitation or admixture of the air so taken in, with the secretion from the lining of the air-passages, and probably also with a small quantity of water. If the animal is kept altogether under water until respiration have ceased, the tra- chea is found perfectly smooth. It must be remembered, however, that this froth may be formed in the trachea of those who die by other forms of asphyxia, espe- cially when protracted dyspncea has caused a great increase in the amount of fluid poured into the air-passages. It Jias been attributed in some instances to putre- faction; but this is evidently erroneous, since, as already stated, when gas is so disengaged in the lungs, it drives the froth upwards into the mouth. Little fal- lacy, then, will be found to exist practically, in regarding the presence of froth in the air-passages of a body taken out of the water as an indication that death has taken place by drowning; but, on the other hand, its absence cannot be relied on in proof of the contrary. We have seen that, in a considerable proportion of cases, it will not be formed at all; and even when it has been formed, it may dis- appear under the following circumstances:—I. If the body remains long under water after death, so that the fluid obtains free admission into the trachea, the froth will disappear; this, it will presently be seen, is no uncommon occurrence. 2. If the body be exposed to the air for some days after its removal from the water, the froth will then commonly disappear. 3. If the body be placed with the head in a depending position after its removal from the water and there be much fluid in the lungs, the draining away of this will wash the froth from the mouth and air-passages. These circumstances have been particularly dwelt upon by Orfila; and they must be carefully borne in mind when the sign in ques- tion is absent in a case of supposed drowning. Connected with the appearance just discussed is another to which considerable importance has been attached in juridical inquiries—the presence of water in the air-tubes. It is strange that this occurrence should have been denied by so many observers, since it is so easily substantiated by experiment. It has been almost invariably found to take place by Orfila, when animals were submersed; and as he used coloured fluids, of which very small quantities could be detected and distin- guished from the serous fluid sometimes excreted into the passages, there is no 448 asphyxia, (Submersion.) room to doubt that some amount of the surrounding liquid enters the trachea in ordinary cases of drowning. The quantity, however, is extremely variable. It probably depends in part upon the number of forced efforts at expiration made by the animal; but it does not according to Mr. Taylor, seem connected with the inspiratory efforts. This author states that he has found it greater in the lungs of those which had been suddenly sunk to a great depth and drowned, than in other cases. (Taylor's Medical Jurisprudence, p. 128.) It has been maintained by some (and amongst them, Dr. E. J. Coxe of Philadelphia,) that the water does not enter until the period of the final respiratory efforts, when the irritability of the glottis is supposed to be so far diminished that it does not resist its passage. But this has been disproved by Orfila, who performed the following experiment with a view to ascertain the truth. Having plunged two dogs under water, he secured the tracheae by ligatures, after the submersion of a minute in one case, and of half a minute in another, the whole of the steps of the operation having been previously prepared. In both of these cases, he found liquid in the bronchial ramifications. After being so introduced, however, it may disappear under the same circumstances as those enumerated in the last paragraph. Still it would be sufficiently easy to make allowance for these, so as to render this sign almost pathognomic, were it not that it may be imitated by the spontaneous entrance of water into the air-passages after death, when the body has remained long immersed. The possibility of this has been denied by many authors, who supposed that the valvular action of the epiglottis would be sufficient to prevent it. Experiment has fully proved it, however, not only in the case of drowned bodies, but where death has taken place from other causes, and the body has been subsequently placed in water. Orfila and Piorry found that the quantity thus admitted depended upon the position of the dead body. If it were retained under water with the head erect, the liquid penetrated freely to the ultimate ramifications of the bronchi; but it entered less freely when the body was in a horizontal position, and probably none would enter if the head were entirely depending. It is evident, then, that little impor- tance can be attached to this sign when taken singly, though it may be useful if viewed in connexion with others. The correspondence in character between the fluid in the lungs and that of the spot where submersion is supposed to have first taken place, and its difference from that in which it is found, may, in some par- ticular cases, afford important evidence. Another sign of corresponding nature, on which, perhaps, somewhat more reliance can be placed, is the presence of water in the stomach. Here, again, a remarkable discrepancy has existed in the opinions of different writers; some maintaining that it never enters during the act of drowning, and others, that it cannot penetrate after death. The truth, as on most disputed questions, appears to lie between the two extremes. The experiments of Goodwyn, Orfila, Taylor, and others, have fully proved that a quantity may be swallowed during the strug- gles of a drowning animal; and Mr. Taylor has shown that the amount is usually the greatest when life is prolonged by occasional respiration at the surface, whilst it is generally absent altogether when the animal has been kept beneath the fluid from the first. We must not, therefore, rely upon the fact of no water being found in the stomach, as disproving the supposition of death having been pro- duced by drowning. It will probably enter but in small quantitv, or not at all, in the three latter classes of instances formerly enumerated; and even when it has been introduced, it may disappear by the effect of position during removal, or by transudation through the body, if it be long exposed to the air, especially when much decomposed. On the other hand, its presence must not be relied on as a proof that drowning has taken place, since there is no doubt that water may enter the stomach of a body which has been submerged after death. It is true that the parietes of the oesophagus are usually so closely applied to each other, that water cannot enter without difficulty. The circumstances which seem to favour its admission, are advanced putrefaction, and the subjection of the. ASPHYXIA, (Submersion.) 449 body to considerable pressure whilst under water. To the latter condition atten- tion has been particularly directed by Mr. Taylor, who found that if an animal be sunk to a considerable depth, the stomach becomes distended with water, even though it be not allowed to respire; and as no deglutition can take place under such circumstances, it is evident that the water must have been forced in by its own columnar pressure, and that the same cause would operate still more effectually on a dead body, where no resistance is offered by the will. It is evident, then, that great caution must be used in drawing inferences from this sign when present; but it is, perhaps, on the whole, the most valuable of all those which may be denominated the accidental signs of death by drowning, as it can only be produced after death under very peculiar conditions. The alteration in the character of the urine is a phenomenon of rare occur- rence, and no decided inferences can be drawn either from it or from the state of the bladder. To this last source Piorry was disposed to look, from observing that dogs usually empty that sac at the moment of violent death, and that it seems to be refilled by absorption from without, previously to the supervention of cada- veric rigidity; this, however, is not the case in man. Little reliance can be placed upon the fluidity or coagulation of the blood, for very obvious reasons. The fluid state, supposing it to exist, may result from many causes besides drowning; and coagulation certainly takes place in the blood of a considerable proportion of drowned persons, being more common in the cavities than in the vessels. With regard to the general value of these signs, therefore, in the determina- tion of a case of suspected drowning, the same must be said as in regard to death by hanging—that our inferences must be founded upon the presence or absence of several conjointly, and not upon any single one. As a useful illustration of the preceding statements, we shall subjoin the summary given by Dr. Ogston (Edin. Med. and Surg. Journ., vol. xlvii.) of the appearances presented in seventeen cases of drowning, mostly accidental, which occurred at Aberdeen. The only phenomena which were all but universal in these cases, were the di- lated pupils, clenched jaws, and semi-contracted fingers. This state of the pupil was common to all the cases. In one only was the mouth open; in the rest it was firmly fixed both before and after the occurrence of rigidity in other parts. In every instance but one, the position of the fingers indicated the convulsive closure of the hands during the last straggle. The peculiar position of the tongue was almost invariably noticed, its tip being found in contact with the incisor teeth; in two cases only was it included between the closed jaws. In six of the cases, seen within six and a half hours after death, the surface was pale when first examined, and the countenance presented an appearance of ex- treme placidity; but discolouration and turgescence of the face speedily took place, especially when the weather was warm. The face was almost invariably reddened when the immersion had continued eight hours in warm weather; and swelling appeared soon afterwards. In three cases the cutis anserina was ob- served; two of these occurred in winter. In no instance were abrasions seen on the fingers, or dirt under the nails; this may be in part due to the local circum- stances. In seven cases froth was found about the lips or nostrils. Out of the whole number only seven were examined internally. Of these, three presented the mucous froth in the trachea; in two, nearly an ounce of water was found in the trachea; and in two others, a considerable quantity escaped when artificial respiration was being practised. In five out of the seven cases examined, water was found in the stomach; and in several others its presence was detected by pressing the abdomen or turning over the body. In five of these seven cases, the blood was found partially coagulated in the heart, though fluid in the vessels. Besides the usual appearances in the thoracic portion of the circulating apparatus, a good deal of venous congestion was found in the head and abdomen in most of the cases examined. Vol. II.—57 450 asphyxia, (Treatment.) Treatment. Little need be added, under this head, to what has already been stated in regard to the treatment of asphyxia in general. The point which will require attention in the resuscitation of drowned persons, is the advantageous application of heat. Owing to the conducting power of water, a body which has undergone asphyxia by submersion will have lost much more heat in the same time than one which has been hung or strangled. Although the warm bath would appear the most advantageous means of restoring this, it is objectionable in the present case, since it prevents the due influence of the air upon the skin, which is important in two ways;—by promoting the movement of blood in the cutane- ous vessels through its direct aerating powers, and by serving as an excitor through the nervous system, to the inspiratory actions. We fully agree then with Dr. Kay, in thinking that, in the treatment of asphyxia by submersion, warm dry air is the best medium to which the body can be exposed. Hot vessels of water, bricks, &c. may be applied to the spine and to the extremities, but not to the abdomen. Friction with warm flannels may be advantageously practised on the trunk; but nothing should interfere with the free contact of air to a large portion of the sur- face. Bleeding should be employed with great caution; but where the habit is plethoric, and the veins of the neck are turgid, they may be advantageously un- loaded. In default of any other means of practising artificial respiration, the bandage of Leroy, or some substitute for it, may be employed. This is simply a large eighteen-tail bandage, formed by tearing a piece of linen into strips about three inches broad, but connected together by an untorn portion at the centre of each. This untorn portion being laid upon the spine, and the strips being crossed over the thorax, compression may be very advantageously applied, so as to pro- duce a partial expulsion of the contents of the lungs, which will be replaced by the elasticity of the parietes when the compression is renewed. This alternate pres- sure and relaxation should be kept up about twenty-five times in the minute; and if no large piece of cloth be at hand, it may be effected almost as well by a few hand- kerchiefs applied in a similar manner. The great principle to be kept in view in the treatment of cases of drownmg is that the attempts at resuscitation should not be intermitted for several hours, nor even then unless there appear no chance of success. Many have been restored contrary to all expectation, when the treatment was continued simply in confor- mity with this principle. The patient should be watched for some time after his apparent recovery, as dangerous reaction sometimes comes on. There is nothing in the characters or treatment of asphyxia by suffocation, or more properly smotherinsr, that requires peculiar notice here; nor in those of asphyxia produced by simply irrespirable gases. As formerly stated, death from carbonic acid and other noxious gases more properly falls under the head Poisoning. ( 451 ) DISEASES OF THE ORGANS OF CIRCULATION. DISEASES OF THE HEART. Preliminary observations.—Anatomy of the heart—its site.—Relation of the lungs to the heart.— Structure.— Weight and measurement.— Motions.—Natural sounds.— Morbid sounds.—Disordered motions.—Arterial and venous pulse.—General observations on diseases of the heart.—Importance of accurate discrimination.—Means of diagnosis by local or physi- cal signs and by general symptoms.—Causes.—Prognosis.—General view of their treat- ment. Or the diseases to which the human frame is liable, few have of late years at- tracted more attention, or been investigated with greater ingenuity and perse- verance, or with more successful results, than affections of the heart. It was im- possible that a class of disorders characterized by symptoms of so prominent and distressing a nature should have altogether escaped the notice of the ancients; and accordingly traces of an acquaintance with them are to be met with in the writings of the Greek and Arabian schools, but generally so faint and indetermi- nate, in consequence of the prevailing neglect of pathological anatomy, that they are now little referred to except as matter of curiosity. The foundation of the more accurate notions which we at present possess on this subject was laid by Harvey by his discovery of the circulation; and for the first solid and conspicuous portions of the superstructure we are indebted more parti- cularly to Lancisi, and the second Albertini and Valsalva, and their distinguished pupil Morgagni, and to Senac. Corvisart's graphic treatise on diseases of the heart, of which the first edition appeared in 1806, formed a new era in respect to the knowledge of these affections, and gave a fresh impulse to their investiga- tion in various parts of Europe, as was speedily evinced by the successive ap- pearance of the valuable works of Burns and Testa, Kreysig and Bertin. By the revival of Avenbrugger's method of percussion, and by Laennec's invaluable discovery of the stethoscope, new and unprecedented facilities were furnished for their study; and that these have not been neglected we have ample evi- dence in the pages of the great pathologist last named, as well as in the con- tributions of a host of able successors in the same path, more especially in this country and in France. Anatomy of the Heart. Before entering in detail upon the particular diseases to which the heart is liable, it may be useful briefly to recall to the reader's memory a few points of practical importance in respect to the site and structure of the organ, its nonnal size and weight, its component tissues, its motions, and the sounds by which they are accompanied. 453 thk heart, (Anatomy of.) Site of the Heart. An accurate acquaintance with the position of the heart within the chest in its natural condition, the space which it ordinarily occupies, and its relation to the lungs and solid parietes of the thorax, as well as to the diaphragm, is indis- pensable to enable us to detect the existence of various degrees of displacement and enlargement of the organ, as well as the effusion of fluid which occasion- ally takes place into the sac, which in the healthy state closely embraces it. The heart, which is of an irregular conical form, flattened on the under surface, is si- tuated in the anterior mediastinum, towards the left side of the chest, behind the lower half of the sternum, the third intercostal space, and the cartUages of the fourth and fifth and sixth ribs* Its base is directed upwards, backwards, and to the right side, looking towards the fifth, sixth, and seventh dorsal vertebrae, the oesophagus and descending aorta intervening; and its point consequently down- wards, forwards, and to the left, answering, in the erect posture, and when the chest is in a medium state of distention, and the heart in the act of systole, to the fifth intercostal space, that is, in a middle-sized individual, to a point about two inches below, and one to the inside of the nipple; or two and a half from the out- side of the base of the xiphoid cartilage. It is protected, and to a certain degree confined to its position by the sero-fibrous sac of the pericardium, which is strongly attached below the diaphragm around its tendinous centre, and made fast supe- riorly to the great vessels some way above their origin, or about as high as the second rib; whilst they are in their turn fixed, in a manner, by their branches, and by connecting ceDular membrane to the upper part of the thorax and root of the neck. The pericardium and heart are covered laterally by the lungs, and also ante- riorly, with the exception of a lozenge-shaped space of somewhat less than two inches across, answering to nearly the whole front of the right ventricle, and to the most anterior portion of the appendix of the corresponding auricle, together with merely the apex and external edge of the left ventricle. These exposed por- tions as well as the root of the pulmonary artery and the ascending aorta, after it has emerged from behind it. are separated from the parietes of the chest only by tlie pericardium and loose cellular tissue. About one-third of the heart, con- sisting principally of the right auricle and the upper and right side of the base of the corresponding ventricle, lies behind the sternum. The orifice of the pulmo- nary artery and its valves, and consequently those of the aorta likewise, which lie posteriorly, but nearly in the same line, are placed immediately behind the upper edge of the fourth sterno-costal articulation of the left side.f The auriculo-ventricular orifices of the two sides of the heart lie to the right and left respectively of the point just indicated, that of the right side being at a lower level by several lines. Where they approach each other most nearly, being scarcely the third of an inch apart, they would be actually covered by the root of the pulmonary artery, but that they are placed a little lower or nearer the apex of the heart. Still a moderate-sized stethoscope, applied over the origin of the pul- monary artery and its valves, will cover also the aortic orifice and its valves, as well as a very considerable portion, nearly a half of each of the auriculo-ventricular openings, a fact to which we shall afterwards have occasion to recur, on account of its practical bearing in the diagnosis of the different species of valvular disease. The bulging portion of the pulmonary artery, just below the division into its two trunks, has been singled out by Dr. Hope as a fixed point of easy determina- * As in fat persons there is often much difficulty in counting the ribs, we may recall to the reader's memory that the nipple generally answers to the fourth rib.—Author. + If examined from the back, they are opposite to a point just above the left side of the fifth dorsal vertebra.—Apthor. the heart, (Anatomy of.) 453 tion; being seated, as he states, between the second and third ribs of the left side, close to the sternum. The aorta inclines "slightly to the right as it ascends, coming in contact with the sternum where it emerges from beneath the pulmonary artery, following, or perhaps slightly exceeding, the mesial line till it forms its arch; the pulmonary artery, which is from the first in contact with the sternum, inclining more considerably to the left until it arrives at the interspace between the second and third rib." A sharp instrument passed through the upper part of the sternum in the median line and on a level with the first intercostal space, would glance along the upper part of the arch of the aorta, as it is passing from the right side of the sternum to the left side of the third dorsal vertebra. The antero-superior surface of the heart, which, as we have seen, is formed chiefly by the right ventricle, is convex; whilst the postero-inferior surface, an- swering to the left ventricle, is flat, and lies upon the tendinous portion of the dia- phragm, the motions of which it must necessarily follow. These, however, are obviously very limited, in consequence of the strong unyielding texture of the peri- cardium, and of the firm manner in which it is attached, as already mentioned, both above and below. Yet the heart is certainly carried a little downwards and backwards in inspiration, its apparent change of place being still farther increased by the sternum and anterior portion of the ribs simultaneously ascending; whilst in expiration, on the contrary, it rises again and moves a little forwards, the ribs at the same moment descending, and thus conspiring to magnify the apparent ele- vation of the heart. Hence a deep inspiration, as is remarked by Dr. Williams in his valuable lectures, makes the apex beat below the sixth rib. "The impulse is then, however, scarcely perceptible, because the chest expands as the ribs rise, leaving the heart and drawing the porous lung in front of it. A forced expiration, on the other hand, depresses the ribs, and transfers the strongest pulsation to be be- tween the fourth and fifth ribs, and by bringing down the walls into contact with more of the heart, makes its impulse perceptible over an extended space, as high as the third rib, and on the lower half of the sternum;" and a knowledge of these circumstances, he adds, enables us to test the freedom of the heart and pericardium, and the anterior portion of the lungs, from adhesions. Where the chest is nar- row or deformed, or contracted from the chronic consequences of pleurisy, the im- pulse of the heart may be perceptible over a much greater surface than natural. " So, also, circumstances displacing the heart, such as tumours and effusions of liquid or air into the pleura, may greatly change the character and degree of the impulse, diminishing or increasing it, according to whether the displacement of the organ is from or towards the walls of the chest. Abdominal tumours, and even a distended stomach, may have to a certain degree the same effect." Changes in the pulmonary tissue are very influential in the same way; emphysema may in- tercept or circumscribe the impulse, whilst consolidation will propagate it over a larger space. That the position of the heart is affected in a very sensible degree by gravitation, and consequently by posture, any one may satisfy himself by applying his hand over the spot where the beat of the heart is usually perceptible, and then turning the body successively on the back, the sides, and the face; when the organ will be felt to incline towards the most dependent part, retreating in the supine posture, and coming forward in the prone. The pulsation will be felt most strongly and over the largest surface when lying on the face and slightly turned towards the left; or, if we be sitting or standing, by inclining the body forwards and to the same side, and at the same moment making a forcible expiration. The change of the place of pulsation thus effected is, however, too inconsiderable to be confounded by any competent observer with the derangements of this kind dependent, on ori- ginal malposition of the organ, or on disease. 454 the heart, (Anatomy of.) Relation of the Lungs to the Heart. The extent of the uncovered portion of the heart may be ascertained, even during life, by the dull sound elicited by percussion from the corresponding portion of the chest. This in healthy well-formed individuals rarely exceeds, as we have seen, an area of about two inches in diameter, reaching from the point where the beat of the heart is felt to the leftside of the lower half of the sternum. And hence arises a valuable source of diagnosis in disease; for in cases of effusion into the pericardium, or of organic enlargement of the heart, and perhaps also of its tem- porary passive distention by the excessive accumulation of blood within its cavi- ties, the extent of this dulness will ordinarily undergo a proportional increase. Yet this, though a very valuable sign, is not to be considered, when alone, as af- fording unquestionable evidence of cardiac affection; for the interposition of a portion of hepatized lung, or of a tumour, between the pericardium and the front of the chest, or a partial pleuritic effusion confined by false membranes, or even a great enlargement of the left lobe of the liver, would give rise to the same physical phenomenon. Nor, on the other hand, is the absence of such preternatural dulness decisive as to the non-existence of the cardiac lesions alluded to above; as an em- physematous state of the lung, or the presence of pneumothorax, or an usual de- gree of gaseous distention of the stomach might, in a great measure, mask an en- largement of the heart or a pericardial effusion.* Even in the natural condition, the dulness ceases on lying back, or taking a very full inspiration; and this is another way, as remarked by the author last quoted, of testing the free and unat- tached condition of the heart and lungs,—for if the dulness still persists over a con- siderable extent, even under those conditions, we must conclude either that the heart or lungs are adherent, or that the former organ, from its great bulk, or the pericardium, from its extreme distention, cannot recede. In the last case the im- pulse will be diminished; in the former it will be increased. We must not expect, even in the natural state, in any posture, to find the region of dulness very sharply defined. It is, in truth, shadowed off in proportion to the thickness of the inter- vening lung, which increases gradually as we recede from the uncovered part of the heart. But the site even of the remoter portion of this latter organ becomes revealed, or proportionably augmenting the force of percussion; for it is only by a pretty sharp stroke that the dulness indicative of a deap-seated solid can be de- tected. By the same mode of proceeding we may sometimes recognise an en- larged heart, even though little of it may be in contact with the front of the chest; and get the better also of the obscurity which, as we have stated, emphysema is liable to create. When there is great enlargement of the heart, very strong me- diate percussion may detect deficient resonance, even in the left lateral and pos- terior portions of the chest. (Williams.) So likewise M. Piorry, who states that the heart in its natural condition is in contact with the parietes of the chest over a space of near two inches in diameter, wherein the dull sound on percussion is very obvious; but that the organ extends from an inch and a half to two inches farther over to the left side, under cover of the lung, where likewise its existence may be detected by forcible mediate percussion. The vertical extent of dulness is slightly less than the transverse. The distance of the heart below the top of the sternum is generally from three to three and a half inches, unless when enlargement of the organ exists, or the diaphragm is thrust upward by disease, when it may be re- duced to one-half less. Immediately after death, the extent of dulness is somewhat less than during life, from the diminished turgor of the walls of the organ. * "The chicken-breasted conformation of the chest, especially when connected with spinal gibbosity," is pointed, out by Dr. Hope us another cause that may prevent the development of dulness on percussion."—Author, the heart, (Anatomy of.) 455 Structure of the Heart. It is not our intention to enter at any great length into the natural structure of the heart; a few circumstances, however, which have a bearing on its pathological anatomy may here be mentioned. The cavity of the right ventricle in the adult is broader but less elongated than that of the left, in consequence of which latter circumstance the apex of the heart is formed exclusively by the left ventricle; the distinction between them, or the direction of the septum, is marked externally by a furrow, in which lies the descending branch of the coronary artery and vein. In the foetus, however, and for some time after birth, the left ventricle is compa- ratively shorter, and the point of the organ is consequently made up by two sides almost equally. The tortuous disposition of the muscular fibres of the heart, which baffled the earlier anatomists, has been more successively investigated in later days by Wolff, Duncan, and Gerdy. The parietes of the left ventricle, ac- cording to the last-named anatomist, contain six muscular layers, those of the right only three. The fibres of the external layers run obliquely from above downwards, from before backwards, and from right to left; the middle layers take in all respects the opposite directions; and the deep-seated ones, which, by their union, form the fleshy columns projecting into the interior of the cavities, are, for the most part, longitudinal. The most superficial layers, passing along the apex, occupy the entire circumference of the ventricles, whilst the others diminish in length and breadth in proportion as they follow a deeper course; and hence it is that the ventricles are so much thicker at the base than at the point of the heart. All the fibres, whatever may be their disposition in other respects, turn upon themselves in such a manner, at their middle point, as to form a species of loop, the convexity of which look towards the apex of the organ; and the more superficial the fibres are at one extremity, the deeper seated do they become at the other: thus the most external fibres, for example, become, before their termi- nation, the most internal, in consequence at once of their having been reflected in the manner just described, and also of having traversed the thickness of the ven- tricle. The extremities of these loops are invariably inserted at the base of the heart around the circumference of the auricular and arterial orifices of the ventri- cles, either immediately or in a smaller number of instances, by the intervention of the tendons attached to the auriculo-ventricular valves (chordae tendineae.) The auricles are, according to the same authority, composed of two muscular layers; the one external, the other internal. In the right auricle, the muscular tissue being less abundant than in the left, leaves occasional intervals between its fibres, where the internal and external membranes of the heart are in almost immediate contact; and this proximity helps to explain the frequent co-existence of inflam- mation of the internal lining of the heart with that of the pericardium. The subject of the structure of the heart has still more recently been investi- gated by Dr. Carlyle, who has arrived at conclusions very similar to those of M. Gerdy; whilst M. Filhos, on the other hand, still calls in question the continuity of the external with the deeper-seated fibres; it appearing to him that, after turning from right to left, and from above downwards, in a spiral direction, near the apex of the ventricle, they terminate in a well-marked raphe, from which the internal fibres likewise take their origin. It appears to us, however, from the careful ex- amination of the heart of an ox, the fibres of which had been rendered easily se- parable by long-continued boiling, that the former view is a true one. The columnae carnae are more numerous in the right ventricle than in the left; but those which act on the valves of the former are smaller than the correspond- ing ones of the opposite side. The fibrous or albuginous nature of the tissue of which the chordae tendineae are formed, and which enters also into the composi- tion of the whitish zones at the base of the valves, surrounding and strengthening the orifices, as well as within the serous duplicature of the valves, enables us to understand why those parts so frequently afford examples of cartilaginous and 456 the heart, (Anatomy of.) osseous degeneration. The knowledge of the existence of such a tissue in this situation, together with that of the sero-fibrous structure of the envelope of the heart, should prepare us to expect this organ to be a frequent seat of rheumatic inflammation. The endocardium, or fine semi-transparent polished membrane lining the inte- rior of the cavities, resembles in nature and tenuity the more delicate of the serous membranes; and like the inner coat of the vessels, it readily receives, by imbibition, under certain conditions, the colouring matter of the blood, whence generally originate the reddish stains so often observed within the heart. It is neglected inflammation of this membrane, according to M. Bouillaud, an author to whom we shall have occasion very often to refer, that a great majority of the organic diseases of the heart have their source, and especially in that portion of it which lines the valves and orifices, where it is naturally thicker than in other situations, and necessarily exposed to a greater degree of stress and friction. Chronic inflammation, it is supposed, may lead not merely to morbid thickening and inequality of this structure, but also to the effusion of coagulable lymph on its surface, as well as to hypertrophy and degeneration of its subjacent cellular and fibrous tissues, inducing immediately diseases of the valves and orifices, and secondarily, thickening of the walls of the heart, and enlargement of its cavities. Though in its natural condition it can be detached only in minute shreds, yet in certain states of disease its adhesion to the subjacent tissues becomes so much di- minished that large patches of it may be raised entire. Around the contours of the orifices or base of the valves, as well as in the situation previously indicated, the inner and outer linings of the heart come into very close approximation, only a very thin layer of connecting cellular membrane intervening; so that here, also, the transmission of inflammation between the two surfaces is peculiarly favoured. Weight and Measurement of the Heart. It would obviously be very desirable towards assisting us in the appreciation of certain cases of enlargement and diminution of the heart, to possess some definite standard of its normal magnitude. This, however, taken in an absolute or mathe- matical sense, is evidently unattainable, for the size of the heart, like that of all the other organs, is susceptible of various shades of difference, all of which may yet be within the natural limit, or the limit of health. All, then, that we can rationally attempt is, either to establish a rough comparison between its size and that of some other organ appertaining to the individual examined; or else to obtain an approxi- mative or average value for it, in figures, deduced from a large number of par- ticular cases. Of these two expedients Laennec contented himself with the for- mer, laying it down as a general rule that the healthy heart was ordinarily about equal in size to the fist of the subject to which it belonged, a rude standard of comparison, of which the chief recommendation is the facility of its application. The walls of the left ventricle, he adds, are about double the thickness of the right, and sufficiently firm to prevent their falling together and obliterating the cavity on being cut across; the right ventricle is a little larger, and from the thin- ness of its walls should in the natural condition collapse on incision. Since the time of Laennec, however, in consequence of the vogue of the numerical method in other branches of pathology, several French, German, and English physicians have endeavoured to solve the physiological problem alluded to by the system of averages expressed in numbers, setting forth thus the medium weight, and mea- surements of the heart. Thus the average weight of the heart of the adult in its normal condition, and after being emptied of* its blood, and having the great ves- sels cut away, was estimated by M. Cruveilhier at 6 or 7 ounces French;* by M. Lobstein, and by Meckel so high as 9 or 10 ounces, the latter adding that its * The French ounce is to the English ounce avoirdupois about as 15 to 14.—Author. the heart, (Anatomy of.) 457 weight is to that of the whole body about as 1 to 200;* whilst by M. Bouillaud and Dr. Clendinning (whose results, having apparently been arrived at from a much larger number of observations, made with peculiar accuracy, are espe- cially worthy of confidence) it is stated at between 8 and 9 ounces for the adult male; the average weight of the female heart according to Dr. Clendinning, being about an ounce less. A heart in a state of hypertrophy will weigh from 11 to 24 ounces, or even more. Laennec mentions one of two pounds and a half, and Dr. Mason Good speaks of some still more enormous specimens; but as they do not expressly state whether or no the blood and coagula had been removed from the interior, we cannot rely on their estimate. A heart in a state of atrophy, on the other hand, has been found to weigh only from five to six or seven ounces; so that the balance, when taken in connexion with previous symptoms, obviously furnishes us with a very satisfactory test of changes in the heart's mass. We cannot, however, with any safety estimate the quantity of matter which it contains by the eye alone, or even by measurement; for as the experi- ments of M. Jules Pelletan, have shown, there is a very considerable difference in hearts in respect to specific gravity. The recent researches of M. Bizot, which were carried on with so much seem- ing accuracy, and on so extensive a scale as to entitle them to a peculiar degree of credit, have led to the establishment of some very unexpected results, which stand in direct opposition to the previous surmises of the highest authorities in medicine. Thus, he has found that the size of the heart continues to increase regularly in proportion with advancing age; and that this depends partly on the 'gradually augmenting capacity of both ventricles, and partly on the steadily in- creasing thickness of the walls of that of the leftside especially, those of the right ventricle remaining almost stationary. In respect to the influence of stature, he has arrived at a startling conclusion, which, though his data are numerous, stands perhaps in need of additional confirmation based on a still larger induction of par- ticulars—namely, that in tall persons the mean dimensions of the heart are actu- ally less than in middle-sized individuals, and that this holds especially in respect to its breadth. The width between the shoulders he has found to afford a much better criterion of the probable size of the heart than the height. It is right to state that Dr. Clendinning's investigations have led him to acquiesce entirely in M. Bizot's assertions in respect to the effects of advanced age and height on the size of the heart. Thus, whilst in individuals above sixty all the other organs have evidently suffered a loss of weight, he finds the heart to be increased, on an average, by at least one-twelfth. Dr. Clendinning is however at variance with Bizot, no less than with Louis, in respect to the state of the heart in phthisis, in which disease he has, like Andral, generally found it in a very appreciable de- gree enlarged; the wasting characteristic of the disease falling rather on the exter- nal parts, or organs of locomotion, than on the internal viscera, as he has proved indisputably by the use of the balance. The mean length of the heart, measured from the base to the apex of the left ventricle, was found by M. Bouillaud slightly to exceed 3i inches:t the breadth at the base was a fraction more than this; the thickness of the base, measured from before backwards, was about 2 inches; the circumference at the same part almost 9 inches; the thickness of the septum measured, in the single instance in which it was examined, 11 lines, but this, we think, is quite above the usual ave- rage. Meckel states it at from four lines to half an inch; the latter measurement, as it appears to us, being nearest the truth. The mean thickness of the left ven- tricle, measured near the base, generally the thickest part, was nearly 7 lines, that of the right about 2d lines; so that Laennec would appear to have somewhat * In infancy the heart, and more especially its cavities, are relatively much larger than in adult age.—Author. t Meckel states the whole length of the heart at five inches and a half, of which four for the ventricle and one and a half for the auricle.—Author. Vol. II.—58 458 the heart, (Anatomy of.) undervalued the difference of thickness of the two ventricles, in stating the one to be only a little more than double as thick as the other; the real proportion being more nearly as three to one. In infancy, however, no such great disproportion exists; and in the foetus their walls are nearly of equal thickness. The mean thickness of the left auricle is about lj line, that of the right about 1 line. The capacity of the right cavities of the heart has been correctly stated by most anatomists, as somewhat exceeding that of the left. The difference, however, is, as we should expect, not very considerable; and even less than from the ordinary state of distention of the right side of the organ after death it would at first sight appear to be. Bizot estimates the difference somewhat higher than Laennec or even than Bouillaud. The cavity of the left ventricle in its natural condition is about equal in capacity to a moderate-sized hen egg. The mean circumference of the left auriculo-ventricular orifice may be stated at about 3i inches, that of the aortic orifice at about 2|. The corresponding ori- fices of the right side are usually, as might be anticipated from what has been said in the last paragraph with respect to the comparative size of their cavities, slightly larger (Bizot says, on an average, by about nine lines:) this, however, if Bouil- laud be correct, is not universally the case. The depth of the mitral and tricuspid valves is from 8 to 9 lines; that of the pulmonary and aortic about 5\- or 6; those of the right side, in each instance ordi- narily exceeding by a fraction those of the left, though somewhat inferior to them in strength. How great a deviation from the above measurements may be induced by disease from the following facts. The circumference of the heart in a state of hypertrophy has been found occasionally to measure 12 inches; the ventricles in length 5} inches, or even more; the wall of the left ventricle from 7 lines in thickness to considerably upwards of an inch; that of the right from 3 lines to 4£ and upwards. The capacity of these cavities in cases of dilatation, with or with- out hypertrophy, is occasionally doubled. The circumference of the auriculo- ventricular orifice of the left side was increased in one of M. Bouillaud's cases of hypertrophy of the ventricles to 4£ inches, whilst in another it was contracted, in consequence of diseased valves, to 2 inches. The circumference of the aortic opening was enlarged in one instance to about 3\ inches, and diminished in ano- ther to less than 1 inch, and still more extreme cases, than those are occasionally met with. In respect to all the above measurements, weights, and proportions, it must never be forgotten, when we go about to apply them practically as standards of comparison, that they are mere averages, deduced, moreover, from but a limited number of cases. Consequently every slight deviation from them, whether in excess or deficiency, is not at once, and without farther consideration of the cir- cumstances of the case, the age, sex, make, and muscular development of the individual, to be set down as evidence of disease of the heart. Thus, for ex- ample, the heart of a man built on a very broad scale may weigh some ten or eleven ounces, whilst that of a small and delicate female on the contrary, may not exceed six or seven ounces, and yet there shall not be disease of the organ in either case. Again, in estimating the thickness of the walls of the heart, we must take simultaneously into consideration the apparent size of the cavities which they bound, the previous symptoms, and the peculiar mode of death; for when from a considerable reduction of the mass of circulating fluids, by profuse haemorrhages, extreme evacuations, or a long-continued low scale of diet, the muscular parietes, in order to accommodate themselves to their diminished contents, have become notably contracted, a proportional thickening will necessarily exist. From this cause, the walls of a heart actually in a state of atrophy have sometimes been found, as M. Bouillaud remarks, apparently even thicker than natural. If these modifying circumstances be kept in mind, the above standard can scarcely fail of being serviceable, at least to the young pathologist, by giving a definite direction to his anatomical researches, and furnishing him with a useful basis of com- the heart, (Anatomy of.) 459 parison, till his eye has been in some degree formed by the frequent inspection of morbid parts.* * Of several measurements of the heart and attempts to appreciate its relations to different points of the chest, made with the assistance of a very accurate observer, Dr. J. Macdonnell of the Richmond Hospital, Dublin, some already have been staled, and a few others may be sub- joined here. The principal object was to determine the relation of the orifices, amongst them- selves and to the surrounding walh of the thorax. Similar investigations have been made by Dr. Hope and others, with nearly, but not precisely, the same results. The points, the establishment of which was especially aimed at, was, the impossibility of discriminating disease of one orifice from that of another, merely by applying the stethoscope over the situation where the morbid sounds are produced, seeing that in no instance are the most adjacent points of any two of the orifices much above an inch apart; and in respect to most of them not above the third of that distance. The aortic and left auriculo-ventricular orifices are nearly in contact at their most adjacent points ; the interval between the former and the orifice of the pulmonary artery, which stands highest, is likewise very inconsiderable, not exceeding a few lines. The distance between the nearest parts of the pulmonary artery and of the right auriculo-ventricular orifice, though greater than in the other instances, scarcely exceeds an inch. The bases of the auriculo- ventricular valves are situated a very little lower or nearer the apex of the heart than the aortic valves, viz. about a quarter of an inch on the left side, and half an inch on the right. At least one-third part of the circumference of each of the auriculo-ventricular orifices and their valves, thus lie close under the semi-lunar valves of the aorta and pulmonary artery; so that a stethoscope placed over the latter would necessarily, as already stated, cover a conside- rable portion of all the four orifices, even if the heart hung vertically in the chest, and obviously a still greater part of their circumference in the actual position of the organ, with its axis form- ing nearly half a right angle with the parietes of the thorax, and deviating so much to the left side anteriorly, where the stethoscopic examination is chiefly made. A horizontal line drawn through the under edge of the sterno-costal articulations of the fourth ribs will cut across nearly the middle of the length of the mitral valve when drawn outwards and downwards by its tendinous cords and column® carnea?, and pass about two or three lines above that portion of the tricuspid which most nearly approaches it, the latter valve lying underneath the sternum, and the former immediately to its left. A frequent re- petition of our observations, and experiments with needles long enough to pass quite across the thoracic cavity and its contents, lead us to believe that the relation of the heart to the parietes is not in all cases accurately the same, though the differences are too inconsiderable to throw any difficulty in the way of diagnosis. They may, however, serve to account for the circumstance of the results given here and at a former page, differing slightly from those of Dr. Hope, who states (p. 3,) that "a line drawn from the inferior margins of the third ribs across the sternum passes over the pulmonic valves, a little to the left of the mesial line, and those of the aorta are behind them, and about half an inch lower down." Again (p. 4,) "The auricular orifices are situated opposite to the interspace between the third and fourth ribs, and the right is rather lower than the left." If the heart hung vertically within the chest, the aortic valves would be at a considerably lower level than the pulmonic valves, as stated by Dr. Hope; but by the oblique position of the organ, intermediate between vertical and horizontal, this distance, if considered in linear relation to the external surface of the chest and the results of stethoscopic examination, is notably diminished. The depressed condition of the ribs in the dead body, like a forced expiration in the living, will tend to make the heart in the corpse appear in a slight degree higher up, in relation to the anterior walls of the thorax, than its natural medium site; and for this, allowance ought to be made.—Author. When the heart of a living animal is exposed, it is seen that its only fixed and stationary point is at the valves of the aorta; the other large blood-vessels at the base revolve partially 460 the heart, (Anatomy of.) As disease of the heart is rarely, if ever, an affection of the whole organ, it is not from a mere general and superficial inspection of its magnitude, such as the old pathologists seem to have rested content with, that any very satisfactory knowledge is to be expected. It is only by the patient examination of all its component parts in detail, their texture, composition, size, form, and mutual adaptation, that a complete insight into the actual condition of the organ, or an explanation of the various functional derangements which preceded death, can reasonably be hoped for. To make a satisfactory post-mortem examination of the heart, we should begin by ascertaining the state of its investing membrane: and then proceed to lay open its several cavities, so as to enable us correctly to estimate their size, the thickness of their walls, the condition of their valves, tendons, orifices, lining membrane, vessels, and nerves. Perhaps the best method of displaying the interior of the heart, without injury to its orifices, nerves, or tendons, is that adopted by Dr. Williams; namely, to make an incision from the around this point, and the body of the heart being free, no fixed relation exists between it and the walls of the thorax, but it hangs, in a certain degree, loose, and liable to displacement by changes of posture and by motions of the chest. It is of the first importance, therefore, that the pathologist should be correctly informed as to the precise situation of the semi-lunar valves of the aorta. Repeated observations made on the dead body have proved, that these valves are pierced, if needles be introduced perpendicular to the plane of the sternum through the middle of that bone opposite the middle of the cartilages of the third ribs; and that, if the wires be passed perpendicular to the tangent of the curved surface of the thorax, between the cartilages of the second and third ribs half an inch from the left margin of the sternum, the semi-lunar valves of the pulmonary artery are entered. The aorta, from its origin, curves upwards towards the right, extending between the cartilages of the second and third ribs slightly beyond the right margin of the sternum; at the lower margin of the cartilage of the second right rib, the arch of the aorta commences and inclines to the left, crossing the pul- monary artery where it lies beneath the cartilage of the left second rib, and ascending as high as the first rib, turns downwards. The pulmonary artery, from its origin in contact with the sternum, commences at the left margin of that bone, where it is joined by the car- tilage of the third rib, bulges at the interspace between the second and third cartilages close to the sternum, and dips beneath the aorta opposite the junction of the second cartilage and sternum. The right divisions of the heart, being most superficial, form the greater part of the ante- rior surface ; the right auricle reaches from the cartilages of the third right rib to that of the sixth : and between the third and fourth, where its extent is the greatest, it extends, laterally, when filled with blood, near one inch and one-third to the right of the sternum. About one-third of the right ventricle lies beneath the sternum, the remaining two-thirds being to the left of that bone ; the septum between the ventricles coincides with the osseous extremities of the third, fourth and fifth ribs, and on the fourth rib is midway between the left margin of the sternum and nipple. A small part, say one-fourth, of the left ventricle, presents anteriorly; and when the lungs are separated, a portion of the left auricle is visible between the second and third left ribs two inches from the left margin of the sternum. With the exception of these portions, the whole of the left ventricle and auricle lie posteriorly to the right ventricle; and the entire left divisions, with the exception of a small portion of the base connected with the pulmonary valves of the aorta, lie on the left of the sternum. In the dead body, the normal situation of the tricuspid and mitral valves have been found to be as follows : the tricuspid valve extends obliquely downwards from a point in the mid- die of the sternum immediately below the third rib, to the right edge of the sternum where it connected with the lower margin of cartilage of the fifth rib; the mitral valve commences beneath the lower margin of the left third rib, near the junction of its cartilage with its osseous extremity, (two and a half to three inches to the left of the sternum,) and runs slightly downwards, terminating opposite the left margin of the sternum, where it is joined by the cartilages of the fourth rib. G. the heart, (Motions of.) 461 apex of the left ventricle, close along the anterior groove indicative of the septum, taking care to cut between, and not across, the semi-lunar valves, or rather to stop a little short of the aortic orifice, until its ventricular aspect has been exa- mined; whilst, to get a good view of the mitral valve, a second incision is to be carried from the apex up along the middle of the flat surface of the heart. In the right ventricle, the first section is likewise to be carried along the anterior edge of the septum; but the second in consequence of the different position of the tricuspid valve, should commence in the middle of the first, and be carried across the cavity at right angles to the heart's axis, till it meets the posterior groove The auricles are to be laid open by a crucial incision, which displays their ven- tricular and venous orifices uninjured, their septum the ossa ovalis, &c. Motions op the Heart. Notwithstanding all the attention recently bestowed upon tlje subjects of the sound and motions of the heart, some abscurity still exists in respect to them. Certain facts, however, appear to have been at length satisfactorily ascertained, and to these chiefly we shall endeavour to confine ourselves, leaving the more debateable ground to works treating expressly of the physiology of this organ. It is known, in the first place, then, that the auricles and ventricles contract alternately, the systole of the auricles being instantly followed by that of the ven- tricles, and this in its turn by the ventricular diastole, and a momentary period of repose. The full dilatation of the auricles is simultaneous with the contraction of the ventricles: the auricles being distended, a portion of their contents over- flows into the relaxing ventricles, and the appendices, after the momentary pause just mentioned, again acting, stimulate the ventricles, by the injection of an addi- tional quantity of blood, to renewed exertions,—a stimulus the more readily obeyed from the inherent tendency in this muscle to periodic action. Such is the order of succession, now commonly known as the rhythm of the heart's motions. Of the whole time occupied by the several elements, which go to make up a complete beat of the heart, somewhere about a half is consumed in the contraction of the ventricles; a fourth in their diastole; and the remaining fourth, as judged of by the ear, is spent in apparent repose, though really the latter portion of it is taken up by the silent contraction of the auricles and their appendices. The impulse of the heart against the ribs, and the pulsation of the great arteries as they arise from it, are synchronous with the ventricular contrac- tion, as has been proved by direct experiment.* The pulse of the arteries at a greater distance from the centre of the circulation is felt a moment afterwards, the interval of time being directly proportional to the distance from the heart The cause of this retardation is to be found in the yielding and elastic nature of the tubes in which the blood is conveyed, in consequence of which a minute portion of time, as well as a part of the onward force of the ventricular wave, are consumed in effecting the dilatation of the arterial walls. The interval which occurs even in respect to the remoter arteries is still very slight, not exceeding perhaps a quarter of a second, and yet with attention and a little practice it is readily appreciable. Any one may perceive it in his own person, especially when the pulse is rather slow, on applying the fingers of one hand to his posterior tibial artery, as it is passing behind the inner ankle, whilst the fingers of the other are simultaneously placed in contact with that portion of the chest where the heart's impulse is most perceptible. In the natural condition of the heart, in most postures of the body, the apex alone seems to be concerned in giving the impulse felt externally. Yet in the prone position, or when the body is leaning much forward and turned a little towards * Drs. Hope and Williams; tho Dublin committee of the British Association, for the inves- tigation of the sounds and motions of the heart; [Drs. Pennock and Moore's Experiments, 462 the heart, (Motions of.) the left side, after a full expiration, and still more remarkably in cases of enlargement of the organ, its whole mass appears to be impelled forcibly against the walls of the chest. Various explanations of the impulse of the heart have been attempted; thus it has been ascribed to the reaction of the blood in quitting the ventricles,—to the tilting forward of the whole organ, by a supposed sudden diminution of the aortic curve, under the influence of the straight-forward impulse of the projected column of blood,—to the simultaneous distention and prolongation of the ascending aorta and pulmonary artery,—to the coincidence of the dilatation of the auricles with the ventricular systole,—to the forcible injection of the ventricles by the auricles (an obvious error,)—and, finally, it has been attributed, and with much more pro- bability than appertains to any or all of the other supposed causes, to the sudden tension of the ventricles in their systole, with the accompanying rapid jerking up- wards of the apex, in consequence of the greater length of the anterior fibres of the heart, and probably of something in the mode of their disposition which has not yet been accurately ascertained. Any one, indeed, who has ever grasped the heart of a living animal in his hand, must have become satisfied, from the force with which his fingers were separated during the ventricular systole that an ade- quate explanation of the stroke of the heart was to be found in the action of the ventricles alone, without being much indebted to any of the other supposed causes. A movement of this kind is quite obvious to the sight in the heart of an animal, even a warm-blooded one, for many minutes after its being quite emptied of blood, and even removed altogether from the body. During its systole, the heart is elongated, its transverse diameter is diminished by the ap. proximation of the walls of the ventricles; the base of the heart at the same time revolves towards the left about one-sixteenth of its circumference, while the apex turns towards the right, thus causing the heart to assume a spiral form. The elongation of the heart, as seen in the sheep, was ascertained in the experiments of Drs. Pennock and Moore to be one-fourth of an inch, measured from the aortic valves to the apex. During- the diastole, the transverse diameter of the heart increases, and that organ assumes a rounded appearance. "■ The auriculo-ventricular valves are slightly raised from their contact with the sides of the ventricles, by the tendons passing into them from the columnae carneae, synchorously with each ventricular contraction, so as to facilitate the insinuation of the blood behind them; and by means of this latter, their complete closure is eventually affected * and all reflux in the natural condition prevented, at least in the left side of the heart; for, with respect to the right side, it has been remarked by Hunter, that the valves do not accurately close the auricular and arterial ori- fices,—this being a provision of nature, he conceived, to allow a partial reflux, into the auricle, when, from any cause, the passage of blood through the delicate texture of the lungs is obstructed, as is often the case during violent efforts, nar- rowing of the left apertures of the heart, disproportionate magnitude of the right cavities, &c, and similar views have recently been advocated by Mr. Adams and Mr. King, who looked upon the tricuspid as exercising a kind of safety-valve func- tion. The dilatation of the ventricles is effected in part by their own elasticity, which will suffice to draw a certain quantity of blood into them; and is proba- bly completed by the auricles transferring as they contract, an additional portion. Some physiologists call in, moreover, the aid of an active dilating power in the heart, but of the reality of this, though not improbable, no absolutely convincing proof has yet been adduced. The feebler muscular structure of the auricles, and the absence of a valvular apparatus at their great venous orifices, indicate suffi- ciently that the propulsive power of these cavities is but slight in comparison with that of the ventricles, and that they play consequently a very inferior part in the business of the circulation. * Heucc M. Bouillaud has denominated the columnae carneoe, the tensor muscles of the tn- cuspid and mitral valves. the heart, (Natural sounds of.) 463 For its motions, the heart, like all other muscles, is primarily indebted to its own inherent contractility, as is obvious from their continuance long after its removal from the body. For nervous influences it is chiefly dependent on the ganghonic system, and not on the spinal marrow. This opinion, advocated by Willis and Bichat, and subsequently impugned by Legallois, may now be considered as fully established by the experiments of Dr. W. Philip, Mr. Clift, and Brachet The pa- thological facts, recorded by Lallemand and Lawrence, of the pulsation of the heart in a monstrous foetus, where the brain and the spinal marrow were entirely deficient, afford additional evidence, if any were wanting, that these organs are not essential to its action. Injuries of the spinal cord, it is true, powerfully affect the heart; but this is now known to take place merely through the medium of sympathy, and similar results equally ensue from extensive and destructive injuries of other parts of the system. That the heart is remarkably under the influence of mental emotions is familiar to every one—but in this there is no contradiction to the views just expressed, nor any infringement of general analogy. Natural Sounds of the Heart and Blood-vessels. When we apply the ear to the region of the heart, with or without the inter- vention of the stethoscope, two sounds are heard, of which the first is duller and more prolonged, synchronous with the pulse in the immediate vicinity of the heart, and consequently with the contraction of the ventricles. The second, which instantly succeeds it, is of a more abrupt and clearer character, and is fol- lowed by an interval of silence. The first sound is loudest over and below the middle of the ventricles; that is, over that portion of the heart which is in contact with the parietes; the second over the semi-lunar valves, and for a short way upwards along the sternum. They are most easily distinguished, by the uninitiated, in thin individuals of a slight and narrow make, and when the pulse is somewhat slow. We may occasionally, in particular states, hear them very distinctly in our own persons, especially when lying on the left side, and when the pulsations have been rendered more energe- tic by violent exercise or the use of stimulents; and in certain disorders of the heart this audibleness of its workings becomes almost a constant, and with some patients, a very distressing symptom. These sounds are sometimes audible even to a by-stander at a little distance from the patient. Thus Laennec states that he had heard them at various distances, from two inches to two feet from the chest, through the medium of the air alone; and he speaks of cases, on hearsay, where the beating of the heart was heard in an adjoining chamber to that in which the individual lay. Mr. Breventani, a recent Italian writer, has met with two cases in which the morbid sounds of this organ were audible at a considerable distance, which in one is specified as being not less than three paces. According to Laennec and many of his followers, the sounds heard under the inferior part of the sternum belong to the right cavities;—those under the carti- lages of the left lower true ribs, to the left. In cases of the morbid enlargement of particular parts of this organ, such distinctions may doubtless be attempted with success, but in its natural condition we agree with Mr. Bouillaud in doubt- ing their practicability, when we take into consideration the limited extent of these cavities, their close apposition, and the manner in which the right ventricle lies over, and in front of, the left. A marked difference exists in the systolic sounds of the right and left ventricles. This dif- ference, which is particularly striking upon ausculting the exposed heart of a living animal, is also observed in the examination of the chests of patients, even when the heart is in its normal condition. The first sound produced by the contraction of the left ventricle, as heard near the loft nipple, being duller and more prolonged than that of the right, heard at the sternum, where 464 the heart, (Natural sounds of.) it is clearer and shorter. These differences are rcferrible to the relative thickness of the wall» of the right and left ventricles. The examination of the sounds of the heart by the flexible stethoscope, greatly facilitates the diagnosis of the precise seat of the lesion, and with great attention it may be generally diagnos- ticated with certainty. G. The intensity of the heart's sounds diminishes in the natural condition in pro- portion chiefly to the distance from the praecordial region. Laennec has certainly limited the extent of surface in which they are audible, in a healthy well-propor- tioned individual of moderate fatness, within too narrow bounds, when he confines it to the praecordial region alone. In very fat persons he states that it is confined to a space of about an inch square. In narrow-chested thin individuals and chil- dren, these sounds may often be heard over the greater part of the thoracic cavi- ty, posteriorly as well as anteriorly; in the neck, and also in the epigastrium, though no disease of the heart exists: and in infants that may sometimes be heard even as low as the buttock. Disease of the heart itself, or of the neighbouring organs, produces remarkable modifications in regard to the intensity and mode of diffusion of these sounds, which are of high importance in respect to diagnosis. Thus they may appear even louder at remote parts of the chest than in the more immediate proximity of the heart; as, for example, when a portion of the lungs is solidified and rendered a better conductor of sound by inflammation, or by tuburcular infiltration or con- densation around a phthisical cavity, or by the compression resulting from pleu- ritic effusion, or by the development of a tumour within the chest, or the en- croachment of an enlarged liver on this cavity. When, from morbid changes inherent in the heart itself, variations arise in re- gard to the extent in which its sounds are perceptible, they manifest themselves, according to Laennec, successively in the following order:—1. Sounds audible in the left side of the chest, from the axilla down to the corresponding hypochon- driac region; 2, in the right side, over the same extent; 3, in the left posterior portion of the chest; 4, but rarely, in the right posterior region. But the practi- cal applicability of this scale, to which Laennec attributed much importance in determining the nature and degree of cardiac disease, is obviously greatly limited by the interference of the several extraneous circumstances to which we have just alluded. The physical cause of the sounds of the heart has been the subject of much discussion. To enter upon a minute estimate of all the theories proposed for their explanation would be inconsistent with the practical nature of this work;. we shall therefore limit ourselves to stating our conviction that the great weight of evidence is in favour of the two following causes:—muscular contraction for the first sound, and valvular reaction for the second. It has been rendered in the highest degree probable, by the experiments of Dr. Williams and others, that the first sound is an example of the " bruit musculaire," or sonorous muscular con- traction, of Erman, Wollaston, and Laennec. All powerful muscles, as the biceps of the arm, the masseter, or the abdominal muscles, if thrown into strong action, gives rise to sonorous vibrations which may readily be heard in our own persons with the aid of a flexible air-tube. That the muscular sound of the heart may occasionally be modified by the stroke of the organ against the side of the chest in the case of violent palpitation, and also in some degree by the action of the auriculo-ventricular valves, is not denied; but the first sound is not mainly depen- dent on either of these, for it is still audible even aftei the removal of the heart from the chest, and when consequently it has no longer either the thoracic pa- rietes to strike against, or blood enough to ensure the action of the valves (Dublin and London Heart Committee—Williams [Pennock and Moore.'] Even the complete obstruction of these valves, by inverting the auricles and thrusting them thus into the auriculo-ventricular openings, [or cutting away the valves,] was not found to annihilate the first sound. After the promulgation of such facts, it is sur- the heart, (Natural Sounds of,) 465 prising to find that so able a writer as M. Bouillaud should persist in attributing it solely to valvular action: and even although independent of these facts, the pro- longed character of the sound appears quite incompatible with the sudden and momentary tension or collision of such membranous structures.* This promul- gation reaches its maximum in cases of great hypertrophy, and especially when the ready escape of the Wood from the ventricles is interfered with by the dis- eased narrowing of the arterial orifice. The contraction of the auricles, according to the experiments of Drs. Pennock and Moore, produces a slight sound, which, occurring at the commencement of the first sound, is merged in that of the ventricular systole. G. With regard to the second sound, it has been rendered equally piobable by the experiments of Elliot, Carswell, Rouanet, Carlyle, Williams, Hope, [Pen- nock, Moore,] and the committees already alluded to, that it depends on the reaction of the column of blood in the artery against the simi-lunar valves; for it is found to cease, or in some cases to be supplanted by a hissing noise, on these valves being hooked up, and held nearly immoveable against the sides of their respective vessels, by a curved needle introduced through their walls from without. It is likewise put an end to on arresting the current of Hood, either by cutting across or compressing these vessels near their origin, and so prevent- ing the falling back of the arterial column against the valves. Making a small opening into the great arterial trunks near their source very materially modifies the second sound (London Heart Committee;) and even cutting across the carotid, by diminishing the arterial tension, greatly enfeebles the same, as does likewise whatever lowers the projectile energy of the ventricles, the reaction of the great vessels being of course proportional thereto. The circumstance of these sounds being loudest in the region of the semi-lunar valves, and commence- ment of the aorta and pulmonary artery, tends still farther to confirm the truth of this hypothesis.t| We are inclined at the same time to think it probable that the second sound, though mainly produced in the way just stated, may yet in * According to Dr. Hope, the causes pf the first sound are compound; consisting, 1st, of valvular sound (and to this he seems still to attribute the most importance;) 2d, the sound of extension,—a loud smart sound, produced by the abstract act of sudden jerking extension of the braced muscular walls; 3d, a prolongation, and possibly an augmentation, by "bruit musculaire." P. 50.—Author. t The discovery of this theory of the second sound of the heart, is claimed by Dr. Cars- well, and was first publicly announced by M. D'Espinc, in a dissertation read by him at the Academy of Medicine at Paris, in July, 1831, though it was made known by Dr. Carswell as early as 1829. There is, in the museum of University College, a drawing (dated 1829) of the case of aneurism of the aorta observed by Dr. Carswell, in the Hospital of La Charite, the physical signs of which case first suggested to him this now almost universally received theory. [Dr. Billing attributes both sounds to the valves alone. See Essay read at the Hunterian Society, Feb. 9, 1832, reported in the Lancet, May 19, 1832; also Principles of Medicine, Preface, p. 21.]—Author. t The presence of coagula in the ventricles, or the preternatural congestion of these cavi- ties from inflammation of the endocardium, prevents the formation of the second sound. In Drs. Pennock and Moore's experiments, it was observed that the second sound ceased upon congestion of the heart taking place—that the right ventricle became congested before the left, and that this congestion invariably obliterated the second sound on the right side, whilst the sounds continued normal over the left ventricle until congestion took place in that cavity. These facts are corroborative evidence that the second sound is caused by the reaction of the column of blood upon the simi-lunar valves by which they become tightened and closed. G, Vol. II.—59 466 the heart, (Morbid Sounds of.) the natural condition, and when the heart is acting energetically, be re-enforced by the diastole of the ventricles: we do not mean to assert that this has been as well made out by experimental evidence as the cause first mentioned; but if as is now known to be the fact, the relative change of place undergone by the constituent molecules of a muscle in the act of contraction be accompanied by the produc- tion of sound, we should expect that the elastic recoil of so powerful a muscular organ as the heart, i. e., the rapid return of these same molecules in their former state, would likewise be accompanied by the same phenomenon, though differing somewhat in character or intensity. This theory is ingenious; but from the fact of the entire absence of the second sound when the closure of the semi.lunar valves is prevented by ossific or cartilaginous depositions, or where the reaction of the columns of blood upon the valves is prevented by extensive ossifica- tion in the aorta or pulmonary arteries near ihe salves, or by an aneurismal tumour, we should consider it untenable. G. Morbid Sounds of the Heart and Blood-vessels. Amongst the most common changes in the sounds of the heart, is increase or diminution of intensity. Thus, in the first place, they may become so feeble as to be heard with difficulty; and this may depend either on general debility of the whole system, or on that of the heart in particular; on obstruction of the pulmonary circulation; on excessive afflux of blood to the heart; on softening of this organ; or, finally, on its extreme hypertrophy, the overgrown muscular mass contracting less perfectly than in the natural condition, and being ill adapted for the production of sound, and at the same time a bad conductor of it. The sounds of the heart may become so loud, on the other hand, as to be audible, as we have already seen, at some distance from the chest. The great majority of the latter eases, as mentioned by Laennec, are quite independent of organic lesion, being mostly instances of nervous palpitation, or the temporary result of violent muscular exertion, the natural sound being not only increased itself, but re-enforced moreover by the addition of a metallic ringing sound, caused by the unusual impulse against, the walls of the chest.* Dilatation of the ventricles, and thinness of their parietes, are also particularly favourable to the augmenta- tion of the cardiac sounds, and tend in a remarkable degree to assimilate the first sound to the second. The natural character of the sounds of the heart may be still farther altered or masked by the supervention of the bellows sound (bruit de soufflet,) of various qualities or degrees of intensity; the simple blowing sound, the hissing, sawing, or still hoarser rasping sounds, all of which are occasionally to be heard in the arteries also, and more especially in the carotid and sub-clavian, the abdominal * Dr. Davies mentions, in his lectures, having heard the beating of the heart of a patient (a female during menstruation) at fife or six yards distance. Laennec, when on his death- bed, heard his own heart beat very distinctly, and it was audible at some inches distance to the by-standers. He had been blooded shortly before. He ascribed the phenomenon to dis. tenlion of the stomach with air, as it ceased immediately after eructation. Dr.. Hope doubts the possibility of sound ever being produced by the impulse of the heart against the walls of the chest; believing this organ to be alwaysj in consequence of the atmospheric prcssuri.1, necessarily in contact with the parietes. As to the accidental metallic "cliquetis," sometimes heard during palpitations, he ascribes it to the apex, as it glides for- wards and upwards in systole, catching against the inferior margin of the fifth rib, having observed it to occur only in the thin subjeets, and that it can be done away with at once by pressing with the stethoscope into the intercostal space, so as to obliterate any internal de- pression at this part.—Aimion. the heart, (Morbid Sounds of.) 467 aorta, and the great arteries of the limbs ; as also in the uterine, or adjacent arte- ries, during pregnancy. Even in the natural state of the arteries, a species of low murmur, compared by Bouillaud to that produced by rubbing the point of the finger against the thumb, as in the action of giving a fillip, accompanies each pulse-wave. On pressing more firmly with the stethoscope, this becomes converted into a " bel- lows murmur." This has appeared most audible when from deficiency of blood, the arteries are less distended than usual, and also when the blood is more watery than ordinary. The sound in question depends, according to Bouillaud, on fric- tion, and may be imitated by injection of the arteries in the dead body, or by driving a fluid in jets through any elastic tube. Dr. Corrigan, on the contrary, from ob- serving the bellows sound to be most intense beyond the point of pressure with the stethoscope, and that it was produced by any condition tending to disturb the natural equable motion of the blood, was led to conclude that it depended, 1st, on a current-like motion of the fluid, tending to produce corresponding vibrations in the sides of the cavities of the heart or arteries; 2dly, on diminished tension of their parietes, in consequenr° of which they are more easily thrown into such vibrations. Dr. Williams and Dr. Todd, on the other hand, from a somewhat similar set of experiments to those previously instituted by Dr. Corrigan, came to a different conclusion; namely, that a certain resistance or impediment to a liquid current is the essential physical cause of all murmurs produced by the motion of fluids in elastic tubes; and that any particular condition of the walls of the tube beyond the obstructing point is not essential to their production* It is possible that here, as in so many other cases, truth may lie between; and that we might be justified in adopting an hypothesis combining the views of both parties. Thus it seems nowise improbable that the sonorous vibrations in question are caused by a current-like motion of the contained fluid; but that this acts first, chiefly, on the narrower portion of the canal, where the friction is greatest, and the pressure of fluid on the farther side least; whilst the vibratory motion so generated is immedi- ately propagated to the laxer parts beyond. There is another rarer modification of this phenomena, first noticed by Laennec, but met with by him only in the arteries, wherein the blowing sound assumes somewhat of a musical or whistling character; occasionally ascending and de- scending through two or three notes of the gamut in a sliding or slurred manner, and accompanied by a slight thrill in the artery perceptible to the fingers. Of its affinity to " bruit de soufflet" we have proof in the fact of its sometimes super- vening insensibly on the ordinary bellows-murmur when the patient is agitated, and again falling back gradually into its former character. It may be either inter- mittent and synchronous with the pulse, or continuous. It seemed generally to Laennec to be connected with a nervous habit of body, or with a chloritic condi- tion, quite independent of organic disease. He cautions us against confounding it with a somewhat similar, or chirping sound, which is occasionally, produced in * Dr. Corrigan, as appears from a recent paper in the Dublin Medical Journal, still adheres to his original opinion; and undertakes to prove that impediment in a tube alone is not suffi- cient for the production of sound,—for if a second and more considerable constriction be made lower down, the bellows-murmUr in the upper and original one ceases as soon as the whole tube has become full and tense. His views are, as usual, supported with much ingenuity; and the question at issue, though supposed to have been set at rest by the investigations of the London Heart Committee, must be considered perhaps as still undecided. It seems to us, however, that he does not take sufficient account of the diminished velocity of the fluid, and consequent reduction of friction, taking place in the arrangement just alluded to. The increased pressure of fluid against the remote side of the upper obstructed portion must also tend to impede the production of vibrations in the part. In respect to the sound generated at the very extremity of a tube discharging a fluid, he supposes the surrounding air to take the place of the flaccid parietes of the tube, and to respond to the vibrations of the rushing stream so as to produre an audible murmur.—Author. 468 the heart, (Morbid Sounds of.) some of the bronchial ramifications from the presence of mucus and the pulsation of the sub-clavian artery against the top of the lungs. M. Bouillaud has twice met with a similar musical sound in the heart itself and compares its varieties to the cooing of the wood-pigeon, the chirping of small birds, or the sibilant rale of bron- chitis. It is supposed by him to be connected with narrowing of the orifices or disease of the valves, and to be only a very intense form of the bruit de soufflet. M. Rouanet has also met with it in the same situation, as have likewise Drs. Forbes, Hope, and Elliotson; and in some few of these instances it has been connected with the existence of a long vegetation attached to the mitral valve. To a singular variety of the belloWs-taurmrmv of a remittent becoming or whirring Character, occasionally heard in chlorotic and nervous subjects, with too fluid or watery a state of the blood and an easily accelerated circulation, particularly above the inner end of the clavicle in the neighbourhood of the carotid and sub-clavian artery and jugular veins, M. Bouillaud has given the fantastical name of " bruit de aiable," from its similarity to the noise produced by the well-known French toy resembling a double humming top, called the " devil on two sticks." It is not ab- solutely intermittent or interrupted, like the ordinary bellows sounds, nor yet equably continuous like another species in which the sounds accompanying the two motions of the heart run, as it were, into one; but, though sustained or pro- longed from pulse to pulse, it has remissions of intensity, and a periodic swell, bearing a fixed relation to the diastole of the arteries, in which vessels, according to the author just named, it has its origin. Dr. O. Ward has, however, rendered it probable that its seat is" very often, if not always, in the external jugular veins (Med. Gat'. April, 1837;) an opinion which is likewise embraced by Drs. Williams and Todd, and has been still more recently advocated by Dr. Hope. Very slight cir- cumstances suffice to alter its character, or to interrupt it: such as, a change of posture; relaxing the side of the heck on which it is heard; pushing over the larynx; muscular efforts which impede the respiration, and the transit of blood through the lungs and right side of the heart; increased pressure of the stethoscope, or compression of the vein above: whilst, on the other hand, it is increased in inten- sity by whatever puts the vessels on the stretch (aS averting the head and raising the chin,) and which, by narrowing their caliber, augments the velocity of their current. Dr. Ward admits that it may sometimes be modified by the proximity of the carotid arteries, so as to appear augmented at each ventricular systole. Dr. Williams does not consider it essentially a morbid sound, as it may be pro- duced at pleasure in the healthiest subject by the pressure of the stethoscope in the region indicated above, so applied as to effect only the venous current It has like- wise been observed, though more obscurely, in the superficial veins of the limbs. An analogous sound is mentioned by Andral under the title of " bruit de mouche," from its close resemblance to the buzzing of a fly. It differs, however, in being continuously sustaihed and equable, not being periodically re-enforced like that just described; and is supposed by him, though perhaps erroneously, to have its seat constantly in the carotids, and always to indicate a chlorotic condition, and the propriety of administering iron and other tonics. It seems probable, from the inves- tigations of the gentlemen preyipusly mentioned, that this sound also very com- monly originates in the veins, and that the pressure of the muscles of the heck may sometimes be concerned in its production. The causes of the arterial abnormal sounds are reducible to the following heads:—1. (Jompression as by a tumour or the stethoscope (murmur blowing.) 2. Contraction of caliber, roughness of the lining membrane, or other partial im- pediment '(niurmur blowing, musical, rasping, &c.) 3. Sudden dilatation, which is so often observed in the ascending aorta, and sometiines ih the pulmonafjr artery, rendering their diameter disproportionate to that of their orifices (murmur, gene- rally grating.) 4. Aneurism (murmur, whizzing or grating.) 5. Passage of blood through an accidental opening in ail artery into a Vein (aneurismal varix; murmur generally whizzing or grating.) In addition to these causes, which are Obviously of a mechanical nature, must be enumerated augmented action of the the heart, (Morbid Sounds of.) 469 heart, a thin condition of the blood, and a nervous habit; for these conditions seem adequate not merely to augment and modify the morbid sounds, but even alone, or at least in the absence of any permanent obstructing cause, to originate them. (Williams.) Narrowing of the orifices of the heart also, or an irregular, rugose, shortened, or imperfect condition of the valves, connected generally with cartilaginous or ossific degeneration, obstructing the onward course of the blood, or permitting of reflux, is commonly accompanied by some of the above-described varieties of morbid sounds. This is the result of M. Bouillaud's experience, and, we believe we may add, of most physicians who have seen much of disease of the heart. The frequency of the coincidence was admitted even by Laennec, though he did not look upon the latter as the immediate or necessary effect of the former. M. Piorry, however, asserts that neither the bellows-sound nor any of its modifica- tions were present in one case out of twenty within his own sphere of observa- tion. Now, as we have already stated in another place (British and Foreign Medical Review, No. ii. p. 451,) when negative evidence is thus set in opposi- tion to positive, we are impelled by a law of our nature to give most credence "caeteris paribus;" to the latter, and to suppose it more probable that existing sounds may have escaped notice on the one hand, than that their existence should have been fancied and recorded when they had no reality on the other. We do not, however, deny that cases of contraction and ossification may occasionally present themselves unaccompanied by any abnormal sounds. They are, however, we apprehend, extremely rare, and form only the exceptions, and not the rule, as M. Piorry would have us believe. We are equally prepared to admit that these sounds often exist without its being possible to connect them with any obvious physical lesion. Bruit de soufflet may originate within the heart, according to M. Bouillaud, from any of the following sources:* 1st, narrowing of the orifices; 2d, smallness of the aortic orifice, even when the valves are perfectly healthy. This condition, whether congenital or acquired, co-exists very often with dilatation or hypertrophy of the left ventricle,—circumstances which will necessarily add much to the in- tensity of the sound; also a similar condition of the pulmonary orifices, but this is much more rare. 3d. Vegetations and calcareous incrustations in the valves, with irregularity of their surface, even when their efficiency has not been alto- gether destroyed thereby, nor the size of. the orifices notably affected. 4th. In- filtration of the valves and deposition of fibrinous matter or coagulable lymph on them, in inflammation of the interior of the heart.t 5. Polypus concretions formed during life, occurring chiefly in the disease just named. 6th. Praeterna- tural adhesions of the auriculo-ventricular valves to the adjacent parietes of the heart. 7th. Dilatation of one or more orifices of the heart, with consequent in- • Much of what ia here said oh the sounds and motions of the heart is taken with little alteration, froih the article alluded to above. Dr. Copland, too, in his valuable Dictionary, appears to have drawn largely and almost literally from the same source ; in one instance even an error of the press has been inadvertently retained. In alluding to this subject we do not mean, in the slightest degree, to censure the learned author for availing himself of every means of facilitating and accelerating the progress of his laborious and admirably executed undertaking; but mention it merely in order to establish at least an equal right on our part to make use of the products of our own previous labour.—Author. f The bellows sound is a very-frequent accompaniment of pericarditis also, and has gene- rally been ascribed to the mere increase of action irt the ventricles; but Dr. Hope, M. Bouil- laud, and others have shown that it really depends, in such cases, on the co-existence of inflam- mation of the internal lining of the heart, and the morbid changes in the valves and orifices just mentioned. The " bruit de frottemeBt," or rubbing sound, afterwards to be spoken of, which depends on coagulable lymph effused on the surface of the pericardium, might also, by the incautious, be mistaken for the " bruit dc soufflet."—Author. 470 the heart, (Morbid Sounds of.) efficiency of the valves. 8th. Hypertrophy with dilatation of the ventricles, even though unattended by narrowing of the orifices; but here the bellows-sound is generally intermittent, and only well marked at such times as the motions of the heart are unusually accelerated. 9th. A chlorotic or nervous condition, the pecu- liar sound in question occurring during the presence of palpitations. 10th. Great and sudden debility from haemorrhage and other lowering causes. Dr. Hope, in a series of experiments performed in conjunction with Dr. M. Hall, ascertained that the bellows-murmur, in conjunction with a rapid small pulse, can be produced at pleasure in the lower animals by repeated abstractions of blood; and it has here been supposed to depend on a narrowing of the cavities and ori- fices, which thus endeavour to adapt themselves to the diminished quantity of fluid circulating through them, and consequently no longer bear a due proportion to the great vessels springing from them; and it has also been in part ascribed to the unnatural tenuity of the blood,* and to what is probably the most indispensa- ble condition of all—the increased rapidity of its current caused by the spasmodic vehemence of the heart's contractions; for, that a tendency to spasmodic action in all muscular parts is an ordinary consequence of extreme depletion, is incon- testible. Laennec, as is Avell known, supposed all these sounds, in every case, whether in the heart or arteries, to originate not in organic lesion, but in simple spasm. This was, however, to take quite too limited a view of their nature. It seems impossible to conceive that the various sounds occasionally taking place in the heart and arteries should ever have been attributed to any thing but a deter- minate physical cause, however difficult it might be in particular instances to as- certain its precise nature. Laennec, indeed, has been taunted with referring them merely to a " peculiar modification of the innervation," but his context shows plainly that this was considered only a link in the chain of causation; the imme- diate condition necessary for their production being obviously a contracted or otherwise obstructed or altered state of the parts concerned, which, from the fre- quently intermittent nature of the phenomena, he supposed ordinarily, as just mentioned, to be the result of spasm, or of a vibratory or intermittent action, such as produces the "bruit musculaire" already alluded to. In nearly all the cases enumerated above, an increase of friction in respect either to the onward or refluent current, originating in disproportionate size, ir- regularity of form, roughness or obstructing substances in the orifices of the heart or in the vessels, is probably the chief source of the phenomenon in question; its proximate cause consisting in a tremulous motion in the solid parietes of these parts, and a rippling eddying flow in the fluid within them: such at least are the principal conditions requisite for the production of sound in other hollow sono- rous bodies. It might appeal* at first sight very difficult, if not impossible to ascertain, by means of these abnormal sounds which of the orifices of the heart, if any of them, is diseased; for though the murmur may be coincident with the ventricu- lar contraction, it may depend either on the rush of blood through a diseased aor- tic or pulmonary orifice, or on reflux through the auriculo-ventricular openings, * This thinness of the blood seems to be a very important element in the production of in- organic murmurs. Thus it is almost solely in anaimic and chlorilic individuals, that the ve- nous murmur already alluded to occurs. The tone and accidental degree of tension of the pa- rietes of the vessels, and the state of the nervous system, appear also to have a great influence in their production. It is a remarkable fact, pointed out some years ago by Dr. Elliotson, that it is invariably during the ventricular systole that such cardiac murmurs as are independent of organic dis. ease occur: for in the diastole no regurgitation can take place through the healthy semi-lunar valves, and the onward current setting in through the auricular valves is too feeble for the pro- duction of sound. Dr. Hope's experience not only confirms this fact, but leads him still far- ther to limit the occurrence of murmurs of this species to the aortic orifice. On the latter point, however, he is at variance with some other observers.—Author, the heart, (Morbid Sounds of.) 471 or both; and if, on the other hand, it co-exists with the diastole of the ventricle, it may originate either in reflux through the former openings, or depend on a mor- bid alteration of the latter, or both conjointly.* Attention to the situation in which the murmur appears loudest or nearest, and its relation to the pulse, will however commonly greatly aid us in forming a diagnosis. Thus, if it be most intense over the apex and middle of the ventricles, we may conclude that it originates in one of the auriculo-ventricular orifices (generally that of the left side,) and that it is caused by the entry of blood if it anticipate the pulse, or by the reflux, if it coincide with the same. Again, if the maximum intensity of the sound be higher up, as in the upper half of the sternum, i. e., in the region corresponding to the sigmoid valves and commencement of the great vessels, we may gather that the obstruction exists in the orifice of one of the great arterial trunks, most probably the aorta and almost certainly so if it be the loudest to the right of the mesial line,-—depending, if coincident with the first sound of the heart, on the onward wave of blood ; if with the second, on the reflux; and if continuous, on both.t The history of the case, the investigation of the general and local symptoms, their degree of intensity, permanence, or variability must never be overlooked in our endeavours to ascertain its seat and nature. But to this subject we shall have oc- casion to recur when we come to treat of endocarditis and its organic conse- quences, valvular disease, narrowing of the apertures of the heart, as well as of the functional disorders of the organ, A bellows sound is sometimes produced by the action of an enlarged heart against the portion of lung interposed between it and the walls of the chest, as has been noticed by Laennec, Hope, Law, and others. It has been suggested, by a recent anonymous writer in the British and Foreign Review that the seat of compression in such cases may be " one or more of the larger bronchi, and that, when considerable, the impediment to the entrance of air into the corresponding portions of the lung is sufficient to produce a succession of interrupted rushings of that fluid during the efforts of respiration, which are not to be distinguished as sounds from those depending on the heart itself," till we cause the patient to hold his breath, when it immediately disappears, and the true nature of the case be- comes apparent. "Its existence on the right side or the left, its affecting the upper or lower lobes of one or both lungs, may assist our conclusions as to which side of the heart is principally affected. Interrupted respiration, voice, and cough are necessarily propagated in the lobe where the ramifications of the compressed bronchi terminate; and diminished respiration, with accumulated bronchial secre- tion, are among some of its secondary effects."J A thrilling vibratory sensation is sometimes imparted to the hand when firmly * These difficulties have been recently greatly diminished by the labours of Dr. J. C. B. Williams, and also by those of Dr. Hope, detailed in the last edition of his "Treatise on the Heart."—Author. t It is highly probable, as suggested by Dr. Williams, that the intermitting regurgitant murmur in the heart, occurring more especially in nervous patients and young females, may be occasionally connected with irregular action of one or more of the columnar corneae; in con- sequence of which, some of the tendinous cords passing into the auriculo-ventricular valves are not drawn upon exactly in the same degree with their fellows, a chink admitting of re- fluence of the blood being the necessary consequence.—Author. t The mechanical influence of the heart or great vessels op the lungs, in the healthy state, is exemplified in the phenomenon described by Dr. Mollison under the title of" the pulmonic pulse," which consists in the expulsion of a certain quantity of air from the chest synchro- nously with each contraction of the heart, as ascertained by introducing a bent glass tube into the nostril, and observing that even while respiration is suspended, the fluid in the curve of the tube moves backwards and forwards near a third of an inch with each beat of the pulse. He ascribes it to the compression of the bronchial ramifications by the diastole of the pulmo- nary arteries which run alongside of them.—Author. 472 the heart, (Morbid Sounds of.) applied to the praecordial region. To this phenomenon first noticed by Corvisart, and by him supposed diagnostic of narrowing of the aortic orifice, Laennec gave the title of " fremissement cataire," or purring tremor, from its similarity to what we feel on touching the back of a cat in the act of purring. A sensation of the same kind is experienced on touching various bodies in strong vibration, as the outside case of an organ, for example, while the instrument is played upon; or the larynx of a person who is singing or speaking loud; or an aneurismal varix. It is very analogous to the sensation occasionally produced by the friction of the opposing surfaces of the pleurae when rendered rough by concrete lymph, or to that felt in some cases of emphysema of the lung. A similar thrill often exists in the arteries also, sometimes simultaneously with that in the heart, but occasionally quite independent of it. In both it seems to originate in augmented friction, caused in the one case by contraction or obstruc- tion in the orifices of the heart, and in the other by a partial or local diminution of caliber or impediment in some of the arterial tubes. In both instances it is commonly accompanied by the bellows-murmur, generally of a grating character, and acknowledging an identical origin. Ossification of the valves, especially of the left side of the heart, and of the fibrous rings from which they spring, is a very frequent, though by no means the invariable, cause of this jarring sensation. Laennec, though well aware of its frequent co-existence with organic lesion, yet as he observed that the connexion was not invariable, conceived that its immediate source must be of a spasmodic nature; and even Bouillaud admits that in many instances no permanent cause of narrowing is demonstrable, and confesses that we have not yet attained to a satisfactory knowledge of all its possible causes. One, however, in addition to those above mentioned, about which there can be no doubt, consists in friction of the opposed surfaces of the pericardium when coated with an irregular layer of lymph, as in a certain stage of pericarditis; and here the thrilling tremor is accompanied by a grating or rustling sound (the "bruit de frottement," rubbing or to-and-fro sound, synchronous with the actions of the heart;) and sometimes by a creaking sound, which has been well compared by Collin to that produced by new leather in a shoe or saddle, and is obviously con- nected with a certain degree of firmness and tenacity in the false membranes lining the inflamed surfaces. A rough ossiffic deposite projecting on the outer surface of the heart has likewise been known to give rise both to the tremulous feel, and to a harsh scraping sound. The pericardial " bruit de frottement" is distinguish- able from a similar phenomenon taking place on the surface of the lungs in pleu- risy and emphysema, by being synchronous with the motions of the heart; it is generally strongest in the systole, and may be discriminated from diseased valvu- lar sounds by being diffused over a larger surface. Disordered Motions of the Heart. The heart is liable to various irregularities m its action; amongst these are to be reckoned double or triple impulse, depending generally on spasmodic and par- tial contraction of the ventricles and perhaps occasionally also, though rarely, on the diastole of these same cavities, when morbidly dilated (back stroke of Dr. Hope,) or, more rarely still, on the transmission of the auricular action.* It is subject likewise to intermittence; to inequality in the strength of successive beats; to diminished energy, under the influence of lowering causes both moral and phy- sical, obstructed pulmonary circulation, over-distention, and thinning or softening of the organ itself; and, on the other hand, to sudden or gradual and great in- crease in the force and frequency of the pulsations, which may be so violent and tumultuous as to give a disagreeable impulse to the ear of the observer, shaking * The reality of this last cause, though advocated by high authorities, is still liable to some doubt.—Author. the heart, (Disordered Motions of.) 473 the whole frame of the patient, and even the bed on which he lies, and being at- tended with a distressing internal consciousness of their presence. The more permanent these and other deviations from the natural condition may be, the more gradual in their supervention, and the more independent of extraneous exciting causes, the greater room is there to apprehend that they originate in organic dis- ease of the heart. The power of diagnosticating morbid states of the heart's sounds and motions, necessarily implies a correct acquaintance with their natural states, and with the degrees of variation in different individuals, consistent with health; for the loudness of the former, and the extent and energy of the latter, are susceptible of various shades of difference within this limit. The extent of surface over which the shock of the heart is felt, varies much in different morbid conditions: thus in cases of great hypertrophy and dilatation it may be perceptible over a space of five or six inches square, its force being at the same time augmented, and its action assuming a slow, heaving, irresistible charac- ter, in proportion as the former morbid condition prevails; and being, on the other hand, diminished in proportion as the dilatation is of a passive nature. In concentric hypertrophy, on the contrary, or that in which the thickening takes place at the ex- pense of the capacity of the cavities, the extent of impulse is scarcely, if at all, greater than natural, though the shock thus circumscribed becomes very forcible and hammer-like. In cases where close adhesions have been contracted between the heart and pericardium, and between this latter and the adjacent lungs and parietes, the place and extent of impulse are, as we have already seen, less affected by pos- ture, and the different states of the chest in expiration and inspiration, than in the natural condition. Again, when fluid exists in large quantities within the peri- cardium, whilst the impulse is greatly diminished, the points in which it is felt at successive moments are often very variable, the organ being no longer in any de- gree restrained or directed in its movements by the enveloping sac. Of extrane- ous circumstances, modifying the extent and situation of the heart's impulse, this is not the place to speak. A palpitation is a beating of the heart disagreeably perceptible to the feelings of the patient, the pulse being commonly more rapid than in the natural state, and occasionally unequal in respect to strength and frequency. Palpitations are often not only felt, but heard also, by the sufferer, and this more especially when in the lying posture. Yet sometimes, even though the pulse may be very quick, and the palpitation greatly complained of by the patient, no increase of impulse is felt on applying the hand to the pericardium; and here, particularly if there be consi- derable morbid augmentation of sound, dilatation of the ventricle may be suspected. If, on the contrary, during the palpitation, the ear of the observer be thrown up very forcibly and over a much greater extent than naturally, hypertrophy is indicated, even though the pulse should be small and feeble. The stethoscopic examination, to be worthy of trust, must, however, be made neither when the circulation is tempo- rarily excited under the influence of mental emotion, or by some extraneous cause, as unusual exertion, febrile excitement, a stimulant diet, or overloaded stomach; nor yet when the patient's strength is greatly reduced by depletion, inanition, depressing passions, or approaching dissolution, or even by the long continuance of the attack of palpitation, or of a fit of difficult breathing; as at such times the beat of the heart, even though the organ be decidedly enlarged, may yet from exhaustion scarcely be felt. When hypertrophy and dilatation co-exist, the impulse and sound, and the extent in which they may be perceived, are all simultaneously To the subject of palpitations of the heart we shall afterwards recur, when it will be seen that in the great majority of instances they are of a nervous or sym- pathetic origin, and altogether independent of organic disease. The irregularity of the heart's rhythm has regard to the relative duration of the first and second sounds, and also to the occasional recurrence of the first sound within less than the regular or equable time. Such irregularity may exist with or without palpitation; that is as we have seen, with or without a conscious- Vol. II.—60 474 the heart-pulse, (Intermillence of.) ness of the lieart's motions. An occasional ventricular contraction may be shorter and weaker than the adjoining ones, in consequence of which the period of silence will be longer, and the idea of intermittence erroneously suggested, the whole time of the beat or complete revolution of the heart not being really greater than usual. This was thought by Laennec to occur mostly in cases of dilatation. On the other hand, a ventricular contraction may here and there be much longer than ordi- nary, so that the first sound entirely obscures the second: this is met with as a perma- nent phenomenon chiefly in cases of considerable hypertrophy in which the sys- tolic sound, though dull, is commonly long drawn out. Finally, there may be a premature reiteration, or a reduplication, of the ventricular contraction, by which likewise the second sound may be masked. Here, if the second wave thrown out from the heart be large enough, we shall have a dicrotous pulse, other- wise there will be an intermittence in the arterial pulse as compared with the pulse at the heart. Such cases are supposed by Bouillaud frequently to depend on narrowing of the orifices, or on valvular disease preventing the speedy filling of the ventricles, which cavities consequently contracting on an inadequate supply are immediately obliged to repeat their action in order to complete their task. The second sound has occasionally appeared to commence, as it were, prema- turely, cutting short and obscuring the first; and in some very rare instances Laennec thought he had heard the second sound twice or thrice reiterated with great rapidity. Now though his theory of this sound, and consequently his ex- planation of these cases, were incorrect, yet the facts themselves, having been recorded by an observer of such acknowledged accuracy, are not lightly to be passed over or discredited. As he has added, in regard to the latter class of cases, that they occurred in every instance in connexion with ventricular hypertrophy, it is possible that the sounds heard may have been but the reduplication of the first sound already alluded to. A repetition of abortive ventricular contractions might readily give rise to such a mistake as he committed in their explanation, especially when the jets of blood propelled from the heart were too inconsiderable to produce corresponding pulsations at the wrist. If reiterations of the second sound ever really take place, we see no other way of accounting for them but to suppose them to depend on the diastole of the ventricles, and that this is effected convulsively, or by a succession of partial or incomplete movements: now this would imply, obviously, either a power of active muscular expansion in these cavities, the pos- sibility of which, though not yet satisfactorily made out, we are not prepared al- together to deny; or else a graduated or intermittent yielding of the contracted muscle to the force of elasticity. In contrast with the various cases mentioned above, there is another class in which the natural double sound of the heart seems altogether absorbed in a single prolonged bellows-murmur. Yet even here, sometimes, a division can be effected, as Bouillaud has remarked, and the murmur answering to the second sound made to appear distinct from that appertaining to the first, by reducing the frequency of the pulse by digitalis or other means; or occasionally by merely removing the stethoscope to some distance from the point where the blowing sound is most in- tense. In cases of extreme debility, however, the second sound is entirely and in all situations inaudible, as we have already seen. Intermittence of the heart-pulse. As the term irregularity has rearard to the actions of the heart in respect to their being prolonged, shortened, interfering, or anticipating; so, intermittence refers to an occasional prolongation of the period of repose or silence beyond the regular or equable time. Here, though the first and second sounds may retain their due relation in respect to strength and duration, the rhythm is, notwithstanding, broken through. The interruption may be equal to, superior, or less than, the ordinary period of a complete revolution of the heart The intermittence of the pulse at the wrist is, however, no proof of intermission at the heart, as it may depend merely on an occasional feebleness of the systole, some of the ventricular contractions being performed with too little energy to make themselves perceptible in the remote arteries. Hence the distinction into true and the pulse, (Arterial.) 475 false intermissions. The latter, as well as the former, are very common in old people, ceasing, in some cases, on the supervention of slight illnesses, especially of an inflammatory kind; whilst in others, on the contrary, it is only under such cir- cumstances that they make their appearance. In persons in the vigour of life, their occurrence, more especially during palpitations, was considered by Laennec almost as decisive proof of the existence of disease of the heart, and more espe- cially of hypertrophy of the ventricles. Our own experience has not led us to ac- quiesce in the justness, of this observation, having met with numerous instances of intermitting pulse^Wyoiing persons without any reason to believe in the presence of organic disease. The arterial puhe. Into this-intricate subject we cannot afford space to enter fully, and must therefore confine ourselves to the notice of a few points of peculiar interest in regard to it' The pulse, which is only incidentally mentioned by Hippocrates, who seems rarely to have drawn his indications from it, had its importance first duly appre- ciated by Herophilus. His opinion as to its practical value does not, however, appear to have been universally adopted by the ancients, for Celsus speaks very slightingly of it, as liable to so many sources of error, in respect to age, sex, idio- syncrasy, &c, as to render it of little avail as a means of distinguishing disease or directing its treatment. To Galen, who made it a subject of peculiar study, and who enlarged to an extravagant degree on its value and niceties in several express dissertations, may perhaps be traced the unmeasured confidence which has been bestowed very generally on the pulse as a ground of diagnosis, prognosis, and management of disease down to our own day. The Chinese have even outdone the nations of Europe in regard to the attention bestowed on the pulse, believing that by it we may not only detect the presence and nature of a disorder, but also decide in which of the great cavities, and on which side of the body, it is situated. Harvey's discovery of the circulation, whilst it gave no support to such extrava- gant pretensions, fixed the real value of this sign on a firmer basis than ever. The invention of the pulse-watch by Sir John Floyer first enabled physicians to indicate, with accuracy, the degree of frequency of the circulation* Various futile or fan- ciful distinctions in the pulse were subsequently attempted to be established by Solano, Fouquet, and Bordeu, but they never seem to have attained to much credit in this country. Drs. Heberden and Falconer, two of our principal writers on the subject, fell, indeed, into the opposite extreme of confining attention almost exclu- sively to the frequency of the pulsations, as if this were the only circumstance re- specting which we can form a determinate notion, or at least the only one as to which we can feel certain of its being appreciated exactly alike by different indi- viduals. The investigations of Laennec have proved satisfactorily that this view is too limited; and shown, at the same time, that much valuable information may be obtained by comparing the pulse as felt at the heart with its condition in the more distant arterial branches. The attempted distinctions of Stahl between the quick or short and the frequent pulse, and between the slow or prolonged and the rare pulse, are now known to be well founded, though opposed originally by the high authority of Hoffmann. The frequency and rareness of the pulse depend on * The natural pulse of the adult male, in a state of health, may be stated as varying be- tween 60 and 70 pulsations in the minute; that of the female on an average being about ten beats higher. In disease, the deviation from the healthy standard is often very remarkable: thus, M. Piorry has observed so few as 17 beats in a minute; and we have, on the other hand, distinct- ly counted as many as 200 beats in one stage of a case of acute hydrocephalus; and Frank a similar number in a case of inflammation of the great arteries near the heart of an adult. We have read moreover of instances where a still greater number of pulsations was noted within the same space of time. Dr. Graves speaks of the singular case of a lady, whose pulse, which was only 38 in a minute, did nut become accelerated during ftbnle illnesses — Author. 476 the pulse. (Arterial.) the number of complete revolutions performed by the heart in a given time;—its quickness and slowness on the time occupied in each ventricular contraction, if we refer to the heart; but partly also on the tone of the arteries, as indicated by the degree of their yielding, and the speed with which they react on the blood in- jected into them, if we refer to the pulse in the remoter parts of the system. The state of the pulsations at the heart was justly held by Laennec as consti- tuting a better index of the degree of danger in a disease, as well as of the ap- propriateness of depletion, and of the length to which it may be carried, than the arterial pulse. In diseases of the heart, for example, the latter may be very feeble, whilst the former by its violence justifies the use of the lancet. It was a rule with him that we may bleed fearlessly, however weak the pulse at the wrist, provided the contraction of the ventricles be energetic; whereas, if the heart's action, on the contrary, be feeble, whatever is the state of the arterial pulse we must abstain from the use of this remedy. The doctrine of the arterial and capillary action being to a considerable degree independent of that of the heart, which has latterly met with many able advocates, was the fixed creed of Laennec, who thought it was in a manner proved by the very different effects of venous, arterial, and capillary depletions. The insulated occurrence of the bellows- murmur and purring thrill in arteries was likewise adduced amongst the evidence of this independent action. The character of the arterial pulse depends, as Dr. Williams remarks, jointly on the mode of action of the heart, on the quantity of blood in the system, and on the state of the arteries themselves; and necessarily varies with changes in each of these elements. (Med. Gaz.) The number of pulsations at the wrist can obviously never exceed that at the heart, but may, as we have seen, sometimes fall much short thereof, viz., where some of the ventricular contractions are so weak and incomplete that the impulse given by them to the blood is lost long before reaching the more distant arteries. Again, when the action of the heart is greatly reduced, as in the state of syncope, the radial pulse may, for a time, be even entirely extinct. In violent palpitations, moreover, the arterial pulse may be quite feeble, and indicate that the action of the heart, though so vehe- ment and tumultuous, is really inefficient. Hence the obvious importance of ex- ploring the pulse simultaneously in the two situations indicated, in order to ob- tain a correct idea of the real state of the circulation as a whole. That the character of the pulse is in a conspicuous degree dependent on the mode of action of the central organ of the circulation we have proof in its be- coming sharp when the contractions of the heart are abrupt, as happens especially in states of nervous irritation, or in febrile conditions when complicated there- with. In active inflammation it commonly possesses, in addition to sharpness, a marked degree of strength. Organic affections of the heart are, as we should expect, peculiarly capable of influencing the pulse. Active enlargement of the organ, when unaccompanied by any very great obstruction of the orifices or inadequacy of the valves, generally gives rise to a full pulse, which will be hard in proportion to the tension of the coats of the arteries. If the heart, on the other hand, be dilated, and its walls thinner than natural, the pulse may be ab- rupt or sharp, but not strong, and is generally slow of reaching the distant arte- ries. Its size will vary with the state of the arteries and the quantitv of blood. Inefficiency of the mitral valves, admitting of regurgitation, tends to deprive the pulse, which is in such cases generally very irregular, of part of its fulness and strength. Imperfect aortic valves, from the same cause, give a jerking or mo- mentary character to the impression of the pulse against the finger, and at the same time render the onward motion of the arterial wave, as has been remarked by Dr. Corrigan, peculiarly visible; for the column of blood, though often ex- pelled with great force, in consequence of the frequently co-existing hypertrophy, is yet, from the inadequacy of the valves, not sustained during the natural period, so that a portion of it almost instantly falls back into the ventricle, and thus effaces in a moment the dilated tortuosity of the vessel. In cases of narrowing the pulse, (Arterial.) All of the left auriculo-ventricular orifice, the pulse is for the most part not only small, but peculiarly irregular, and it is in this form of disease that we have very often, as pointed out by Mr. Hodgson, two beats at the heart for one at the wrist; both of which circumstances are ascribable to the imperfect supply of the left ventricle with blood. Narrowing of the aortic orifice, if considerable, must necessarily diminish the force of the pulse, but, unless existing in an extreme degree, it may still be possessed of much hardness. (Williams, loc. cit.) Of the influence of the quantity of blood on the pulse, we have a striking ex- ample in cases of plethora, in which it is distinguished by its fulness as well as strength, unless where, from over-distention or some other cause, the action of the heart is temporarily oppressed; and, even here, blood-letting will often im- mediately lead to the development of its true character. Again, loss of blood in ordinary cases renders the pulse softer and less frequent; but if carried to excess, or performed in particular states of the system, such as exist in nervous or chlo- rotic individuals, it seems to exalt the irritability of the heart, and consequently renders the pulse more rapid and sharper; but even then it will have a quick jerking or bounding character, without fulness or permanency under the finger, sufficiently indicative of deficiency of blood in the vessels and abrupt systole of the heart. The state of the arteries, in respect to tone and elasticity and thickness of parietes, necessarily exercises a considerable influence on the pulse. When they are large and yielding, supposing the heart to be acting with its ordinary rigour, the pulse will be full and soft. When, on the contrary, they are contracted and tense, it must be hard and small. The tone of the arteries, or their contractility, is notably modified by temperature and hygrometricity, being augmented by a cool dry atmosphere, and diminished by the opposite conditions. Where the coats of the arteries, as in the aged, are rigid, the impulse given to the blood by the heart will be transmitted with little modification; whereas, if the arteries are thin, elastic, and imperfectly distended, they must tend to reduce its hardness and force, and retard its progress, and, if any of the pulsations be particularly weak, to obliterate them altogether. In inflammatory conditions of the system, in consequence of the increased tension of the arteries, the pulse in the extremities is almost synchronous with that in the heart; whilst in debilitated states, on the contrary, in which the vessels parcipitate, the transmission through the relaxed arterial tubes is much slower, and consequently the interval between the pulse in the two situations just indicated is remarkably augmented. The state of the capillary circulation is like- wise to be taken into account amongst the circumstances capable of modifying the arterial pulse. An artery running to an inflamed part throbs with unusual vehe- mence, and seems to participate with its ultimate ramifications in a state of exalted action. The condition of the veins and capillaries often, moreover, throw much light on the state of the general and pulmonary circulation, and should always be carefully investigated. A swollen state of the venous trunks, and pulsation in the jugular, frequently point unequivocally to over-distention of the right side of the heart, and imperfect action of the tricuspid valves ; whilst a general overloading of the capillaries with arterial or with venous blood, which displays itself so peculiarly in the cheeks, conjunctiva, lips, and extremities, is likewise indicative of various states or stages of deranged or obstructed circulation, and remarkably charac- teristic of disease of the organs within the chest, and most particularly so of organic affections of the heart. The condition of the lungs, placed as they are between the right and left sides of the heart, very materially influences the pulse. The numerical relation between the pulse and the number of respirations in a given time may be stated in the healthy condition to be about as 4| to 1. Dr. Hooker, in an interesting communication in a recent number of the Boston Medical and Surgical Journal, says that this is so universally true, that any great deviation from it may be looked upon as evidence of mal-formation or disease, provided there be no mechanical impediment within 478 THE PULSE, [.■h.'rriul.) or without the body to the descent of the diaphragm. Where the rate of the respi- ration to the pulse is notably increased, it generally indicates some impediment to the aeration of the blood, either from disorder in the air-passages or lungs (pneu- monia, oedema of the lungs, incipient phthisis, &c.,) mechanical impediment, or im- perfect function, of the organic nerves of the lung. In typhus and delirium tremens, on the contrary, the relative frequency of the respiration is remarkably diminished, which may be ascribed to the disordered condition of the brain and spinal cord, and impaired function of the motor respiratory nerves. The relation of the breath- ing to the pulse has also engaged the attention of Dr. Macdonnell, of Belfast, for many years; but it is to be regretted that the result of his investigations, which were carried on, on a very extended scale, have not yet been communicated to the public in a complete form. Some notice of them is to be met with in the reports of the medical section of the British Association for the year 1835. The obstruction of the lungs, as in severe and very extensive cases of pneumonia and bronchitis, and of profuse pleuritic effusion, necessarily causes an overloading of the right cavities; whilst those of the left side are inadequately supplied with an imperfectly arterialized blood, and consequently contract for the most part with diminished energy; under these circumstances the pulse, notwithstanding the pre- sence of inflammation, will be comparatively soft and feeble, though it may occa- sionally have a certain degree of abruptness or sharpness about it which might by the inexperienced be mistaken for strength. It is accordingly a very general rule, that when the respiration is profoundly impaired the pulse soon loses its body and strength. (Williams.) There is a peculiar state of the pulse, mentioned by Laen- nec, in which it remains for some time tense and full under the finger, and which seems, occasionally at least, to be produced by obstruction of the pulmonary circu- lation, for it is felt in a very marked manner during a fit of coughing, and may possibly also be sometimes caused by a spasmodic continuance of the ventricular systole leading to an overloaded condition of the auricles, and consequently to mo- mentary obstruction in the capillaries, and an interruption to the onward movement of the arterial current. To prepare us for forming a just estimate of what constitutes in any given case a morbid condition of the pulse, we must be aware of the varieties to be found in the natural state,—varieties dependent partly on the strength of the heart, and partly on the natural constitution of the arteries. Thus persons in whom the arteries have thin and yielding coats, and are at the same time of large diameter, will (the action of the heart being moderate) ordinarily have a soft large pulse; if their caliber be small, as is frequently the case in females, the pulse will be small and weak; if the walls on the other hand, be deficient in elasticity and very firm, as in the aged, the pulse will then commonly be hard and strong, as well in health as in disease,—a circumstance which often takes greatly from the value of this sign as indicative of inflammatory action, or particular diseases of the heart, in advanced life. The pulse is influenced not only by diseases, temperature, age, sex, tempera- ment, and idiosyncrasy, but also, and very remarkably, by moral emotions, by diet, by the recent taking of food or other stimuli, by inanition, by narcotics, by exercise, posture, sleep, and watching, and the period of the day, It Avould per- haps, however, be nearer the truth to say, that they originate sometimes in the one way, and sometimes in the other, or that both, when the excrescences are considerable, may be concerned in their formation. The very fact of their more frequent occurrence on the left side, where coagulation is a much rarer, and in- flammation a more frequent event than on the right, must prevent us ascribing them solely or even chiefly to the source advocated by Laennec. The blood, when once it is coagulated, and organized Avithin the heart, as in other situations, exercises the power of a living substance, and occasionally secretes within its new- formed tissue purulent, tubercular, or even osseous matter. The ossific concre- tion met with by Burns within the heart, Avhich was about equal to a hen's egg in size, had probably originated in this manner. Kreysig has attributed to the inflamed parietes of the heart and blood-vessels a power of determining the coagulation of their contents. That inflammation of the endocardium promotes in some degree the formation of polypous concretions is indeed highly probable, the effused lymph or pus forming a centre, around which the morbid solidification commences; but the existence of such a condition cannot be admitted as essential thereto. The low degree of inflammatory action re- quisite, in order that they shall become eventually solidly adherent to the interior ofthe organ, may as well be considered the result, as the cause, of their presence, and probably often ensues merely upon the pressure and irritation produced by them. It is not in the young and sanguineous most commonly, but rather in the THE HEART, (PolypOUS CoilCretioHS.) 581 aged and debilitated, that this morbid appearance is met with; and the stagna- tion of the blood, however induced, seems alone, in any case, quite sufficient to cause its separation into its elements. The symptoms of polypous concretions of the heart are nearly all referrible to the impediment to the circulation which they cause; as, for instance, the ex- treme dyspnoea, violent palpitation, and tendency to faint, sudden venous congestion, coldness of the skin and sense of sickishness, extreme distress and restlessness,— all of which are particularly characterized by the suddenness of their supervention. They are in some cases intermittent, making their appearance at uncertain inter- vals, and ceasing as instantaneously as they commenced. In such instances it seems probable that a portion of the newly formed mass floats loose by at least one of its extremeties, so as to permit of its being carried temporarily by the cur- rent of the circulation into the auriculo-ventricular opening, or into the orifice of one ofthe great vessels. When the effects are more permanent, this circumstance may with great probability be ascribed to the greater magnitude and fixity ofthe fibrinous substance, and its constant interference with the play of the valves and with the freedom ofthe orifices ofthe heart. The existence of polypus, says Laennec, is almost certain, when the motions of a heart, which had previously been beating regularly, become all of a sudden irregular, obscure, and confused to such a degree that we can no longer analyze them. The group of symptoms specified by Bouillaud as diagnostic, if they come on all at once, is as follows:—tumultuous pulsations of the heart, with dulness or obscurity of its natural sounds, together Avith a blowing, hissing, or musical mur- mur, orthopnoea, or a degree of difficulty of respiration bordering on asphyxia, in consequence of the obstructed state of the pulmonary circulation, extreme anxiety, congestion ofthe venous capillaries, and even loss of consciousness, coma, stertor, and occasionally convulsions resulting from the gorged state of the cerebral vessels, together with a remarkably small pulse and cold extremities. If in the course of an acute inflammation of the heart, very great difficulty of breathing and extreme disturbance of the circulation set in suddenly, the rapid for- mation of the concretions in question may be suspected, with a high degree of proba- bility, as their source; so likewise when there is sudden and very violent aggrava- tion of an habitual dyspnoea. The prognosis in this affection is, generally speaking, of the worst possible(kind. As, however, coagula within veins have been known to undergo absorption, it is just Avithin bounds of possibility, that those of the heart also when small may, in some very rare cases, be susceptible of spontaneous removal. The best prophylactic treatment, according to Bouillaud, consists in the re- peated abstraction of blood and free use of diluents in those cases of organic and inflammatory disease, in which their occurrence is most to be apprehended; but Dr. Hope very justly cautions us against the empirical or indiscriminate use of blood-letting in organic diseases of the heart, and especially in cases of dilatation and softening, or even in the advanced stage of valvular lesions when there is already great debility, as here it will not only fail to prevent the formation of polypi, but, like the imprudent employment of digitalis and nauseants under the same cir- cumstances, will, by augmenting the languor ofthe circulation, directly favour their occurrence; Avhilst at the same time it tends unnecessarily to reduce the strength, accelerate the advance of dropsy, and the fatal termination ofthe complaint. M. Legroux puts some faith in the exhibition of potass or soda, or their sub- carbonates, from their poAver of diminishing the tendency of the blood to coagu- late,—a property of the alkalies well known to Huxham, Avho deprecates their continued use, lest a dissolved state of this fluid should be induced. Dr. Copland thinks the sub-borate of soda the most influential agent for preventing the concretion, of fibrin, and dissolving coagulable lymph. The efficacy of mercury in effecting the latter object is also well known; but unfortunately in the vast majority of cases there is little time for the trial of this or any other remedy. 582 HYDRO-rERICARDIUM, (CUXISCS.) HYDRO-PERICARDIUM. Causes.—Symptoms.—Treatment. Dropsy of the pericardium may, like that of the other serous sacs, be either of an active or passive nature. The active species, or that depending on increased energy ofthe exhalants, is scarcely ever observed save as a consequence, or one of the latest stages, of inflammation of the pericardium, in which, when the original turbid, albuminous, or sero-purulent effusion has been absorbed, a transparent Avatery secretion gradually takes its place, which is either colourless, or wtih a slight greenish or pale yelloAvish tinge. Its occurrence in an active form, as an idiopathic and insulated affection, is so extremely uncommon, that it is difficult to point to an unequivocal example of it even in the writings of authors who have had the largest experience in diseases of the heart. The passive form, or that resulting from impediment to the circulation, in con- sequence of obstruction in the heart or lungs, or from debility of the heart's action, is, on the contrary, by no means unfrequent; and its existence may be anticipated in most cases when there is a general dropsical tendency throughout the system, as well as in the final stage of many typhoid and malignant diseases, in which the fluids are deeply contaminated, and the capillaries relaxed; as in cases of cancer, for example, the Avorst forms of puerperal fever, the exanthe- mata, when accompanied by symptoms of putrescency, &c. As to the quantity of effusion requisite to constitute hydro-pericardium, authors are not agreed. After death, whatever may have been its source, there is usually found a small portion of a serous fluid, amounting generally to a few drachms, Avithin the pericardial sac, poured out either during the mortal struggle or after its termination. An effusion in such minute quantity, and taking place under such circumstances, does not fall Avithin the scope of the term hydro-pericardium; nor does Corvisart recognise any thing under six or seven ounces as being enti- tled to the appellation. Laennec has not ventured to fix on any precise quantity as a minimum, contenting himself with saying, "a few ounces or a quantity ex- ceeding that commonly found after lingering deaths." Bouillaud thinks that any thing above a couple of ounces may be considered as an example of dropsy of the pericardium, even though the mode of death may have been tedious. In many cases, hoAvever, there is no room for doubt as to the amount of fluid being sufficiently great to constitute a morbid state, as so much as one, two or three pints are sometimes found; and Corvisart mentions an instance where there Avas no less than eight pounds. The serous membrane in some of these cases has been observed to have an opaque whitish or macerated appearance.* Amongst the symptoms occasionally present, are a sense of Aveight about the heart and inferior part of the chest, and oppression in the breathing depending probably on the pressure of the distended sac on the lungs, diaphragm, and neighbouring parts. The pulse is generally small, frequent and irregular, the integuments of the praecordial region being occasionally cedematous, Avhilst orthopnoea and tendency to syncope frequently co-exist. But all these symp- * Under the title of hernia pericardii, a curious case has recently been described by Mr. Hart, in which, along with hypertrophy of the heart, and dropsical effusion into the pericardium, there existed a pyriforrn sac, likewise containing water, occupying the anterior mediastinum, and connected by an aperture at its narrower end with the pericardial sac, close to its reflec- tion on the aorta. If not congenital, it was probably formed by gradual pressure of the effused fluid against a weak and yielding portion of the pericardium.—Author. hydro-pericardium, (Treatment.) 583 toms taken together are very far from being conclusive as to the existence of an unnatural effusion; nor even, though it should be present, do they necessarily depend on it, but much more frequently on co-existing organic lesion within the heart. Senac declares he had seen a motion of fluctuation in the left side of the chest in cases of pericardial effusion; and Corvisart believed he had himself felt a simi- lar motion in the same situation; but as nearly all subsequent observers have sought in vain to confirm these observations, it seems probable that the tremulous feeble impulse of the heart may have led to deception. In cases of considerable effusion there is a striking prominence of the praecor- dial region with bulging of the corresponding intercostal spaces, together with a very extensive dulness, sometimes reaching even from nipple to nipple, and all along the sternum from near the second rib to the ensiform cartilage, in a pyra- midal form with the base towards the diaphragm. The pulsations are frequently quite imperceptible, at least in the supine position, and when felt in the erect or prone posture often present themselves at successive moments, as Corvisart re- marks, in different points of the praecordium, sometimes more to the right, some- times more to the left than natural, giving the idea of the organ floating free, and altogether unrestrained by its enveloping sac; and they are usually, moveover, preceded, with an appreciable interval, by the commencement of the systolic sound. The sounds of the heart are feeble and distant, as heard immediately opposite the organ, but are much more audible at the top of the sternum oppo- site the arch of the aorta, and over the great vessels at the root of the neck; which latter circumstance aids us in distinguishing the case from one in which the heart is really acting very feebly. Withal, the diagnosis of hydrops pericardii is extremely difficult unless the effusion be considerable: if it were less than a pint, Laennec thought the recog- nition of its presence impossible; and not by any means certain though of double or even triple this amount: but fiom its rarity as an idiopathic or leading affec- tion he considered the discovery of it of the less importance. The greater tact which many now possess in regard to the practice of percussion, has, however, recently, in a considerable degree, diminished the difficulty of ascertaining the presence of pericardial effusion. Thus where it is only of a moderate quantity, M. Piorry speaks confidently of being able to detect it by making the patient whilst lying down turn alternately on the right and left side, and finding, by practising percussion successively in these two postures, that there is an obvious dulness which changes its place correspondently from the right edge and the upper part of the sternum to its left and upper part, and cartilages of the upper ribs. Treatment. The active idiopathic form of hydro-pericardium, if recognised in its earlier stage, would of course require to be treated on the same principles as other active dropsies—by blood-letting, mercurials, purgatives, and counter-irri- tants, and subsequently by diaphoretics, digitalis, and other diuretics. And similar means in a modified form may afford useful aid in the passive or se- condary variety; though here the proper management of the primary affection or organic cause forms, in cases which are not as yet altogether hopeless, the chief object. As a forlorn hope the removal of the fluid by a surgical operation has been re- commended by high authority, but the practice has as yet but little support from actual experience. The operation proposed by Senac was paracentesis of the pericardium, by the introduction of the trocar between the ribs. Corvisart thought that if an operation were justifiable at all, the best method of proceeding would be to lay open the parietes first, and then the pericardial sac cautiously with the knife; whilst Laennec expresses a preference for trepannation of the sternum just above the ensiform cartilage, as in this way we avoid laying open the pleurae, and escape the error of Desault, who, attempting to perform the operation previously de- scribed, and having made his incision between the sixth and seventh rib of the 584 the pericardium, (Secondary Effusions.) left side opposite to the apex of the heart, mistook a circumscribed pleuritic effu- sion for a distended pericardium, as was subsequently obvious on dissection. It has been proposed, somewhat too boldly we think, by Laennec, to inject the serous bag when emptied of its contents with some slightly irritating fluid with a view to inducing adhesion of its opposed surfaces, as in the ordinary operation for hy- drocele. Bouillaud, without advocating either the operation or this addition to it, of which he has had no experience, yet thinks that what we know of the history of pericarditis and of its frequent termination in comparatively salutary adhesions, proves that the danger from such a proceeding is at least much less formidable than was once thought. Romero, who has thrice made an opening into the peri- cardium, in order to evacuate praeternatural accumulations of fluid, and twice suc- cessfully, makes his incision between the fifth and sixth rib, first into the pleural sac; and then having satisfied himself of the existence of a fluid in the pericardium, he next lays this open with a pair of curved scissors, and lets its contents run off into the pleurae, from whence they are subsequently drained away by placing the patient in such a posture as favours their escape by gravitation. During the whole proceeding every care must be taken to prevent the entrance of air. This operation has the advantage over that of Laennec of evacuating any fluid which may happen, as is so frequently the case, to co-exist in the pleural sac; whilst at the same time if an error in diagnosis, similar to that recently alluded to, have been committed, it may be detected in the first stage, the actually existing effusion evacuated, and the additional risk of opening the pericardium avoided. But this or any other operation can scarcely ever be Avarrantable, except where the affection sought to be relieved is idiopathic, or depending on local inflammation or increased action of the serous membrane. Where there is organic disease of the heart or lungs, or constitutional diseases of the kinds already specified, no ju- dicious practitioner Avould ever for a moment think of having recourse to it. SECONDARY EFFUSIONS INTO THE PERICARDIUM. Fluids of various kinds have been known to make their Avay into the peri- cardium from neighbouring organs in which they were originally poured out Thus those of a purulent or semi-purulent description may get into the pericardial sac in consequence of the bursting of abscesses in that direction which had been formed in the cellular membrane of the mediastinum or in the lung, or from the irruption of a circumscribed pleuritic effusion through the medium of a gradual pro- cess of interstitial absorption. An instance has been recorded by M. Alibert of the rupture into the pericar- dium of a very large hydatid or serous cyst, said to equal the foetal head in mag- nitude, and which had been developed between the lung, diaphragm, and exterior of the pericardial sac. It had previously considerably displaced the heart to the left side. Its bursting in the manner indicated gave rise to sudden praecordial pain, orthopnoea, tumultuous action of the heart, and a membranous crackling sound, synchronous Avith the respiration; and was followed by death Avithin a few hours. A very interesting case has been recently described by Dr. Graves, of abscess of the left lobe of the liver making its way through the diaphragm into the peri- cardium, and also by three several perforations into the stomach. The abdominal tumour which had previously been very obvious, began, soon after the formation of these preternatural communications apparently, to diminish in size, and no longer imparted a sense of fluctuation, but became tympanitic, doubtless from the PNEUMOPERICARDIUM. 585' entrance of air into it from the stomach. The secondary pericarditis thus induced manifested itself in the first instance by the sudden supervention of acute pain, by palpitation, and a sense of burning heat under the left breast; a rough bellows murmur and a species of creaking accompanied both sounds ofthe heart; and this was converted into a loud frottement when considerable pressure was employed. On the following day a metallic click indicative of the dropping of a fluid, and an emphysematous crackling were present. The patient being eventually run down by diarrhoea, caused by the escape of the purulent matter into the bowels, on dis- section the pericardium* which was of four times its natural thickness, was found sprinkled internally with red dots, and arborizations, and coated over with lymph and minute semi-transparent granulations. A remarkable case has been recorded by Mr. Thurnam Avhere the pericardium of a man who had been knocked down by a carnage, and thus almost immediately killed, was found filled with blood, though there was no rupture of the heart or great vessels within the sac. The effusion appeared to have its source in rupture of the veins in front of the trachea by the ends ofthe fractured clavicles, and to have forced its way through the inter- vening cellular membrane till it reached the apex of the pericardial sac, which it lacerated at length by its accumulation and pressure. PNEUMOPERICARDIUM AND HYDROPNEUMO-PERICARDIUM. When bodies have been kept for several hours after death before being opened,! especially when the atmospheric temperature is somewhat high, air is very fre- quently found within the pericardium, as well as in other shut sacs, and escapes on an incision being made, with a hissing noise. But besides these instances in which the air has obviously its source in post mortem decomposition, examples, are occasionally met with where there is every reason to believe that it had existed during life, being evolved generally either during the final struggle or at the most but a few days before dissolution. It is in such cases almost invariably accompa- nied by a liquid effusion, from the decomposition of which, if of a foetid character* it has for the most part its origin, though at the same time we are by no means prepared to deny the possibility of its being occasionally a product of direct secre- tion from the vessels. Its presence during life is indicated by a preternatural de- gree of resonance, of a tympanitic character, elicited on percussion in the praecor- dial region, as also by a sound of fluctuation produced by the motions of the heart through the elastic and inelastic fluids, as well as by forcible inspirations—a sound compared by Brichetau to the plashing of the wheel of a watermill. On dissec- tion, if we Avould ascertain accurately the quantity and quality of the gaseous fluid present, the body should be opened under water, in order to facilitate its col- lection. Laennec has expressed his belief that those cases in which the sounds of the heart are audible at some distance from the chest, depend for this peculiarity on the existence of air within the pericardium; but in support of this very improbable opinion he adduces no proof DISPLACEMENT OP THE HEART. We have already seen that the heart when greatly increased in size is felt to extend its pulsations to unusual situations, generally more to the left side or lower Vol. II.—74 588 the heart, (Displacement.) down than natural; but besides this enlargement of the limits within which it is perceptible, it may be thrust out of its place by various extraneous causes, such as tumours in its vicinity, augmented dimensions of neighbouring organs, and morbid effusions. Such unusual position then, when ascertained not to have been con- genital, is to be considered an evidence of some serious organic change having taken place within the thoracic or abdominal cavity. The most frequent cause of this phenomenon is, unquestionaly, a large pleuritic effusion, which, according to its situation and quantity may push the heart over either into the centre of the chest or to the right side, or, on the contrary, farther than natural to the left. Haemorrhage into the pleural sac from injury will have similar results. Sudden and even permanent displacement has been known to result from external violence, as in the remarkable instance recorded by Dr. Stokes when it originated in the compression of the chest by a mill-wheel by Avhich the heart was forced into the right side of the thorax. The individual, notwithstanding the severe symptoms Avhich immediately supervened, survived the accident many years, and was occasionally even capable of taking very violent exercise, his heart ever after continuing to beat on the right side. Aneurisms of the aorta, pneumothorax, or an emphysematous state of the lung, thoracic and abdominal tumours, ascites, and enlarged liver, are amongst the occa- sional causes by Avhich respectively the heart may be displaced, either doAvn wards, laterally, or upwards. Instances are alluded to by Dr. Stokes where this organ has been felt beating as Ioav as the ninth intercostal space, in consequence of very extensive pulmonary emphysema, a morbid affection which, as has been remarked by an able anonymous Avriter in the British and Foreign Medical Review, must, by the pressure caused by it on the great vessels, tend greatly to the development not only of asthmatic symptoms but of actual organic disease ofthe heart. It has farther been supposed, Avith great probability by Dr. Stokes, that the heart may sometimes be draAvn over in a very remarkable degree to the right side, by the absorption of a large pleuritic effusion in that part of the chest; especially when it takes place rapidly, and when in consequence of the lungs being closely and exten- sively adherent, the parietes of the thorax cannot fully accommodate themselves to the diminished contents of the cavity: and a case by Dr. Abercrombie, in the Edinburgh Medical Transactions, shows that a similar effect may sometimes be produced by atrophy of one lung, accompanied by an hypertrophic condition of the other. In a case Avhich occurred to Dr. Hope, in which the heart was just so far dis- placed towards the right, by a pleuritic effusion of the opposite side, as to be impacted betAveen the sternum and unyielding spine, the augmented impulse was such as to have conveyed to a less experienced auscultator an erroneous idea of the existence of hypertrophy; and Dr. Stokes has knoAvn a similar effect produced by tubercular consolidation ofthe lung behind the heart In cases of diaphragmatic hernia, generally of congenital origin, the introduction ofthe intestines into one side ofthe chest necessarily displaces the heart more or less to the opposite side. Prolapsus ofthe heart, or that condition in which, from its unusual weight, and the relaxation of the parts by Avhich it is suspended, it pushes the dia- phragm before it, and encroaches on the abdominal cavity, is a very uncommon state, if indeed it is at all to be recognised as a distinct affection. Corvisart, who speaks of it, supposes it capable of causing severe pain in the oesophagus and car- diac orifice of the stomach, difficulty of deglutition, and imperfection of the diges- tive process, with frequent tendency to nausea and vomiting. The diagnosis of displacement ofthe heart is based on the results of percussion and auscultation, and the examination of the praecordial region by the eye and by the touch, taken together with the history of the case, from Avhich last Ave learn whether the phenomena are of comparatively recent origin, or at least not coeval Avith birth, and so independent of congenital transposition of the organ hereafter to be spoken of. When the displacement is very considerable, the functions ofthe heart may be much embarrassed, as is manifest from the severe palpitations occa- the heart, (Hernia.) 587 sionally complained of in these cases. In the instances described by Dr. Graves and Dr. Stokes, where the heart was thrust upwards and to the right side, as high as the third intercostal space, by an aneurism of the abdominal aorta, the aneu- rismal tumour itself presented a double pulsation (the first stroke coinciding with the arterial pulse,) imparted to it obviously by the contact of the heart; Avhilst at the same time two sounds were audible corresponding to the natural double sounds ofthe latter organ. A similar double pulsation was observed by the same authors in a case of aneurism ofthe ascending aorta, and in two others of a like nature by Dr. Townsend. HERNIA OF THE HEART. Hernia of the Heart, (Ectopia cordis,) though of congenital origin, may as well be briefly alluded to here. From original deficiency of a portion of the sternum, cartilages of the ribs, diaphragm, or abdominal muscles, the heart of the foetus, or new-born infant, may be found protruding either on the exterior of the neck or chest, covered only with the common integuments; or into the abdominal cavity; or finally forming a portion of the contents of an umbilical hernia. Such ex- amples of displacement as are here spoken of, generally occur in connexion with other congenital malformations, often from their very nature incompatible with the continuation of existence for any length of time after birth, and are hence obvi- ously rather matter of curiosity than of practical interest. In some very rare in- stances, however, life has been prolonged even to a very advanced period, not- withstanding the existence of such singular malposition of the heart, as in the very remarkable case recorded by Deschamps, in Avhich this organ was found on dissection occupying the place of the left kidney. An interesting case of partial " ectopia cordis," in an infant Avhich survived its birth for three months, has been lately published by Dr. O'Bryen, of Bristol, in the sixth volume of the Transactions of the Provincial Medical and Surgical Association. In consequence of absence of the ensiform cartilage and of the part of the recti muscles and diaphragm usually attached thereto, a portion of the pericardium con- taining the apex of the left ventricle preternaturally elongated, protruded through the opening, and lay immediately underneath the common integuments, along with a portion ofthe transverse arch ofthe colon. In this tumour the following motions, were observed:—1st, a lessening in size and contraction of its whole body, which was obviously the systole, as being synchronous with the first sound ofthe heart, and with the pulsation of the carotid; whilst at the same time its whole mass was car- ried forcibly downwards: 2d, a movement of dilatation during Avhich the tumour became tense and appeared shortened; while at the same time it was much en- larged by as active a force as that of contraction, powerfully separating the fingers when an attempt was made to compress it; and immediately after Avhich a sensa- tion was imparted as if of a wave of fluid rushing into it and communicating a thrill to its Avails. This movement of dilatation was synchronous with the second 60und of the heart, but appeared to continue for some time after it. No distinct period of rest was perceptible after the dilatation. The heart in this as in Har- vey's case appeared insensible to the touch. If the phenomenon accompanying the second sound be admitted to have been accurately observed, they afford stronger evidence in favour of an active power of dilatation in the ventricles, than any we have yet met with. 588 the heart, (Malformations.) MALFORMATIONS OF THE HEART. Congenital Malformations, Transposition of the heart.^-Acardia.—Bicardia. Congenital irregularities in the structure and relations of the heart, as may be deduced from the works of Winslow, Beclard, the St. Hilaires, &c., are referrible either to diseases occurring during the progress of the evolution of the foetus, in- clusive of interrupted development, or else to primitive anomalies in the germ (excess or malposition of parts,) or to both these sources together. Of the reality of the second of these causes, we have incontestable evidence in cases of Trans- position of the Heart, in Avhich the organ is not only placed in the right side of the thorax, but has, moreover, its aortic ventricle turned to the right, and the pulmo- nary ventricle to the left, and where a similar transposition of all the other tho- racic and abdominal organs co-exists, the aorta running down along the right side of the spinal column, the vena azygos along the left; the lung on the right side having but two lobes, that on the left three; the liver, duodenum, head of the pancreas, and the caecum being in the left side of the abdomen; the great curva- ture ofthe stomach, the spleen, and descending colon, lying to the right side. Such anomalies of position are by no means incompatible with the due exer- cise of the functions, or Avith attainment of advanced age. Though very rare, the practical physician should be aware of the possibility of their occurrence, to prevent the mistaking the physical signs of such irregular congenital conditions for evidence of acquired disease. Acardia. The heart has been discovered to be altogether wanting in some foetuses; and this is said by Beclard to be universally the case in acephalous mon- sters, atrophy or absence of the upper part of the spinal marrow also ordinarily co-existing. Bicardia. Two hearts have, on the other hand, been found within the chest of the foetus in some extremely rare instances; but the accompanying pleurality of other organs naturally single, has indicated the source of this phenomenon to be the intermixture of tAVO germs. A case in which three ventricles were supposed to exist, has been recorded by Chemineau, but M. Is. G. St. Hilaire thinks it Avas probably only an example of a supernumerary septum. A second appendix has been noticed, in connexion with the left ventricle by De Haen; and we have the authority of Breschet for believing tha,t the pericar- dium has been observed to be entirely absent. PRETERNATURAL COMMUNICATION BETWEEN THE TWO SIDES OF THE HEART. forms of preternatural communication between the two sides of the heart.—Cyanosis.— Symptoms of this lesion.—Progress.—Treatment Of this, the chief forms are permanence of the foramen ovale, abnormal aper- tures in other parts of the septum of the aurielesl or in that of the ventricles, or in the heart, (Malformations.) 589 the common point of junction of both septa, throAving the four cavities into one; origin of the aorta or pulmonary artery from both ventricles simultaneously; and continued patescence of the ductus arteriosus. Many of these irregularities have, in several instances, been known to co-exist in the same individual, and frequently along with additional anomalies in the origin of several of the great vessels.* When only one of these preternatural communications exists, by much the most common is the first of those mentioned above. A mere oblique opening between the over-lapping and imperfectly adhering edges of the foramen ovale does not, however, constitute an example of the malformation or lesion here spoken of; for a valvular aperture of this kind, in consequence ofthe counter-ba- lancing pressure made on each of its sides simultaneously, will obviously not allow of the mixture of the contents of the adjacent cavities, and accordingly, though it is a condition so often found on dissection (in one out of every four subjects^according to Bizot,) it is known not to give rise to any morbid symp- toms. To have an injurious influence, it is necessary that the opening should be nearly at right angles to the septum, direct and patulous; and even here, many months of early infancy may elapse, ere any very obvious functional disturbance ensues; it^ first manifestations taking place occasionally during the irritation of dentition, or when the child begins to walk. The diameter of the open foramen ovale, in these cases, varies from two or three lines to upwards of an inch; whilst, in other instances, in place of one large opening, there are several smaller ones. M. Louis, after investigating the matter very scrupulously, has come to the conclusion that the perforated condition, not only of the auricular septum, but also of the ventricular, is congenital in almost every instance, as the edges of the aperture are rounded off, smooth, and polished, and occasionally membranous, or even somewhat tendinous, and without any traces of softening or other recent morbid process; whilst farther, the co-existent lesions are frequently of an ob- viously congenital nature, such, for instance, as the permanence of the ductus arteriosus, the origin of the aorta from the right ventricle, &c. The greater fre- quency of morbid alterations in the right side than in the left, contrary to what is observed in ordinary or acquired disease of the heart, is likewise adduced in proof of a primordial source; as is also the commonly existing contraction or ob- struction in the orifice of the pulmonary artery. M. Louis does not, however, altogether deny that such openings might in some very rare cases originate in * In a "Treatise on Cyanosis," by Dr. Gintrac of Bourdeaux, published in 1824, the fol- lowing results have been deduced from 53 cases analyzed by him :—In 33 instances the for- amen ovale was open; in 22, aorta arose from both ventricles; in 22, the pulmonary artery was contracted; in 14, the ductus arteriosus was open; in 5, ventricular septum imperfect; in 5, pulmonary artery obliterated ; in 4, a single heart, i. e, only one auricle and ventricle; in 4, the aorta arose from the right, and the pulmonary artery from the left ventricle (foramen ovale open, and occasionally also the ductus arteriosus;) in J, the aorta obliterated. The following additional deviations from the natural state have been noticed by other au- thors:—The existence of two auricles with only one ventricle; or, in other words, total ab- sence of the ventricular septum (Wolff, Breschet Farre;) the four cavities thrown into one, from a deficiency ofthe septa at their common point of junction (Thibert, cited by Laennec;) the pulmonary artery arising from both ventricles, and sending off the descending aorta,— the ascending originating naturally (Sir A. Cooper;) the right auricle opening into the left ventricle, the ventricles communicating by a preternatural opening, and the auricles by the open foramen ovale (Holmes;) the right ventricle bifid (Kertcringius;) the arch of the aorta double (Bertin, sen.,) the coronary veins opening into the left ventricle; the inferior or the superior cava opening into the left auricle; the foramen ovale closed in the foetus; the valves of the heart, adherent along their edges, and consolidated into one substance, leaving only a small central aperture, or else perforated by numerous holes, or altogether absent (Morgagni, Bertin, Laennec, Destres.)—AvTiion. 590 the heart, (Malformations.) ulceration. The frequency of these exceptional cases appears to M. Bouillaud, on the other hand, much more considerable, in consequence of his having fre- quently noticed the co-existence of traces of inflammatory action in the lining membranes of the heart along Avith the unnatural communications alluded to, as well as from the occurrence of the symptoms taking place often suddenly, and for the first time in advanced childhood, or even in adult age. The valves, in particular, according to the same authority, very often present changes of an in- flammatory nature, more especially those of the right side, and particularly of the pulmonary artery, the orifice of which is at the same time, and, as he thinks, from the same cause, very commonly contracted. We are bound, however, to confess that M. Louis's view of the case seems much the most consonant with the facts, and that the more frequent occurrence of the concomitant lesions or malformations on the right side appears altogether decisive against their inflam- matory origin. The heart in these cases is usually much enlarged, and transversely placed within the chest, the right cavities, and more especially the auricle, being almost invariably the subject either of dilatation, or hypertrophy, or both. When hyper- trophy exists, it is not unfrequently, as Bouillaud remarks, of the concentric kind,—a circumstance which has been attributed by Bertin with more ingenuity than probability to the contact of the arterial blood unnaturally admitted into the right cavities. The additional work thrown on the right side of the heart, as well from the opposition encountered in the delivery of its contents through the contracted pulmonary artery, as from its unnatural participation in the labours of the gene- ral circulation, would seem sufficiently to account for its being the principal seat of enlargement. Besides, as Dr. Hope has remarked, this hypertrophy is often most considerable in those cases where, in consequence of the contraction of the pulmonary orifice, the current through the opening in the septum must decidedly have been from right to left, so that no arterialized blood could possibly have entered the right side. There are a few cases on record Avhich would seem to shoAv that the foramen ovale may be violently reopened even in adult age by severe falls or Woavs, prolonged fits of coughing, or other fatiguing muscular efforts. The sudden supervention of the symptoms is not, however, sufficient to prove indubitably that such is the fact; it may, perhaps, be nearer the truth, even here, to suppose that the malformation alluded to had all along existed, but that it required some unusual derangement of the circulation in order to its revealing itself by external signs. With regard to the septum of the ventricles, a preternatural opening may be met with in any part of it; but it is certainly found most frequently in that por- tion which adjoins the auricular septum, near to the insertions of the aorta and pulmonary artery. It is from this cause that the former of these vessels in par- ticular has in these cases often an equal connexion with both ventricles. From the almost invariable co-existence of some of the complications just alluded to (hypertrophy, dilatation, disease of the Aralves, narroAving of one or more of the orifices, &c.,) it is nearly impossible to fix on any set of symptoms as strictly characteristic of the preternatural communications in question. The bluish colour of the skin of the Avhole body, and of the face, extremities, and parts covered with a thinner cuticle particularly, Avhich had commonly been looked upon as its pathognomonic sign, and which led to the use of the terms cyanosis, morbus, coeruleus, the blue disease, blue jaundice, §c, has been clearly BhoAvn by M. Bertin and by M. Louis to be often entirely absent; and even when present to depend with much greater probability on co-existent lesions capable of obstructing the course of the circulation, and so causing accumulation of venous blood in the capillaries. So likewise with regard to the frequent co-existing dis- order of the heart's action, indicated by palpitations, purring tremor, belloAvs- murmur, fits of excessive dyspnoea, occasionally amounting almost to asphyxia, with proneness to syncope on the slightest exertions or unusual mental excite- the heart, (Midformulions.) 591 ment, irregularity and feebleness of pulse, and extreme suffering from defective power of generating heat,—these, together with an occasional tendency to serous effusions, being, as Ave have already seen, morbid phenomena of ordinary occur- rence in cases of enlargement of the heart and obstruction of its orifices, whether from contraction or valvular disease. The narrowing of the pulmonary artery, which so commonly exists in cases of cyanosis, appears to be a very important element in the production ofthe peculiar appearance ofthe skin, as it must needs cause, as Morgagni has pointed out an embarrassment of the circulation through the right side of the heart, and consequent stagnation throughout the whole venous system; and especially at such moments when paroxysms of dyspnoea have been induced, and the circulation is peculiarly obstructed. That the deep colour of the skin, interior of the mouth, &c, occasionally observed, is not a necessary consequence of the mere communication between the two sides of the heart, Ave have proof, as M. Fouquier remarks, in the fact of its not being observed in the foetus when such communication naturally exists, and when dark blood is neces- sarily circulated. When the communicating cavities are of equal strength, it has been ingeni- ously suggested by M. Jules Cloquet, that no admixture of their contents in all probability takes place; whereas, if the left cavity exceeds the right in power, which in the natural state at least is always the case, the arterialized blood should make its way into the venous receptacles; so that if this view be correct, it may be only in a smaller number of cases that the contents of the right cavities are propelled immediately into the greater circulation; and even here it will not be in such quantity as to account for the deep blue tinge Avithout taking the co-existing sources of obstruction into consideration. M. Louis, on the contrary, believes that, whether the two ventricles be equal in strength or not, no mixture will take place during their contraction, provided all their orifices be free; but as the pul- monary artery is very commonly contracted, a portion of the blood of the right side of the heart will usually make its way through the preternatural opening at the moment of systole, or if" not then yet in every case during the diastole, or entry of blood into the cavity; so that a certain degree of admixture will occur in every instance: but this he believes to be quite inadequate to the production of the deep blue or violet colour of the skin, unless the co-existent sources of ob- struction in the heart, and consequent stasis in the venous and capillary circula- tion be taken into account; for the fluids circulating in the cutaneous vessels in most parts of the body are in the natural state colourless; Avhilst, moreover, in M. Ribes' remarkable case, though the aorta sprung from the right ventricle, and the circulation of venous blood in the arteries must have always existed, yet no such peculiarity in the colour of the surface manifested itself till the third year, when it made its appearance in company Avith other symptoms of heart disease. M. Breschet, again, mentions an instance where the left sub-clavian artery arose directly from the pulmonary artery, and yet the colour of the corresponding limb was altogether free from any blue tinge. Of all the symptoms usually attributed to the lesion under consideration, the one in Avhich M. Louis is most disposed to confide is the recurrence of suffoca- ting paroxysms at periodical or at least at very short intervals; these paroxysms being often' accompanied or followed by fainting, and induced by very inconsider- able causes; whilst, as for the blue colour, it may be either present or absent. The existence of a bellows murmur and thrilling tremor, if permanent and unattended with a marked disposition to dropsy, is considered by Bouillaud as strongly con- firmatory ofthe above symptoms. The blueness ofthe surface, we repeat, may or may not exist; and even when present, Laennec thought it was often rivalled in intensity by the dark colour of the skin in certain diseases of the lungs, and more especially emphysema; but this Dr. Hope doubts. As active enlargement of the heart is an almost invariable accompaniment of these preternatural communica- tions there is commonly a very considerable extent of dulness in the praecordial region, along with increased impulse, and at the same time often a superficial 592 the heart, (Malformations.) hissing murmur, with the first sound, about the middle of the sternum, in conse- quence either of the contraction of the pulmonary orifice or of the unnatural aper- ture through the septum, or both.* In infants with this malformation, even the effort of sucking is often sufficient greatly to embarrass the respiration and circulation ; and the suffocative parox- ysms so induced are occasionally accompanied by convulsive nxrvements. In childhood there is an inability to participate in the sports of that age; the sufferer is disposed to crouch over the fire even in summer, and is very easily benumbed in cold weather. The ends of the fingers and toes are often bulbous as well as discoloured; there is a tendency to cough on making use of any mus- cular exertion, and pulmonary congestions very frequently manifest themselves under the influence of slight exciting causes. The discolouration of the skin and interior of the mouth is sometimes, as Dr. Hope expresses it, as deep as the stain of the small black cherry. The contractions of the pulmonary artery, Avhich so commonly exists, is looked upon by M. Louis not only as of indubitably conueni- tal origin, as already stated, but also as a chief cause of the prevention of the closure of the aperture in the septum, by means of the over-distention ofthe right cavities kept up by it. The progress of the disease is very variable. In most cases the sufferers are cut off early, in infancy or childhood, in the midst of one of the suffocative pa- roxysms : in some instances a precarious existence has been prolonged to middle life, or even to advanced age. One of the cases alluded to by M. Louis reached to the fortieth year, and another to the fifty-se\7enth, and then terminated by the supervention of a new disease. The treatment of this affection is simply palliative, as its organic cause is irremediable. The judicious management of co-existing diseases in the heart and other organs, together with exemption from mental and corporeal excitement or over-exertion, and from every thing Avhich might hurry the breathing or the pulse, the early reduction of all inflammatory attacks, the enjoyment of a pure mild air, the avoidance of cold and damp, together Avith great temperance, and a due regulation of the digestive functions, and the promotion of all the natural ex- cretions, are the points tOAvards which attention should chiefly be directed. * The murmurs indicative of a communication between the two sides of the heart, though not yet fully ascertained, Dr. Hope conceives would be nearly as follows :—" An unusually loud and superficial or near sounding murmur with the first sound, immediately over the semi-lu- nar valves (i. e„ about opposite to the inferior margin of the third rib) is generally seated in the mouth of the right ventricle, and may proceed either from a contraction of the pulmonic valves or orifice, or from an opening out ofthe right into the left ventricle, or from both these lesions conjoined. If it proceed from contraction of the pulmonic valves or orifice alone, it will be audible along the course of the pulmonary artery, up to the second intercostal space, much more distinctly than along the course of the aorta, and will be attended with a thrill. If it proceed solely from an opening out of the mouth of the right into the left ventricle (the pulmonic orifice being either healthy or totally obliterated,) it will be more audible along the course of the aorta than along that of the pulmonary artery. If it proceed from the double lesion, viz., a contracted pulmonic orifice, and an opening into the left ventricle, it will he loudly audible along the course of both vessels, and a thrill will be felt over the pulmonary artery. When these signs of a lesion in the mouth ofthe right ventricle coincide with cyan- osis, the evidence of a communication between the two sides of the heart is almost positive; and as hypertrophy of the right ventricle is usually a concomitant, its presence is a corrobo- rative circumstance. When the signs in question do not coincide with cyanosis, an appeal must be made to the history of the case. If it appear that the patient has exhibited the symp- toms of organic disease of the heart from early infancy, yet has never been affected with endocarditis,^ which the valvular disease could be ascribed, there ure strong probabilities of a congenital malformation, and presumptions of a communication between the two sides, though without so considerable an intermixture of blood, or so great an obstacle to its ingress into the lungs, as suffices to occasion cyanosis.—Author. ( 593 ) DISEASES OF ARTERIES. FUNCTIONAL DISEASES OF ARTERIES. Functional disorder ofthe aorta and arteries arising from it.—Neuralgia.—Inordinate pulsa- tion.—Treatment. In treating of the disorders of the arterial system which fall more particularly under the care of the physician, we commence with those of a purely functional kind, passing afterwards to others of an inflammatory and of an organic nature. 1. Neuralgia. The most remarkable of the nervous and functional derange- ments of the arterial trunks, consist, first, in an intense neuralgic pain in their course, having its seat most probably in the minute ramifications of the ganglionic nerves which form a close network around them and penetrate into the substance of their Avails; and, secondly, in such inordinate pulsation as is independent of any appreciable inflammatory action or organic change in their coats. Both of these affections may exist simultaneously; but the latter, or increased force of pulsation, occurs much more frequently alone, and the affected artery generally presents during its continuance the additional phenomenon of bellows-murmur, which is occasionally audible at the same time in other portions, also, of the arte- rial system. This sound is ascribed by Bouillaud, Williams, Piorry, and most others who have alluded to it, as we have already seen, to constriction of the tube in which it originates; whilst Dr. Corrigan, on the contrary, recognises its imme- diate physical causes in the laxity of the coats of the vessel below such obstruc- tion facilitating their vibrations, and in the current-like flow of the blood which plays against them and throws them into tremulous motion (p. 263.) The occa- sional existence of a variable and intermitting bellows-murmur behind the upper part ofthe sternum, in the absence of all evidence of organic disease, shows that the thoracic portion of the aorta, or the great vessels arising from it, may some- times be the seat of increased action of the kind here spoken of; but it is in the upper part of the abdomen, Avhere the aorta and its branches fall more within the reach of the sense and touch, and where their vitality is most exalted, if Ave may judge by the innumerable nervous filaments by which they are embraced and penetrated, that this phenomenon is most frequent, and has particularly attracted attention under the title of— 2. Inordinate, abdominal, or epigastric pulsation. The diastole of the abdo- minal aorta, which may often be distinctly felt, even in the natural state in thin individuals, on making firm pressure with the points of the fingers in the epigas- trium, a little to the left of the median line and downwards, becomes in the mor- bid condition here spoken of much augmented in force, and disagreeably per- ceptible to the subject of it, who, in addition to the physical uneasiness caused by it, suffers still more from the alarming apprehensions he often entertains as to its nature and tendency. It was frequently, indeed, mistaken even by medical men in former days for evidence of the existence of aortic or cceliac aneurism, till in the progress of pathological investigations, and especially those made by Mor- Vol. II.—75 594 FUNCTIONAL DISEASES OF ARTERIES, (Pulsation.) gagni, and subsequently by the late Dr. Baillie, it became certain that it was alto- gether independent of organic disease in a very great proportion of these cases where it occurred. But though epigastric pulsations have thus been deprived of much of their for- midable character, it still remains in many instances dubious to what particular state they owe their origin, the cause by which they are induced, as well as the precise condition of the vessel in which they have their seat, being both often almost equally obscure. It is even sometimes very difficult to decide whether it is not in the coeliac axis or some of the subordinate branches of the aorta rather than in this vessel itself that they take place. Their variable and intermitting nature, the suddenness of their appearance and cessation, the freedom from any severe fixed pain in the spot or in the surrounding viscera, as well as in the cor- responding portion of the spine, such as might indicate internal pressure, toge- ther with the absence of all evidence of mechanical obstruction to the circulation or permanent alteration in the caliber of the vessel, prove them to be altogether independent of organic narroAving of the artery on the one hand, as well as of its enlargement or aneurism on the other. The pulsation, occasionally accompanied by a feeble murmur, especially when in the horizontal posture, is confined to the natural line of the vessel, its extent in the lateral direction being much more limi- ted than in the longitudinal, as becomes manifest on making firm pressure with the stethoscope successively over its course, and to each side of it: and though it may sometimes be accompanied by a degree of fulness in the epigastric region, yet this is commonly readily distinguishable from that caused by aneurismal tumour, by its being of less definite outline, as well as less permanent, depending as it often does on flatulence or faecal accumulation in a portion of the colon or of the small intestines, which has the effect at once of irritating the vessels by compression, and of conveying towards the surface the bellows-murmur and im- pulse so produced. The short jerking impulse, moreover, is commonly very different from the gradual and expansive heaving of an aneurism. The attentive consideration of the accompanying symptoms will tend still farther to elucidate the diagnosis. Pulsation of the kind alluded to is peculiarly frequent in hypochondriacs, and, in those whose digestive organs are deranged, or in whom an habitual effusion of blood from the haemorrhoidal veins has suddenly ceased, as Avell as in indi- viduals of a highly nervous temperament, in anaemia, and particularly in hys- terical and chlorotic females, when labouring under deficiency or irregularity of the menstrual evacuations. Its connexion Avith a disordered state of the abdo- minal nerves is recognised by Senac, Albers, Burns, Laennec, and Hope. M. Dance conceives it to originate more particularly in a morbid state of the func- tions of the solar plexus, its ganglia and ramifications, an opinion which has likeAvise been advocated by Dr. Law and many others, and very recently sus- tained with much zeal by Mr. Faussett, who, however, at the same time depre- cates the idea of its being a merely nervous affection in the common sense of the term, as he believes that there exists in every instance more or less congestion of the ganglionic centres, as Avell as of the viscera which they supply, these pro- bably reacting mutually on each other, and as Avell as on the walls of the aorta through the medium of the nervous filaments distributed to them. That such a local plethora exists, or even in some instances a state of sub-acute inflammatory action, he is led to believe by the frequent presence of tumefaction in the epigas- tric region, accompanied by tenderness on pressure, and a sense of anxiety or sinking at the pit of the stomach, or just over the suspected ganglia; as well as from the efficacy of active depletory measures in the reduction of the morbid pulsation and attending symptoms. It is indeed now generally admitted that abdominal plethora is concerned in the production of the pulsation in question in a great many instances, but the peculiar temperament and the state of the heart's action in particular are also very important elements in perhaps a still greater number. Some Avriters, amongst whom Dr. Johnson is to be classed, seem dis- functional diseases of arteries, (Treatment.) 595 posed to confine its occurrence to those cases in which there is either an excited state ot the arterial circulation generally (so often observed in connexion with gastric irritation and its sympathetic influence on the heart,) or else a local ob- struction in the capillaries of some ofthe abdominal viscera, as in congestion and inflammation of the liver, faecal accumulation, &c, acting as it were like a liga- ture, and rendering the pulsation of the arteries leading to them more obvious. 1 wo remarkable cases have been recorded by Albers, in which this mor- bid symptom ceased immediately on the passage of abundant dark evacuations from the intestines, proving its occasional dependence on deranged secretion of the liver and mucous membrane; and a still more striking example is mentioned by De Haen, Avhere it existed in a most violent degree along with many of the Avorst symptoms of aggravated organic disease of the heart, all of which vanished at once on the occurrence of a spontaneous purging of greenish fetid matter. Cases of such happy termination must not, however, make us forgetful of the fact of the frequent connexion of aortic pulsation with real structural dis- ease of the heart, and more especially with hypertrophy. The co-existence of tenderness in the spine, in some cases of abnormal pulsa- tion, has been particularly insisted on by Mr. Teale. Dr. Baillie speaks of an instance of its sudden cessation on the supervention of gout in the extremities. Haemorrhage from the gastro-intestinal mucous membrane has been occasionally preceded or accompanied by this phenomenon, and a case of the kind, which, from the supervention of haematemesis on violent action in the aorta, had been mistaken for rupture of an abdominal aneurism, is alluded to by Dr. Law. In- creased abdominal pulsation, if attended with fever and unaccompanied by a pro- portional increase of strength of the pulse of the wrist, has been pointed out by Dr. Stokes as one of the symptoms of intestinal inflammation. Where epigastric pulsation occurs in hypochondriacal and nervous subjects it is very commonly attended by a sense of fulness and throbbing in the head, with coldness of the feet, and most frequently makes its appearance in the sedentary, and those about the middle period of life. When but of momentary duration it very often depends,—according to the remark of Laennec, the correctness of which we have had frequently occasion to verify,—on imprisoned flatulence in the super-incumbent intestine, concurring occasionally with a state of nervous excitement of the heart's action. When of a more permanent character it has been known to originate in the pressure of enlarged viscera and other abdominal tumours, Avhich at once narrow the caliber of the artery and transmit its aug- mented impulse to the surface ofthe abdomen.* Treatment. As to neuralgia affecting the arteries, it is to be combated on the same principles as when it occurs in other parts. (See Neuralgia of the Heart, &c.) On the treatment of abdominal pulsation it is likeAvise unnecessary to enter ?t length, seeing, from all that has been said above, that it is obviously nothing but a symptom. The morbid conditions from which it springs are, as we have just shown, various, and consequently the remedial measures appropriate in different cases must be no less dissimilar. It may, however, here be said generally, that the first object to be aimed at in almost every case is to get the secretions into a healthy state, especially those of the chylopoietic viscera, seeing that dyspepsia * A distinct " encephalic bellows-murmur" has been noticed by Dr. Fisher, an American physician, on the application of the stethoscope to the upper part of the head in eases of meningeal inflammation, and is supposed by him to be connected with compression of th« numerous arteries at the base of the brain. Dr. Forbes, to whose early and able advocacy the cause of auscultation has been so much indebted in this country, pointed out, many years ago, the occurrence of a similar phenomenon in the mass of the thyroid gland, when enlarged, as in cases of bronchocele,—the sound originating probably in compression of the carotids, orthpir branches.—Author. 596 arteritis, (Anatomical Characters.) and derangement of the alvine evacuations are so often present. In females, moreover, the regulation of the uterine functions is never to be overlooked. Where there is evidence of a plethoric condition of the organs within the ab- domen, in addition to the steady use of mild aperients, especially of the saline class, together with the occasional exhibition of a mercurial purge, restriction to a vegetable or farinaceous diet, and the renunciation of wine, coffee, and other sti- mulants is indicated; and in addition to these measures the local abstraction of blood, either from the epigastrium or haemorrhoidal vessels, or in some instances even general blood-letting, may be proper, along with counter-irritation, either over the seat ofthe abdominal pulsation, or in the portion ofthe spine just oppo- site to it, which latter situation should of course have the preference in those cases where spinal irritation co-exists. In particularly obstinate cases, Avhere the pulsation and visceral congestion with which it is associated are the source of very serious and prolonged annoyance to the patient, it may be justifiable to fol- low the example of Mr. Faussett, and employ, in addition to the antiphlogistic remedies already detailed, mercury in combination with antimony and sedatives in such a manner as slightly to affect the mouth, and subdue any existing local determination. Hohnbaum, a recent German writer on the subject of epigastric pulsation, having himself suffered for years from it in connexion with various dyspeptic symptoms, venous plethora of the abdomen, debility of body, and despondency of mind, found more relief from the use of the aperient waters of Carlsbad, along with the accompanying change of air and scene, and relaxation from the fatigues of his profession, than from all the very numerous and diversified methods of treatment he had previously essayed. Where a chlorotic or anaemic, a nervous or irritable state of the system consti- tutes the predominant feature of the case, all weakening losses of blood and ex- cessive evacuations should be controlled; and the employment of tonics, and more especially iron or bark; the tepid or cold shower bath, are called for, along with a liberal supply of light nutritious food, the enjoyment of a dry bracing atmo- sphere, and daily exercise in the open air. These, together with early hours, cheerful society, and freedom from anxiety of every kind, are the means which give the patient the best chance of at once getting rid of the annoying symptom we have been considering, as Avell as of the numerous associated derangements in other parts. ARTERITIS, OR INFLAMMATION OF ARTERIES. Anatomical characters and effects of arteritis.—Predisposing causes.—Exciting causes.— Symptoms.—Treatment of arteritis and its consequences. There has been much difference of opinion amongst pathologists as to what constitutes adequate anatomical evidence of the existence of arteritis: redness alone certainly does not, as staining of the inner membrane, and even of the cel- lular tissue on its adherent surface, is often a mere cadaveric phenomenon, the joint result of softening of the tissue from incipient putrefaction, and of the con- tact of the contained blood, which, especially when in a fluid or imperfectly co- agulated condition, as for example in typhoid diseases, or after a long final agony in various chronic disorders, readily affects, by imbibition, the interior portion of the arterial tubes. Redness from this source is most apt to be met with when the temperature is elevated, and the examination of the body has not been made till several hours after death. arteritis, (Anatomical Characters.) 597 mm b* lnvestlSation of this subject, a vast number of horses were opened by MM. Kigot and Trousseau at various intervals after they had been slaughtered, and they assert that in no instance did the appearance in question present itself to their notice when sought for immediately after the creature had fallen, though it was common enough after the lapse of some hours; a fact which proves that redness of the arteries proceeding from a morbid or vital action, must be, at least in these animals, of very rare occurrence. But we must here beware of genera- lizing too hastily and exclusively. In particular epidemics amongst horses, such as that Avhich existed at Paris in 1825, and which was characterized by gastro- enteritic symptoms, and a difficulty of breathing independent altogether of pulmo- nary inflammation, redness of the interior of the arteries as well as of the heart, apparently of an inflammatory nature, was occasionally detected by Dupuy, Bouley, and Andral, even immediately after the diseased animal had ceased to breathe. All analogy, indeed, would prepare us to expect that inflammation should sometimes originate spontaneously, or at least independently of all direct external injury, in the membrane in question. In the human subject, where we find a diffused redness of the internal tunic, delicately shaded off on its edges, accompanied by softening, pulpy thickening, and infiltration of this and of the middle coat and their connecting cellular membrane, along with unusual facility of their separation, and distinct increase of vascularity in the same situations, the probability of these changes depending on inflammatory action is very strong; and where coagulable lymph or pus has been effused on either the free or the at- tached surface ofthe lining membrane, or ulceration taken place, the evidence of the existence of this morbid process becomes complete. Now all these appear- ances have occasionally, though rarely, been met with independent of all external violence done to the vessel, proving sufficiently that the arterial tissue enjoys no absolute exemption from spontaneous inflammatory action. The middle or fibrous coat in these cases loses much of its natural elasticity, and becomes re- markably fragile, and even the external or cellular one, though much less prone to disease, is somewhat softened and less capable of suffering distention with im- punity. It is obvious that from the facility with which morbid effusions are washed away by the passing blood, there may be many incipient cases of real inflamma- tion in the interior of the vessels, as to the true nature of Avhich, as judged of by the appearances on dissection alone, Ave shall yet remain in doubt, in consequence of the absence of the most characteristic and indisputable of the evidences men- tioned above. It has been satisfactorily proved by M. Bizot, by tracing the transformation step by step, that the white cartilaginous patches so often observed in the interior of the arteries originate in the albuminous exudations of acute arteritis, which, at first of a viscid gelatinous consistence, and of a pale or rosy hue, become gradually whiter and firmer, and eventually supplant the lining membrane, on the inner or free surface of which they were originally poured out. The result of his re- searches does not, however, countenance the common opinion of these patches being a preparatory state to ossification; for he has never succeeded in detecting them in the state of transition. (Brit, and For. Med. Rev., No. xi.) The ulcerations occasionally observed in the lining membrane are very com- monly connected with atheromatous or osseous depositions in the fine connecting cellular membrane between it and the middle coat, which by the pressure and irri- tation to which they give rise eventually make their way through the delicate inner tunic, so as to come into actual contact with the blood. Whether these deposites ordinarily originate in a local inflammatory process of a sub-acute or chronic character, is still a litigated point; but as to their influence in destroying the elasticity and producing ulceration and perforation of the coats, gradual aneurismal tumours, or sudden and fatal rupture of the vessels, there can be no question. Sometimes all the layers of an artery are found of an unnaturally white colour, 598 arteritis, (Anatomical Characters.) and more opaque and less elastic than usual: a condition in which, obviously, they can no longer respond to the heart's impulse with the same safety to their own tissue. The atheromatous patches so often observed in the aorta and larger arteries, consisting of matter of a cheesy friable consistence and yelloAvish hue, commence, according to Bizot, who has very minutely investigated this point of morbid ana- tomy, by innumerable minute granules of a pale yellowish colour, situated between the middle and inner coats, adherent to both, and unattended by any redness or trace of inflammatory action in the surrounding tissues. These granules, as they accumulate, coalesce into groups or masses, which subsequently may become the seat either of a process of ulcerative softening, or else of ossification. When the former of these two changes occurs, the softened matter in some degree resembles pus, and the appearance so produced has by some observers been described, but erroneously, as an abscess or a pustule in the interior of the wall of the vessel, whereas it approximates in reality much more nearly to the process by which tu- bercles become softened. The calcareous deposite commences by minute, hard, semi-transparent specks in the substance of the atheromatous patches, especially Avhere in contact with the middle coat, which becomes wasted beneath their in- fluence, as does likewise the inner membrane even to its total destruction. As the atheromatous matter frequently lines the back of the whitish or cartilaginous patches mentioned above, and may equally here become the seat of bony deposi- tion, the common error of ascribing the osseous scales, in general, to the transfor- mation of previously existing cartilage is, in some degree, accounted for. The smaller arteries may be entirely obstructed by these morbid deposites, and the elasticity of the larger being greatly impaired, they readily become the subjects of gradual dilatation. These perversions of nutrition take place at a much earlier period of life in the lower extremities than in the upper, and generally in symme- trical order; that is, the same arteries and corresponding portions of them become, for the most part, almost simultaneously affected on the two sides of the body. The yellow spots make their appearance first in the arteries nearest the aorta; the ossific deposites, on the contrary, earliest in those most remote. Arterial lesions are most frequent in the proximity ofthe branchings ofthe vessels. The extent to which calcareous degeneration may take place is very considera- ble, as it manifests itself sometimes not only in the aorta and its primary branches, but also in the arteries of the heart, brain, and extremities, which may thus be converted into rigid tubes, or haA'e their interior irregularly lined Avith a scaly de- posite like loosely adherent fragments of egg-shell, a condition which interferes much with the natural functions of these vessels, and lays the foundation for apo- plexy, aneurism, gangrene, and other formidable species of disease. It adds much, likewise, to the uncertainty of the result of all surgical operations in which vessels have to be tied, both on account ofthe risk of secondary haemorrhage, and also, in some cases, from the difficulty of the establishment of the supplementary or col- lateral circulation. According to Morgagni, sudden death is not unusual in indi- viduals in whom no other morbid appearance is detected besides numerous ossific scales, or ulcerative depressions in the spots where these scales have become de- tached. A very singular case has been recorded by Dr. Abercrombie of the total cessation of pulse in every artery in the body except the carotids, in consequence of ossification of their coats; and a still more remarkable one is detailed by Mr. Adams, in the Dublin Hospital Reports, where there was no pulse at all in any part, and even at the heart no indication of motion beyond a very feeble undulating sound. On dissection the aortic valves were found ossified, and the coronary ar- teries of the heart obliterated for near an inch at their origin,—a state of things which accounted at once for the diminished action of the heart and impeded flow ofthe blood. The principal remaining symptoms were dyspnoea and sleeplessness, of many Aveeks duration, terminating in stupor and death. In a case spoken of by Andral, in Avhich the pulse in the left Avrist was peculiarly feeble, a round cre- taceous tumour Avas discovered on dissection within the brachial artery, nearly arteritis, (Anatomical Characters.) 599 filling its caliber. Such loose concretions originate probably, for the most part, in the walls of the vessel from which, in process of time, they become detached, and may be the source of complete obstruction in the smaller branches. All the morbid deposites above spoken of are of peculiarly frequent occurrence in the aorta, especially about its commencement and arch, and account, in part, for the very great frequency of dilatation in this portion of the vessel. Ossifications are of so common occurrence in advanced life, that their absence noAV excites more surprise than their presence. That they should be so much more frequently met with in the aged than in the young shows that, even if their origin be some- times determined by chronic inflammation of the coats of the vessel, still a certain predisposing condition of the system is, at least, equally concerned. The arte- ries of the young are not, however, altogether exempt from this change, and ex- amples of it have been discovered even in the bodies of infants. Its extensive existence, at a later period of life, serves to account for some anomalies in the pulse of old people, its hardness and occasional difference at the two wrists, and the slight degree in which it is effected by venesection, as well as for the diffi- culty with which the circulatory system, in many instances, accommodates itself to this evacuation. Ossification of the vessels is almost confined to those which carry red blood: it has, however, in some very rare instances, been noticed in the pulmonary ar- tery. The cartilaginous change is less infrequent. The inner membrane of arteries is sometimes found in a state of chronic soft- ening; and, when in such a condition, its laceration may be determined by very slight causes, such as would have no influence on it in a state of health. In some very interesting cases of this kind, which have been published by Mr. Turner, portions of the interior lining were found retracted and rolled up within the canal of the vessel. In this manner, and by the accompanying effusion of plastic lymph and the formation of a coagulum of blood, the artery may become completely ob- structed and obliterated in a portion of its course; all pulse below the spot ceasing immediately on the occurrence of the accident. The seat of the local lesion is commonly indicated by the sudden supervention of pain and swelling. Occasion- ally the arteries of the upper and of the lower extremities become thus affected in succession on the employment of the slightest exertions, indicating a very ex- tensive affection of the arterial system. In most of the cases recorded there had been previous febrile symptoms of some continuance and originating commonly in cold. Paralysis and gangrene of the limb, and death, were occasional conse- quences ofthe impervious state of the artery. The cold dead state of the part was, in some instances, supplanted by obvious inflammatory reaction on the re- establishment of the collateral circulation. In a case which occurred to Dr. Aber- crombie ulcerations were found to co-exist Avithin the aorta; and this, as Avell as the cause and symptoms of the disease, all seem to point to an original inflamma- tory action as the source of the softening of the vessel. Some interesting cases bearing on this connexion of gangrene with arteritis have also been published by Dr. J. Graves and Dr. Stokes in the 5th vol. of the Dublin Hospital Re- ports. The obliteration of arteries may also take place from the mere inflammatory thickening of their coats, or the effusion of lymph into the cellular membrane connecting them, or into the interior of their canal without any previous rupture of the inner coat. Even the innominata has been found almost filled by an unna- tural growth from, or hypertrophy of, its lining membrane, and the aorta itself, quite independent of congenital narrowing, has thus, in more instances than one, been detected in a state of perfect obliteration, whilst the arteries which arose above the obstructed point, being much dilated, in a great degree supplied its place. The thoracic aorta has, in several instances, exhibited an abrupt constriction, especially at that point where the ductus arteriosus penetrates its coats; a condi- 500 arteritis, (Symptoms.) tion attributed, with much probability, to the communication of the contractile action naturally taking place in this passage at the period of birth to the adjacent fibres of the arch. Amongst the predisposing causes of arteritis have been enumerated a plethoric and irritable state of the body, habitual over-distention of the vessels by frequent violent exertions, the excessive use of spirituous liquors, and hypertrophy of the heart, as likewise a gouty or rheumatic habit, to which Scarpa, Hodgson, and some others have added, on more dubious evidence, the morbid conditions of the constitution induced by the poison of syphilis, or the long-continued use of mercury. The exciting causes of inflammation of arteries, independent of wounds, pres- sure or ligature, sudden and violent elongation of the vessel, and other external injuries by which the inner coat is so often lacerated, may be referred generally either to exposure to cold, violent mental emotions, excessive bodily fatigue, or else to the spread of inflammation from the cyst of an abscess or ill-conditioned or gangrenous ulcer; to unhealthy pus and various morbid poisons, such as that generated in puerperal and other malignant fevers, glanders, &c, introduced into the torrent of the circulation; and, finally, to the repulsion of measles or small- pox, scarlatina, or erysipelas, or other acute cutaneous inflammations. In several of these latter cases the inflammation of the lining of the vessel has presented somewhat of an erysipelatous character, spreading rapidly towards the heart from being unattended by any effusion of coagulable lymph by which its progress might be limited; Avhilst the accompanying fever is commonly of a low or malig- nant kind. The symptoms of arteritis even in its acute form are very obscure. Those usually ascribed to it are, increased energy of pulsation in the inflamed vessel, a sense of heat and pain along its course, together with restlessness, extreme anxiety, and a frequent feeling of sickness or faintness, and all the other common sympa- thetic effects which the inflammation of any important part of the body exerts on the heart, brain, skin, digestive organs, &c. The opinion of Frank, that arteritis gives rise to a peculiar fever of great inten- sity, has not, however, been confirmed by subsequent observers. In the carefully noted cases of Mr. Turner, already alluded to, the fever did not usually run very high: nor indeed is there any one of the symptoms enumerated above, which can be considered as truly characteristic. We are not as yet, it must be confessed, in possession of any unequivocal diagnostic mark ofthe mflammation spoken of: and it is for the most part only by negative signs that we can attain even to a probable suspicion of its existence when it occupies the interior of the body—namely, by the absence of all evidence of any other thoracic or abdominal inflammation, aneurism, or other tumour pressing on the vessel in its course, as well as by the absence of reaction from the loss of large quantities of blood, or of the nervous pul- sations already described, and in short of every other cause by Avhich either the energy ofthe action ofthe suspected artery might be augmented in the first instance, or its channel subsequently obstructed. As the disease proceeds, if a large extent of the arterial lining becomes impli- cated, or effusions of a purulent or sanious character take place into the canal of the vessel, the accompanying fever changes from the inflammatory to a low typhoid type, the pulse becoming very quick, feeble, and unequal, the respiration hurried, the capillary circulation embarrassed, and at length muttering delirium and spas- modic tAvitching ofthe limbs supervening, the scene soon closes, and on dissection effusions are often found to have taken place into the several serous cavities. Where, however, healthy coagulable lymph has been effused, and the inflammation thus limited to a single artery, the caliber of Avhich becomes obstructed, and the communication Avith the rest of the system impeded, the effects ofthe morbid pro- cess are of a less rapid and certainly fatal character. If it be confined to the artery of a limb the part becomes pulseless, incapable of motion, cold, swollen, and pur- arteritis, (Treatment.) 801 plish; large vesications making their appearance, and fully formed gangrene even- tually ensuing, whilst the ultimate result depends mainly on the patient's consti- tution and remaining strength. Treatment of arteritis and its consequences. Where, after a scrupulous exa- mination of the symptoms, both negative and positive, there appears a very strong presumption for the existence of inflammation of the aorta or other large internal artery, either alone, or, as pathological researches show to be so commonly the case, in combination with serious disease of a similar nature in some ofthe viscera to which their branches are distributed, active antiphlogistic measures are imme- diately to be resorted to, general and local bleeding, aperients, antimonials, and diluents, together with strict confinement to the horizontal posture and perfect quietude. If the inordinate pulsation, the fever and other distressing symptoms, be not then very speedily reduced, the exhibition of mercury so as to affect the consti- tution, provided there be not a decided contra-indication to its employment in the state of the patient's strength or general habit of body, together with digitalis or colchicum to keep down the heart's action, and narcotics to assuage pain, form our chief remaining resources. At a somewhat later period, or in a more chronic form ofthe affection, active counter-irritation by blisters, tartar-emetic ointment or croton oil should also be practised. With a view to controlling the occasional chronic consequences of arteritis, and limiting more especially the progress of osseous deposition (which whether or no it be ever in its essence an inflammatory process, seems at least most prone to take place in parts which have been once the seat of inflammation,) as well as to retard the secondary affections dependent thereon, as aneurism, apoplexy, &c, the most rational plan of practice appears to Consist in such a regulation of the diet, secre- tions, and excretions, as may at once keep the action of the heart moderate, obviate plethora, and subdue any tendency to sub-inflammatory action Avhich may exist, without at the same time too much enfeebling the system. The greatest modera- tion in respect to fermented liquors and animal food should be enjoined, as the free indulgence in their use is well known to produce the very states which it ought to be our chief aim to avoid, and in a particular manner to augment the tendency to arthritic or calcareous deposites throughout the body. Depletory measures car- ried to a moderate extent should be very early had recourse to on the occurrence of inflammatory action in any part of the system, or Avhere there is evidence of any unusual degree of vascular repletion, lest the Aveakened vessels should give way under the temporarily augmented action of the heart: and in general even when the patient is in his average state of health, the action of the liver and bowels as well as of the kidneys and cutaneous surface should be promoted, and the func- tions of the stomach which are so often, especially in gouty subjects, inadequately per- formed, should be corrected and strengthened. Regular but very moderate exer- cise in the open air is to be enjoined, together with the scrupulous avoidance of all those agencies, physical or moral, by which the circulation might be deranged or unduly accelerated. Inflammation ofthe aorta is not susceptible of even probable diagnosis except when it occurs in the aorta, especially at the arch. It then offers the usual characters of inflammation; that is, a quick active pulse, often With unusual degree of vascular excitement. The local signs are throbbing in the region of the aorta, which is distinctly felt by passing the finger above the top of the sternum, and by ausculting at the bend of the front bone. The sound on per- cussion is not usually altered. In many cases oedema may occur as an additional sign, but it is one which is quite secondary, and in itself of little importance, because it does not occur in the majority of cases; it will, however, corroborate the other symptoms. It is clear, therefore, that the direct signs of aortitis are not conclusive, and we are obliged to trust to the negative evidence of exclusion ; and if we find that the oppression ofthe respi- ration and the excitement or uneasiness about the chest cannot be accounted for, by any obvious Vol. II.—76 602 aneurism of the aorta, (False and Hernial.) disease of the heart or lungs, we arc obliged to admit the probability of aortic inflammation; this is converted into certainty if tho local signs be present. The diagnosis, although not ab- solutely certain, is less difficult than is often supposed, for there are few cases in which a sufficient number of symptoms cannot be discovered. G. ANEURISM OF THE AORTA. Varieties—true—false—mixed—hernial.— Comparative frequency in the sexes.— Predis- posing causes.—Symptoms of aneurism ofthe aorta and effects on contiguous structures.— Spontaneous cure.—Aneurism of the thoracic aorta.—Aneurism ofthe pulmonary artery.— Aneurism ofthe abdominal aorta.—Treatment of aortic aneurism. An artery may become abruptly enlarged in some parts of its course either by means of the simultaneous dilatation of all its coats from their being peculiarly weak and deficient in elasticity at the affected point, or else by the rupture of the inner and middle coats and the subsequent gradual distention of the outer or cel- lular one. In both these forms of aneurism the surrounding portions ofthe artery almost invariably present obvious marks of alteration both in colour and texture, the strength and elasticity of the vessel being very commonly remarkably impaired either by atheromatous or osseous depositions or both, and where the lesion is of recent origin, the inner membrane being sometimes of a bright reddish hue mot- tled Avith white spots. The first of the two A*arieties of aneurism just mentioned constitutes the true aneurism of systematic writers, and may either implicate the entire circumference of the vessel in one or more points in its course, giving to it for the most part an ovoid or fusiform outline at these portions, or else, as has been observed in some very rare instances, it may be confined to one side of it, and so form a hollow lateral protuberance or pouch communicating freely Avith the arterial tube. The reality of this latter form of true aneurism, though doubted by Scarpa and some other distinguished pathologists, has yet in a feAv cases been fully ascertained by subsequent investigators, by carefully tracing all the membranes of the vessel in unbroken continuity in the parietes of the appended tumour. The tunics thus dilated have in some instances appeared of their natural thickness; but more commonly they are thickened decidedly in some spots, and attenuated in others, as becomes obvious from their unequal transparency on vieAving them against the light. True aneurisms have been divided by Breschet into the sacculated, the fusi- form, the cylindroid, and the varicose. The second is the most ordinary form: in the cylindroid a large extent of the artery longitudinally is implicated, as like- wise in the varicose in which it becomes tortuous and knotty from the irregular dilatation ofthe walls ofthe vessels Avhich are here peculiarly thin and flaccid. The term false aneurism is applied to those more common cases alluded to above, where the inner and middle coats being either ruptured by violence, per- forated by ulceration, or lacerated by the detachment of a scale of osseous matter, the outer or cellular coat becomes exposed to the distending impulse of the circu- lating blood, by Avhich, as Avell as by the pressure of the accumulating coagulum which soon forms in the depressed surface, it is gradually dilated into a pouch which communicates by an aperture of greater or less size with the canal of the artery. Sometimes again this laceration of the coats is consecutive, supervening upon their inordinate distention in cases of true aneurism; and here the false aneurism aneurism of the aorta, (Symptoms.) 603 surmounts the tumour previously formed by the true, and to this compound lesion the name of mixed or consecutive false aneurism is commonly given. The outer coat of the artery growing gradually thicker, and being for the most part still farther strengthened and supported by the cellular membrane exterior to it becoming condensed and closely adherent to its outer surface, is frequently capable of resisting for a great length of time the internal distending force. The contained blood moreover coagulates within the sac in concentric layers, which increasing in density as they are older and more external, and becoming occasion- ally consolidated with the walls ofthe aneurism, add in a remarkable degree to its power of resistance. In true aneurism, especially when occupying the whole con- tour of the vessel, the formation of laminated coagula is much more rarely ob- served than in the false species, in consequence of the freer circulation ofthe blood through the cavity in the former; and in the few instances where it has been met Avith here, the inner membrane was usually found to have been considerably roughened either by ossific deposite or else by effused lymph, a condition pecu- liarly favourable to the retardation ofthe blood and its coagulation. In addition to the forms of aneurism already mentioned, there is yet a rarer species which has been met with by Dupuytren and others, where the outer and middle coats being alone perforated, the inner one protrudes through them, thus forming what has been called a hernial aneurism. Where an aneurism commences by the rupture of some of the coats of an artery in consequence of violent muscular exertion, there is reason to believe that the vessel must have been previously in a morbid state, either from steatomatous, osseous, or other degeneration: for the partial laceration of a sound artery in place of leading to its dilatation would rather, as Dr. Jones's experiments evince, give rise to the effusion of coagulable lymph and the obliteration of its canal. For the determination of an aneurism, however, something more than the mere morbid state of the vessels above alluded to would seem to be indispensable, for whilst aneurism is peculiarly the disease of the prime of life, these other lesions predomi- nate more remarkably in advanced age. And again, notwithstanding the great frequency of aneurism in men as compared with women, there is no equivalent disparity in regard to the occurrence of these other preliminary morbid alterations; and finally, Avhilst these latter, as we have seen, for the most part occur in a sym- metrical manner, that is, attack corresponding arteries of the two sides ofthe body about the same period, no such law is observable in respect to aneurism.* In regard to the influence of sex, it would appear from a large number of cases analyzed by Mr. Hodgson, that aneurism, if all kinds be taken promiscuously, is more frequent in men than in women, in the proportion of eight to one. With regard to internal aneurism, however, their relative frequency in the male sex as compared with the females is by no means so disproportionate as this; probably from their origin here being commonly more independent of external injuries, vio- lent efforts, &c. Of the predisposing causes. One ofthe most influential, as has been remarked by Mr. Guthrie (and our own experience is quite in unison with the observation) is the inordinate use of spirituous liquors, by Avhich apparently a sub-inflamma- tory condition ofthe coats of the vessel is induced, leading to their gradual soften- ing and disorganization, whilst at the same time the force of the heart's con- tractions is inordinately increased to such a degree that the weakened artery is no longer capable of sustaining them with impunity. Enlargement of the heart often arises pari passu with disease in the great vessels, and the disturbance in the cir- culatory system is thus raised to its highest pitch. Violent blows or falls, and sudden vehement muscular efforts, have appeared in some instances indubitably the determining cause even of internal aneurism. Symptoms. When the aneurismal tumour is so situated as to be Avithin reach of tiie touch, it is generally sufficiently characterized by its expansive pulsation j Bizot, loco citato. 604 aneurism of the aorta, (Causes—Symptoms.) and even where it lies without the limits of immediate examination, it for the most part eventually gives rise, by its pressure on surrounding parts, to a variety of symptoms, from which its presence may often be at least very strongly suspected. Thus mechanically it may cause displacement and deranged action of various or- gans in its immediate neighbourhood, and at length absorption of their structure, as well as fatal haemorrhages into their substance or cavities. When nerves are compressed by it, pains like those of neuralgia are the consequence; when it comes in contact with bone, even this dense texture yields to the wearing influence and is destroyed to a greater or less depth, a result often observed in cases of aneurism of the thoracic and abdominal aorta, in which the sternum, ribs, verte- brae, and even the shqulder-blade may be perforated by it. Cartilage, on the con- trary, very often escapes, having a much greater power of resisting the influence of the constant pressure and pulsation than the harder osseous tissue, probably in consequence of the elasticity and lower degree of organization of the former; and accordingly we often find even where the vertebrae have been extensively removed, the intervertebral cartilages still almost uninjured, though actually bathed in the fluid contents of the sac, the parietes of which are themselves so prone to be absorbed under the reactive pressure of contiguous organs. The compression of the spinal cord by an aneurismal tumour, as well as by the ef- fusion of its contents into the vertebral capal, has been known to induce sudden paralysis. An aortic aneurism may farther give rise, according to its situation, to compression or perforation of the pulmonary artery, or vena cava, or even of the cavities of the heart itself* the thoracic duct, oesophagus, trachea, bronchi, lungs, Stomach, intestines or bladder; or it may open immediately into the pleural or peritoneal sacs, or into the cellular membrane behind them. The contiguous ves- sels may be contracted or obliterated by the pressure, the nerves flattened, and the muscles wasted in a remarkable manner. The periosteum of the bones with Avhich it comes in contact may be either thickened or absorbed, or even, as Andral has pointed out, become the seat of an abundant secretion of osseous matter, increasing the tumour, and restraining in a certain degree its farther growth, and retarding its rupture. The sac itself generally becomes at length the seat of increased action, and its perforation is commonly the eA'entual result, which in its turn leads to a haemorrhage, for the most part at once fatal; unless, as sometimes happens, the power of resistance in the surrounding cellular mem- brane, condensed by the previous pressure and matted together by effused lymph, is such as to enable it to limit, at least for a time, all farther effusion of blood. In this latter case a new sack, as it Avere, is formed around the original one, and thus what is technically called a diffused false aneurism is formed. But diffused aneurism may also originate in a primary form, by the simultaneous rup- ture of all the coats of the vessel in the very first instance, without the formation of any sac, and the immediate pouring out of the blood into the lax and unaltered cellular membrane, or into one of the great serous cavities in its neighbourhood. Where the tumour bursts through the skin, or into a canal or cavity lined by a mucous membrane, these textures appear to be destroyed by a sloughing process; whereas in the case of serous membranes, the rent is effected by laceration from over-distention. The patient may, however, be cut off Avithout the intervention of rupture or haemorrhage, by the mere effect ofthe compression ofthe surrounding parts, the oesophagus, air-passages and lungs, the nerves, thoracic duct, or large veins, giving rise to inanition, or asphyxia, exhausting pain, or cerebral compres- sion. Congestion and inflammation ofthe mucous membrane and parenchyma ofthe lungs are very frequent results, especially when the disease is seated in the tho- rax. But aneurism happily does not always terminate fatally, whether by rupture * In a remarkable case recorded by BeauchGne, the aneurism burst into one of the au ride*. G. aneurism of the aorta, (Symptoms.) 605 or any of the other modes just enumerated. On the contrary, in some few in- stances a spontaneous cure ensues, either by the gradual condensation of the coagula, and the contraction of the walls of the sac, or by the pressure of its ex- terior surface upon the portion of the artery above it, the consequent obliteration of the vessel, and cessation of the distending supply of blood to the tumour, or finally by inflammation in the parietes of the cavity, either commencing there, or communicated from an abscess formed around them, and terminating either in adhesive inflammation, or in gangrene, with the formation of coagulum Avithin the artery, and its consequent obstruction. Aneurisms within the thorax may have their seat, not only in the ascending aorta, its arch, or descending portion, but also in the innominata and origin of the great vessels proceeding to the head and arms: abdominal aneurism in like manner is by no means confined exclusively to the aorta, having been met with also in most of the larger branches arising directly or mediately from it, as the coeliac axis, hepatic, splenic, gastro-epiploic, coronary ofthe stomach, spermatic, iliac, &c. The abdominal arteries, indeed, as pointed out by Professor Harrison, are pecu- liarly prone to the lesion in question, in consequence apparently of their great tortu- osity, the weakness of their proper coats and the slightness of their cellular sheath in particular, as Avell as of the little support they receive from surrounding organs, and their rapidly varying degrees of distention, in connexion with the intermit- ting nature of the functions of the organs they supply. In their incipient stage they are for the most part unattended by any symptom by which their presence can be even suspected, and it is only when their bulk and pulsations have become notably increased that attention is at length called towards them. Their effects will obviously vary much in relation to their situation, indeed more in respect to it than to their mere magnitude: thus, for example, in a remarkable case of aneu- rism of the hepatic artery, detailed by Dr. Stokes, jaundice, from the compres- sion of the biliary ducts, was a leading symptom. The coronary arteries of the heart have in some very rare instances been dis- covered in a state of aneurismal dilatation; and examples ofthe disease in its sac- culated form haA'e been met with even within the cranium, in the internal carotid, vertebral and basilary arteries. In these latter cases the symptoms have been very obscure, such as obstinate headachs, singing in the ear or deafness, with more or less derangement of the sensitive and intellectual faculties, and finally apoplectic attacks. It is probable, however, that the careful employment of the stethoscope would in some of these cases reveal the existence of a belloAvs-mur- mur and facilitate their diagnosis. It is chiefly to aneurism of the aorta, as being of most frequent occurrence, and productive of very formidable and embarrassing symptoms, that Ave mean in the remainder of this article to direct the reader's attention. Where the disease is seated in the ascending aorta or its arch—portions of the vessel, Avhich from their form and situation exposing them to the first concentrated impulse of the blood, are peculiarly liable to it—the morbid change appears much more commonly to commence as a true aneurism or general dilatation of the tube of the vessel in its whole circumference. Its inner coats may, however, subsequently give Avay, and the lesion will then present itself in the form of mixed aneurism, where a pouch of more definite outline surmounts the previous enlargement. The extent however to Avhich dilatation of all the coats is sometimes carried without rupture is enormous, the caliber of the vessel being occasionally twice or thrice as great as natural, or even more. These enlargements being commonly partial, present in most instances the ovoid or fusiform outline already spoken of, though some- times even the entire vessel to its very bifurcation being strikingly dilated, the cylindrical form is more or less perfectly retained. Sacculated aneurism takes its rise more ordinarily from the front or side of the vessel or from its arch than from its back part, Avhere it is better supported by solid parts. In extreme cases it may attain to a magnitude much greater than that of the heart itself, and if directed upwards may by its pressure distend and even 606 aneurism of the thoracic aorta, (Signs.) dislocate the sterno-clavicular articulation. Where planted near the root of the aorta, the rupture of the aneurism gives rise to the effusion of blood into the pericardial sac, as Ave should expect from the anatomical relation of the parts. The vessel in this portion of its course being destitute of the proper cellular coat, and the pericardial investment Avhich supplies its place being comparatively little capable of distention, the dilated portion generally bursts before it has attained to any great magnitude, and often without passing through the form of either false or mixed aneurism. Sometimes again the rupture of the inner and middle coat is followed apparently within a few hours by that of the outer covering, and the case thus terminates fatally almost in its very commencement Yet Scarpa was certainly in error in supposing this portion of the vessel altogether exempt from the sacculated form of the disease. Indubitable examples of it so situated have been recorded by Guthrie, Smith, Hanna, and others, in some of which the pouch Avas actually imbedded in the parietes of the heart, whilst the aperture by which it communicated with the vessel was placed either in the sinuses of the aortic valves or only a very few lines higher up. The reaction of the vessel on its contents, by which the blood receives at every systole of the artery a retrograde impulse towards the valves, has been suggested by Mr. Smith as the cause why aneurism of this part is always directed downward toAvards the heart; and an ad- ditional and perhaps equally influential reason may be found in the form of the enveloping pericardial sac, which from its pyriform shape leaves much more facility for the descent than for the ascent of the tumour. There i3 a very rare form of the disease, generally described under the name of the " dissecting aneurism of the aorta," in which the blood is found exten- sively diffused between the middle and outer coats, which are thus separated oc- casionally for the length of several inches. In such cases it is generally found on examination that the blood has made its way out of the canal through a large fissure embracing a considerable portion of the circumference of the vessel, and generally either at right angles to its axis, or very irregular, so as to allow the im- pelled fluid to play at once upon a large extent of the connecting cellular membrane and rapidly overcome its resistance: \vhereas, in the sacculated form the dilatation seems to commence on a much smaller scale, to proceed in a more gradual man- ner by the simultaneous distention and growth of the external coat, whilst the connecting cellular tissue having thus time to become consolidated, resists more effectually the insinuation of the blood between the adjacent tunics. Laennec mentions an instance of dissecting aneurism where the blood had forced its way along the greater part of the extent of the aorta. The late Mr. Shekelton has described a still more remarkable variety of the disease, Avhere the blood after thus detaching the two inner coats from the outer for some distance, re-entered the aorta again lower doAvn; thus passing along for a certain way in an adventitious collateral canal, Avhilst the original channel Avas narrowed or obliterated by the pressure; and Mr. Smith speaks of a somewhat similar case where the additional complication of a subsequent rupture into the pericardium co-existed. An interesting case is admirably described by Dr, Pennock in the American Journal, illus. tratcd by one ofthe most perfectly executed anatomical engravings which have ever been pub- lished. G. Aneurism of the Thoracic Aorta. The general signs of this affection are commonly very obscure, many ofthem being almost identical with those of disease of the heart, in complication Avith Avhich, moreover, as Ave have seen, it very often co-exists. The chief of these are such as originate in obstacle to the circulation and respiration—as palpitation, tendency to syncope, cough, dyspncea occasionally in the form of asthmatic pa- roxysms, preference for the sitting posture, Avith the body bent forwards or a little to one side, so as to relax the parietes ofthe chest, haemoptysis, frightful dreams ANEURISM OF THE THORACIC AORTA, (Signs.) 607 and other evidence of cerebral congestion, together with a livid or otherwise un- natural complexion, and finally dropsy of the serous cavities and cellular mem- brane of the extremities. But indefinite as these general symptoms are, the dif- ficulty is still farther increased by many of them being often moreover altogether absent, very slight cough and almost unnoticed embarrassment of the respiration n?ghU Several cases alone Preceded the sudden and unexpected fatal event. Of the symptoms which are someAvhat more characteristic, though obviously not absolutely peculiar to this lesion, are a sense of oppression, tightness, or wan- dering pain in the chest, tenderness on pressure in some of the dorsal vertebrae, together with pain of a boring kind in the same situation, and occasionally lanci- nating thence through the chest and towards the neck, shoulder, and arm, along with numbness, a creeping sensation and loss of power in the latter, and swelling both there and in the corresponding side of the thorax—effects of the pressure of the aneurismal sac on the brachial plexus, sub-clavian artery, and vein. Weak- ness or total absence of the pulse at one wrist, more commonly the left, is not unfrequently observed, together with difficulty and pain in the act of swallowing, from the pressure on the oesophagus, the latter being most apt to occur where the aneurism is seated in the arch or descending aorta; a whispering or croaking voice, together Avith a deep-seated Avheeze or a sibilant character of the respira- tion from narrowing of the trachea, retraction of the larynx, and compression of the recurrent nerves.* There is often, likewise, marked impairment of the vesi- * Resilience of the pulse, produced by the resilience of the aneurismal tumour after each beat of the heart, has been pointed out by Dr. Billing (Med. Gazette, December 14, 1833,) as a sign by which aneurism in the chest may be discovered in its incipient state. While the resilience is as yet slight it requires, he adds, some practice to feci it, and the finger must be kept with a light elastic pressure on the artery at the wrist. It is said to be perceptibly diffe- rent from the double pulse sometimes connected with valvular disease. Its presence in the ar- teries, both of the upper and lower extremities simultaneously, might, we apprehend, become an index of aneurism being seated near the commencement ofthe aorta or in its arch; whereas, if it were observed only in the pulse of arteries coming off from the aorta in a subsequent portion of its course, it might render it probable that the disease had its seat somewhat lower down. We have already alluded to Dr. Billing's early advocacy of the dependence of both sounds ofthe heart exclusively on valvular tension, but are induced to recur to the subject here from having just noticed a new and able statement of his arguments in favour of this view, in the Medical Gazette for April 3, 1840. "I contend," he says (in opposition to Dr. Hope and others) "that the first sound as well as the second is entirely valvular, and deny that any part of it depends on muscular noise.......for when there is simple hypertrophy (increase of muscle and muscular action) there is diminution of sound, although more ofthe condition ne- cessary to 'bruit musculaire,'.... it is the valves being encroached upon, and their having less blood to stretch them, which prevents their producing the usual sound. Again, where there is moderate hypertrophy with proportional dilatation, there is not appreciable increase of sound .... as the valves are in their usual relative condition. Again, where the heart is enormously enlarged by hypertrophy and dilatation, in which cases, there ought to be enormous first sound, if 'bruit musculaire' were a cause, there is none, or scarcely any, because the openings are so dilated that the valves cannot act." As to the difference of character of the first and second sound, he says, "1 have accounted for the difference of sound by the difference of shape ofthe auriculo-ventricular valves; their attachments are different; they are set in stronger rims: the sigmoid valves are merely attached in a tube as it were, whereas the auriculo-ventricular have a firmer and different attachment to the parietes of the ventricle, which being in systole at the time of tension, altogether a flatter and longer tone is produced. The second sound being admitted to depend on valvular tension, respect for Newton's doctrine of simplicity of causa- tion should, he thinks, prepare us to recognise a similar origin of the first. He farther shows that those who suppose the valvular explanation of even the second sound to have originated with Dr. Elliott, or to have been clearly advocated by him, arc in error. Dr. Bryan also supported 608 ANEURISM OF THE THORACIC AORTA, (Signs.) cular dilatation in one lung from the obstruction of the corresponding bronchus, but which may occasionally be momentarily overcome by making a very deep and forcible inspiration, whilst in the opposite lung the breathing may be of a decidedly puerile character. To the importance of such a comparative estimate of the state of the respiratory murmur on the two sides of the chest in the recog- nition of thoracic tumours, attention has been particularly drawn by Dr. Stokes and Dr. Greene in their valuable contributions to the pathology and diagnosis of aortic aneurism. Sometimes each inspiration has at the affected part a peculiar puffing character, as if the result of several very short and rapidily successive respiratory efforts, but really depending on the intermittent compression of the air-passages by the pulsations of the tumour. The face is often remarkably swol- len, in consequence of the compression of the cava descendens and other cervical veins; and from the same cause, there frequently exists, as pointed out by Dr. Stokes, an unnatural thickness around the root of the neck, Avhich he supposes to consist rather in a general turgor of these vessels than on serous effusion. With regard to the physical signs, it may be remarked, that as the disease pro- gresses, there may usually be detected an unnatural dulness on percussion in the upper part of the chest, and most frequently just below the left sterno-clavicular articulation, along with an abnormal pulsation of an expansive character in the same situation, Or else between the cartilages of the ribs, or beneath the sternum, or just behind the upper edge of the same bone. It is, however, occasionally only to be felt on thrusting the fingers down as deep as possible at the root of the neck, whilst the sterno-mastoid muscles are at the same time relaxed by bending the head forwards. The percussion of the sternum is in some instances produc- tive of pain. If the aneurism arise from the ascending aorta, it generally presents on the right side of the sternum; but if seated on the arch, or innominata, it usu- ally makes its appearance at the Upper part of this bone, and toAvards the inner ends of the clavicles. Auscultation generally reveals a bellows-murmur of a peculiarly loud, rough and abrupt character, above the clavicles, and perceptible also in the carotids and sub-clavians, and sometimes for a short way along the back; Avhilst beneath the sternum it is of a more superficial or whizzing character, and is commonly inau- dible in the region of the heart. From the obstructed state of the pulmonary circulation and the interference with the nervous functions of the lungs, congestion of the pulmonary tissue and pain is frequently produced, as well as extensive bronchial rales. The expecto- ration is sometimes bloody, and even sympathetic haematemesis occasionally takes place. The cough which so commonly accompanies these cases, is apt to come on in suffocative paroxysms—in some instances it has a ringing croupy cha- racter, a sense of retraction of the trachea and larynx being produced by the tu- mour, and so much distress of breathing as to have given rise to the erroneous impression of the existence of an acute or chronic laryngitis in its final stage, and the valvular theory of the sound, but not so early as Dr. Billing. (See Lancet, January, 1833.) Whilst we readily admit that there is much force in several of the above arguments, and that they lead us to doubt whether we have not somewhat under-stated, in the text, the influ- ence of valvular tension in augmenting and modifying the first sound of the heart, we con- fess we still find a difficulty in reconciling the very prolonged character of this sound with simple tension of the auriculo-ventricular valves, or in getting rid of the fact, alluded to at p. 262, of the continuance of this sound with a certain degree of strength, after the ven- tricles are emptied of their blood, and these valves otherwise completely incapacitated for action. Nor is extreme thickening of the muscular parietes of the heart, the condition which we should a priori expect to be the most favourable to intensity or rapidity of con- traction, and sonorous vibration. It is, wc think, in the thinner and more expanded muscles, that " bruit musculaire " has been most generally audible.—Author. ANEURISM OF THE THORACIC AORTA, (Signs.) 609 even to the performance of the operation of tracheotomy. The absence of pain in the larynx on pressure, and the circumstance of this part not being moved up and down so rapidly and extensively, should, as Mr. Porter has remarked, aid us in avoiding so gross an error. Though the only certain evidence of the existence of aneurism is, to use the words of Dr. Hope, a tumour presenting externally and offering an expansive as well as a heaving pulsation synchronous with the action of the heart, still, when a large number of the signs and symptoms enumerated above co-exist, they will even AVithout such pulsation render its presence highly probable, as it certainly is by far their most frequent source. It is plain, however, that some of them may be produced by any tumour of a certain bulk, so situated as to compress the same organs as usually suffer from the proximity of an aneurism. Thus, when a large tumour presses on the heart, especially if in an hypertrophic state, or on the aorta of great vessels arising from it, it may transmit their pulsations to the surface, and so far simulate aneurism; and the resemblance will be still closer where the oesophagus or air-passages are simultaneously implicated; but on the other hand, the murmur, if any, will be of a much softer kind when it originates in mere compression of the vessels. It has been suggested that the diagnosis may be aided occasionally by observing the effects of exercise on the phenomena in question; for it seems probable, that in the case of aneurism they will become more prominent when the sac is most fully distended: hence in doubtful cases we should direct the patient to take a few rapid strides up and down the room in the interval of our examinations, and notice the changes so effected on the breathing, &c. Before forming our final judgment, all the possible causes of dyspnoea should be passed in review, such, for instance, as an hysterical habit, flatulence in the stomach or intestines, tumours of various kinds, as scrofulous glands, &c, pressing on the trachea or lungs, or in the nerves Avhich supply these organs or the diaphragm. We have knoAvn the most obstinate paroxysms of periodic asth- ma, ascribed during life to organic disease of the circulatory system, to have their real source in an osseous tumour not larger than a pea imbedded in the substance of the phrenic nerve. In respect to dysphagia, the knowledge of its occasional connexion with aneurismal compression shows the necessity of great circumspec- tion in all dubious cases where the employment of the probang is meditated. Of the signs of thoracic aneurism, one of the most characteristic, after the expansive pulsation above alluded to, is doubtless the belloAvs-murmur or harsh rasping sound which is of a much more constant, abrupt and rough character, as Avell as more localized or limited in its site, than that connected with anaemia and nervous excitement, and where present (for it is by no means an inevitable ac- companiment of the disease) serves often to disclose the precise situation of the tumour. It is louder than most cardiac murmurs, and the depth and holloAvness of the tone is generally greater above the clavicles than below, which has been ascribed to its being reverberated through the chest before it reaches the ear. A vibratory thrill also is sometimes very perceptible to the hand applied over against the aneurism either in the upper part and front of the chest or in the back; but this is rarely the case till it has attained to a very considerable size, and either spread beyond the edge of the sternum, or caused the absorption of the corre- sponding portion of this bone or of the vertebrae and adjacent portion of the ribs. In dilatation of the arch of the aorta purring tremor above the clavicles is, accord- ing to Dr. Hope, an almost constant, and therefore very valuable sign. In the sacculated variety it is much less frequent. Where the parietes of the sac have become thick and unyielding, and lined internally with dense coagula, they will obviously be so much the less suited for generating vibrations calculated to affect either the hand or ear. " In all cases of dilatation, and the majority of sacculated aneurisms, the sound is loudest above the clavicles, even though the impulse be stronger below." In the sacculated kind it is in some few instances louder on the side of the neck, opposite to that where the tumour exists; which is ascriba- ble either to additional disease in the lining of the artery at a point beyond the Vol. II.—77 610 ANEURISM OF THE THORACJp AORTA, (Signs.) aneurism, or, in other cases, to the remoteness of the mouth of the sac from the side which the great mass ofthe tumour occupies. It was at one time supposed that the abnormal pulsation of aneurism might be distinguished with certainty from that connected with an enlarged heart, by the former being accompanied by only a single sound audible in the upper part of the chest, of an abrupt hoarse character, instead of having the gradual swell and fall of that produced by the heart, and by its diminishing in intensity as we descend towards the cardiac region. To the sufficiency of this latter part of the attempted diagnosis Laennec objected, apprehending that the second sound of the heart, especially when the organ is at all dilated, may often be sufficiently loud to be heard in embarrassing connexion with the single sound of the aneurism. Dr. Hope, on the other hand, in the first edition of his work, expressed his belief that this difficulty may always be got over by attention to the peculiar character of the aneurismal sound, to the circumstance of its being often louder above than below the clavicles,* and finally and chiefly to the assumed fact of the second sound, Avhen audible, ahvays increasing in intensity as we carry the stethoscope from the top of the sternum towards the heart, whilst the other sound becomes simultaneously feebler. As to the correctness of this supposed fact, there is, however, much room for doubt; for various recent observers have on the con- trary ascertained that the aneurismal pulsation is occasionally double, and accom- panied by a double sound of such a kind that the second part is absolutely louder near the top of the sternum than that heard opposite the heart itself.t This has been ascribed, and in some cases apparently justly, to the contact of the tumour Avith the heart, and the more vivid transmission of the sounds of the latter through the condensed walls of the sac than through the flaccid heart just then in its dias- tole. But in other instances, again, the heart and aneurism not being in close connexion, this explanation fails, and we are then obliged to rest in that proposed by Dr. C. Williams, viz., that the sound is transmitted upwards from the semi- lunar valves, through the tense column of arterial blood. From the contiguity of the arch of the aorta and great vessels arising from it to the top of the sternum, this valvular sound is here generally actually louder, both in health and disease, than a little way loAver down and nearer the heart, where the spongy tissue of the lung intervenes and deadens it. In the recent edition of his treatise Dr. Hope still maintains that aneurismal pulsation, though double, may readily be distinguished from the beating of the heart, inasmuch as the first aneurismal sound will be decidedly a morbid murmur, and therefore very different in cha- racter from the first sound of the heart If there be no valvular disease this * The diagnosis of aneurism of the aorta is like that of inflammation, deduced as much from the absence of signs of other diseases as from the positive symptoms of the dilatation of the artery. Indeed these are often so obscure, that individuals placed near the patient are unwilling to believe that with the general characters of good health, he should be labouring under a serious disorder of an organ essentiaUo life. The positive signs of most value, are a persistent throbbing behind the sternum, which raises the finger with a momentum not unlike that of a hypertrophied heart, the pulsation being in most cases increased by exercise: if the tumour be at all large, the percussion becomes dull below the first bone qf the sternum, and even in the earlier stages there is heard a very distinct double sawing sound. We do not believe that this double sound is owing in most cases to actual disease of the valves ofthe heart, and that the column of blood in the artery is merely a conductor; on the contrary, it seems to arise from a reflux of blood-through a cavity which breaks up the con- linuity of the regular current; and in some of these cases the proof of it is, that the natural valvular sound may still be heard at the region ofthe semi-lunar valves. The secondary symptoms, such as dyspncea, oppression, and neuralgic pains, or even para- lysis from the pressure of the tumour upon the bodies of the vertebra, are of more value, if the diagnosis ofthe signs of disease of the heart itself are wanting. G. 1 Williams, Stokos, Furguson,JLc. aneurism of the tuoracic aorta, (Sacculated.) 611 murmur will become progressively weaker as we descend towards the lower ^fi heart' whereas the first cardiac sound becomes loudest here. But if the first sound of the heart, in consequence of co-existing valvular disease, be attended with a murmur, this must depend either on auricular regurgitation, or else on obstructive disease of the sigmoid valves. The first of these alternatives may be confidently rejected when the murmur is loud and distinct, at any part above the third rib. But if the murmur be loud and near-sounding at about an inch above the apex of the heart, a situation in which the aneurismal murmur would be nearly inaudible, we may feel certain on the other hand that such reflux actually takes place. If the concomitant murmur be a semi-lunar obstructive one, the diagnosis is more difficult, but still generally practicable, the valvular murmur will be propa- gated, as we have already seen, two inches or more along the course of the ves- sel, whether the aorta or pulmonary artery, in which it originates—but when considerably louder, and in a higher key, at two inches or more above the valves than opposite to them, we may conclude that it results from the roughened coats, dilatation or aneurism of the vessel. It being thus possible, continues Dr. Hope, to distinguish with certainty the first sound of an aneurism from the first sound ofthe heart, whether natural or with murmur, the presence or absence of the se- cond sound of the heart on an aneurismal tumour is unimportant; "yet even this sound can generally be traced up, with a progressive increase of intensity, either to its immediate source, the semi-lunar valves, or to the line of the aorta and pulmonary artery, along Avhich and the sternum it is propagated as far as the clavicles." "The second sound of an aneurism is occasionally attended with a feeble murmur arising from the expulsion of a portion of its blood by the elastic contraction of its walls during the ventricular diastole." (p. 443.) But this is easily distinguishable from the murmur of semi-lunar regurgitation, by the lat- ter being audible along the course of the ventricles and by its being exceedingly prolonged, namely, through the whole diastole and period of repose. A diastolic mitral murmur Avould be too feeble to be heard in the situation of the aneurism. Dilatation of the aorta. The loudest and hoarsest aneurismal sound is that caused by dilatation, and it is the more grating the rougher the interior of the vessel. " Where the dilatation is confined to the ascending aorta, the sound, impulse, and purring tremor above the clavicles are stronger on the right than on the left side; and the sound along the mesial part ofthe sternum, the tract of the ascending aorta, is often superficial, and of a Avhizzing character." Purring tre- mor is greater in simple dilatation than in sacculated aneurism, inasmuch as it is particularly favourable to the production of eddying currents; it is, moreover, permanent, restricted to the space above and between the sternal ends of the cla- vicles, and always accompanied by the peculiarly hoarse murmur already de- scribed; whereas the thrill occasionally connected with anaemia is feebler, occurs when the heart's action is excited, pervades the adjoining arteries, and is accom- panied by a murmur of a soft character, as well as by a venous hum in the jugu- lars. In dilatation pulsation exists above the sternal ends of the clavicles only, and on both sides simultaneously, though if the enlargement be confined to the ascending aorta, it is stronger on the right side than on the left. Sacculated aneurism of the thoracic aorta has for its physical signs. 1. " A pulsation, both above and below the clavicles, but usually stronger below. If the tumour occupy the ascending aorta its impulse is most perceptible on and to the right of the sternum, often with a visible intumescence of the parts. If it is 3eated in the commencement of the descent, the pulsation and swelling incline to the left side." 2. An abrupt murmur similar to that described under dilatation, only somewhat feebler, and less rasping. 3. A purring tremor above the clavi- cles, but very rarely below, unless erosion of the bones has already occurred. (Hope, 3d ed., pp. 441 to 456.) . To what we have already said on the diagnosis of other affections from thoracic aneurism, we may here add from Dr. Hope, that "pulsating glands or other tu- mours in'the anterior mediastinum are not attended Avith the aneurismal sound, 612 ANEURISM OF THE AORTA, (Pulmonary.) or only in a slight degree; no impulse and tremor are felt above the clavicles; and symptoms of a disturbed circulation either do not exist at all, or do not corre- spond in severity with the magnitude of the apparent disease. Enlarged glands or other tumours above the clavicles, receiving pulsation from a subjacent artery, rarely occasion sound; if any exist it is a feeble whizzing, such as is produced by compressing an artery with the edge of the stethoscope. Both it and the pul- sation are* confined to the side affected. If the tumour can be grasped it will be felt not to dilate laterally during the ventricular contraction; and if it can be raised from the subjacent artery, its beating and whiff will cease entirely. An enlarged heart produces an impulse which is strongest at the apex, and decreases progres- sively on receding from it; the beating of an aneurism is stronger on the tumour than at some point intermediate between it and the apex of the heart; and in most instances it is stronger than even the beating of the heart itself. Hence an aneu- rism distinctly conveys the impression of there being two centres of motion, the tumour and the heart. Finally, the ventricular contraction of an enlarged heart produces an ordinary sound, but is not attended Avith aneurismal murmur or pul- sation above the clavicles." Varix ofthe jugular veins is distinguishable by the absence of sound and impulse, and by the compressibility of the tumour: but it is to be remembered that their swollen condition may depend on the pressure of an aneurism against the descending vena cava, as well as that of any other tu- mour. Aneurisms ofthe innominata, of the root of the carotid, and ofthe sub-clavian, where they have already attained to a considerable magnitude, are scarcely to be dis- tinguished from those ofthe arch ofthe aorta. It has indeed been suggested, that from the circumstance of their producing impulse and sound only on their own side of the chest and root of the neck, they may be discriminated from the latter ; but we apprehend that in practice this will often be found a very insufficient criterion, es- pecially in respect to distinguishing them from aneurism of the commencement of the descending aorta and adjacent portion of the arch. Their true nature may, however, frequently be recognised with some confidence from their accompany- ing impulse, sounds, and thrill, being peculiarly superficial and distinct The morbid murmur of sub-clavian and carotid aneurisms resembles, as Dr. Hope re- marks, the blast of a small hand-bellows, rather than the hoarseness of a forge- bello\vs. Aneurism of the descending thoracic aorta is generally much more difficult of recognition than that seated higher up, as there rarely exists any external pulsa- tion indicative of its presence. The symptoms which occasionally point to it are pain in the corresponding portion of the back, a thrilling tremor imparted to the hand firmly applied there, and a hoarse single bellows murmur, much stronger in this situation than in front over the heart, together with impaired respiration in a portion ofthe lung, without any other evidence of pulmonary disease, as likewise dysphagia seated low down in the chest. The absence of such symptoms as are peculiarly indicative of aneurism ofthe arch or commencing aorta, as numbness of the arm, resiliency of the pulse, unequal pulsation at the tAvo wrists, sAvelling at the root of the neck, stridulous respiration, may aid us still farther in localizing the disease in the descending portion ofthe vessel. A strong double jogging impulse, in the absence of adhesion of the pericardium, and of displacement ofthe heart to the front of the spine, is proposed by Dr. Hope as a new sign of an aneurism of the descending aorta, or other tumour situated behind the heart, so as to push it forward. When the descending aorta is the seat of the aneurismal tumour, the left lung is the most likely to suffer from its pressure, and it is into the pleura of this side that fetal haemorrhage is most apt to take place. Dilatation of the Pulmonary Artery. This is very rare. Its presence, according to Dr. Hope, may be ascertained when very considerable, by the existence of an abnormal pulsation, and purring aneurism of the aorta, (Abdominal.) 613 tremor between the cartilages of the second and third ribs ofthe left side, together Avitn an extremely loud, superficial, and harsh sawing sound, decreasing down- wards towards the heart, and at the same time not appreciable above the clavicles; and the evidence will be greatly strengthened if there exist an obvious prominence in the above-mentioned situation. A sacculated aneurism of the ascending aorta, if so large as to reach to the left side of the sternum, would cause so extensive a dulness, or so great an obvious tumour, that it could not readily be mistaken for the disease in question. Besides, in the former there would exist pulsation, murmur or tremor above the right cla- vicle also, or on the right side ofthe sternum, or above both clavicles; Aneurism ofthe Abdominal Aorta. The aorta, in its passage through the abdomen, being, as well as its branches, closely embraced by innumerable nervous filaments proceeding from the solar plexus, the irregular or sacculated dilatation of any portion of the vessel is gene- rally productive of a set of very painful and often extremely embarrassing symp- toms, which vary remarkably in their site and character in proportion as the tumour increases in bulk and comes to press on new parts. There is scarcely any organ within this cavity, which has not, at one time or other, presented from this cause notable derangement either of a nervous or functional, or of an inflammatory character: and the concatenation of disorders has sometimes been so intricate, that we have known many of the first practitioners in Europe to have been con- sulted in succession without any of them even surmising the real source of the complicated evils. Thus a case of this kind has been alternately viewed as an in- stance of inveterate rheumatism of the lumbar and abdominal muscles,—as neu- ralgia of the sympathetic and associated nerves,—as aggravated dyspepsia, obsti- nate constipation, and violent colic, or even stricture of the rectum—as hepatic or renal affection, diseased spine, or psoas abscess.* From all this it is apparent that the general symptoms of abdominal aneurism are, especially when taken separately, in the highest degree fallacious and per- plexing. There is often intense pain, though generally of an intermittent charac- ter, in the loins, lancinating occasionally upwards and fonvards into the hypochon- driac regions and abdominal muscles, and downwards into the testicles and lower extremities, the latter being at times cramped or convulsed, or at length even completely paralyzed, as are likewise the bladder and rectum, where the tumour by its pressure comes to interfere with the functions of the spinal cord; and under the same circumstances even perfectly formed tetanic symptoms (opisthotonos and emprosthotonos) have been known to occur. Where the sac is so placed as to be closely bound down by the crura of the diaphragm, acute pain is often felt in the attachments of this muscle all round, espe- cially if the enlargement takes place in an upward direction; and as it often by its bulk greatly impedes its motions, and sometimes, moreover, bursts at length into the pleurae, it is not extraordinary that severe pulmonary distress should occa- sionally be complained of, particularly in the latter stages ofthe disease. The liver is sometimes thrust down by it below the margin of the ribs, and many of the symptoms of even an acute hepatitis have been occasionally induced. One of the commonest features is vehement colic not unlike that produced by lead, of fre- quent recurrence, and aggravated by the constipation and flatulence so frequently present in this affection, as also by particular postures; and it has been ascribed, together with the occasional occurrence of nausea and vomiting, and pain and « See, in confirmation of this, the very interesting case of Mr. Mayne, by Dr. Beatty, in the fifth volume of the Dublin Hospital Reports, and various recent ones in other medical journals.—Author. 614 aneurism of the abdominal aorta, (Diagnosis.) tenderness at the pit of the stomach, to sympathy ofthe aUmentary canal with the injured coats of the artery, but with still greater probability to the pressure made by the tumour on the nerves of organic life. The pulse is unaffected throughout a great part of the duration of the disease, and the appetite in some cases very good, whilst the effects of indulging it are by no means productive of the rapidly injurious consequences which are sure to ensue where the same abdominal organs are the seat of idiopathic disorder. Ofthe physical signs, the most characteristic, where it can be detected, is doubt- less the existence of a fixed pulsating and somewhat compressible tumour in the course ofthe aorta, which can sometimes be very satisfactorily ascertained through the abdominal parietes, and even its outline traced out by the firm application of toe stethoscope or points of the fingers over its confines, and this- especially when the enlargement is seated in the front or sides of the vessel, and not so high up as to be tightly tied down by the diaphragm. In making such an examination, the pa- tient should be in the recumbent posture, Avith the knees and chest raised, so as fully to relax the abdominal parietes, and a period selected at which the stomach may be empty, and the bowels have been well cleared out by an aperient, especially if there is reason to apprehend the presence of scybala in the intestinal canal. It has been farther suggested by M. Piorry, that by pressing firmly with one hand on the abdomen, and the other at the same time on the spine, we may form a tolerable guess as to whether there is a greater thickness of solid parts than natural, and still more accurately if we have recourse to the callipers used by midwifery practi- tioners. Percussion may also at times afford us material aid, by revealing a pre- ternatural degree of dulness where the tumour is large. By auscultation a bellows murmur of a brief and generally of a rough character is very commonly to be recognised in the epigastric region or lower dbAvn in the abdomen, and sometimes also in the corresponding portion of the spinal column: it may be conveyed downwards for some distance below the point where it origi- nates, but rarely extends upward, so as to give rise to its being confounded Avith morbid sounds in the heart. It is sometimes accompanied here, as in other situa- tions, with a vibratory thrill, perceivable on the firm application of the hand over the part. This sensation becomes most evident in those cases where the tumour has already caused the destruction of a portion of the vertebrae and heads of the adjacent rids, and begun to form a distinct prominence in the dorsal or lumbar regions. In some rare instances the pulsation of the tumour has been double, a phenome- non generally ascribable to its spreading upwards into a close contiguity with the heart, and the consequent transmission ofthe action of the latter. In respect to the bellows murmur as connected with aneurism of the abdominal aorta, Dr. Corrigan has observed, that in some cases where it is altogether imper- ceptible in the erect posture, it may be rendered quite distinct by causing the pa- tient to assume the horizontal one,—a fact Avhich he explains in conformity with his views ofthe mode of generation of this sound; namely, by the reduction ofthe hydrostatic pressure within the sac, the consequent relaxation of its parietes, and greater facility of vibration under the influence of the current-like motion of the blood simultaneously produced. According to Dr. Graves, by elevating the pelvis, and depressing the thorax, the intensity of this phenomenon, whether the pulsation be aneurismal or merely nervous, may be still farther increased. In regard to diagnosis, it must be recollected that abdominal pulsation may ori- ginate, as already intimated, under veiy dissimilar conditions, nervous, inflamma- tory, and obstructive, quite independent of aneurismal disease. When either the pulsation or the accompanying bellows murmur depend on scirrhous or other tumours ofthe viscera, stomach, pancreas, liver, &c, on the distention ofthe intes- tines by hardened faeces, or conglomerated masses of worms, the impulse will be of a less truly expansive character, as ascertained by the lateral application of the hand or stethoscope, and the sound of a less hoarse and grating kind. In case of the existence of fungus haematodes or other very malignant form of disease, the aneurism of the aorta, (Treatment.) 615 general aspect ofthe patient, the rapid wasting, and perhaps also the greater con- stancy of the pain in respect to site and duration, may afford useful aid in the formation of the diagnosis. Where the augmented pulsation is connected with the pressure and conducting power of a serous effusion in the peritoneal sac, the sen- sation of fluctuation, on striking the parietes, will serve to elucidate the true nature of the case. Though organic disease of the heart very commonly co-exists with aortic aneurism, yet in some instances it is only simulated, the organ being dis- placed, and its action deranged in a very remarkable degree, by the pressure of the tumour. Aneurisms of the branches of the aorta, as the coeliac axis, mesen- teric arteries, &c. may generally be distinguished in their earlier stages from those ofthe aorta by their greater mobility. When an aneurism has burst into the cellular membrane behind the peritoneum, an accident which has sometimes been survived for a very considerable period, pulsating tumours will manifest themselves in various situations, in the lumbar, iliac, or hypochondriac regions, with a corresponding increase of dulness on per- cussion, and a diminution ofthe previously existing circumscribed enlargement of the aorta. The magnitude to which ventral aneurisms sometimes attain before becoming ruptured is enormous: thus in a case recently detailed by Sir David Dickson in the Medico-chirurgical Transactions, the tumour which originated by a kind of neck from the back of the aorta about two inches above the coeliac axis, expanded over the whole abdomen Avith the exception of the caecal region, and protruded in a conical form under Poupart's ligament, where it might have been mistaken for an aneurism ofthe external iliac artery. Treatment of aortic aneurism. The two principal indications to be held steadily in vieAV in the management of this affection, as tending in all cases materi- ally to retard, and in some even to arrest its progress, are—1st, to keep the action of the heart within moderate bounds—and 2dly, to reduce the quantity of circulating fluid without impoverishing its quality. It is under these conditions that the distending impulse within the tumour being restrained, whilst the capacity of the blood to coagulate and form firm and adherent fibrinous concretions is un- impaired, the current through the sac becomes limited, the parietes strengthened, and the best chance afforded for the filling up of its cavity with organized matter. Quietude of mind and body, or rather the avoidance of all fatiguing exercise of either—the enjoyment of a pure air and easy gestation at frequent short intervals, so as to support the general tone of the system and promote the due performance ofthe secretory and excretory functions—a dry and moderate but not a very low diet—and attention to the state of the alvine evacuations, which are so often irregular (and not without great aggravation of many of the symptoms, especially where the aneurism is situated Avithin the abdomen,)—are points of great impor- tance and very general application. Where there is plethora of the system at large, congestion or inflammation in the lungs or any other important organ, the early but moderate employment of venesection is for the most part demanded, and either this or the application of leeches over the seat ofthe disease, together with the exhibition of digitalis, should be had recourse to where the aneurismal sac or the parts on which it bears be- come the temporary seat of increased action and augmented pain; and opiates and other anodyne remedies externally or internally employed, together with counter-irritants, will often prove valuable auxiliaries. With regard to leeching, however, there is a caution necessary—namely, not to practice it in those cases where the tumour has already advanced so near the surface that there is great ten- derness along with redness or other discolouration of the skin, which has now be- come thinned and coherent, lest the irritation of the leech-bites might accelerate the sloughing process. As to the propriety of enforcing the rigid plan of treatment practised by Val- salva and Albertini, which has already been alluded to in the section on hypertro- phy ofthe heart, there has long been some difference of opinion. The voice ofthe more judicious part of the profession and of nearly all those who have of late 616 aneurism of the aorta. (Treatment.) devoted their attention more particularly to the treatment of cases of intemal aneurism on a large scale, is we think at present decidedly adverse to its employ- ment, except perhaps in individuals of a very robust constitution. We do not mean at the same time to insinuate that it is equally rarely applicable as an ad- junct in the treatment of aneurism of the extremities, or in such situations as are within the reach of local applications; as ice, evaporating lotions, compression, and such other means as are daily employed by surgeons for reducing the size of pul- satory tumours and promoting the coagulation and organization of their contents. In aneurisms of the aorta, however, an extremely lowering system is generally found to do more harm than good, by inducing arterial reaction or a nervous and irritable state of the constitution incompatible with healthy reparatory action in any part of the system, by weakening the coats of the artery as well as by giving rise to a thin watery condition of the blood by which even the existing laminated concretions, so far from being augmented and consolidated by plastic lymph, are apt to get detached and washed away, one great bulwark against fatal rupture being thus speedily removed. In those rarer cases where the state of the general health and strength and the poAver of maintaining a rich state of the blood, almost in spite of an extenuating diet and reiterated venesection, are such as to induce the practitioner to recommend, and the patient to submit to the full employment of the Italian method, strict confinement to the horizontal posture and the most perfect rest must be simultaneously enjoined, along with the unwavering perseve- rance for months in order to give this treatment any chance of success. Half measures here are worse than nugatory, as they would only impair the general health without holding out any rational prospect of beneficially modifying the local disease ; Avhilst their precipitate renunciation after having been unnecessarily em- ployed for a time, would soon give rise to its turn in the additional inconvenience of an artificially created plethora. Of the numerous cases supposed to have been cured in former days by Valsalva's treatment, not a few were probably altogether exempt from organic disease, the method of diagnosis being then very imperfect. With a vieAV to augmenting the coagulability of the blood the super-acetate of lead in half grain or grain doses thrice a-day, guarded if requisite Avith opium, has been occasionally employed in Germany and France, as Avell as in this* country, with some appearance of benefit. Its effects must however be carefully watched, and any irritation of the gastro-intestinal mucous membrane subdued by the exhi- bition of oleaginous purgatives and other remedies appropriate to cases of poison- ing by lead. It appears incontestable, from several cases recently published by the most competent observers, that a tonic treatment, along with a reparative and rather generous diet, is in many instances much more applicable than the opposite; it has occasionally, indeed, been productive of the most marked and immediate re- lief of the intense neuralgic suffering, the colics, muscular pains, &c, by which abdominal aneurisms are so often accompanied; whilst a very lowering plan has seemed in the same individuals as decidedly injurious, both in respect to the se- verity of the symptoms and the progress of the disease towards a fatal result.* In advanced and aggravated cases of thoracic aneurism, the paroxysms of dysp- noea, the harassing cough and dropsical symptoms which at length set in and add so heavily to the patient's sufferings, may often be for a time relieved by the moderate exhibition of mercury combined, according to circumstances, either with digitalis, squills, ipecacuanha, or sedatives, together with the occasional though very sparing employment of the lancet in moments of peculiar exasperation, es- pecially when connected with inflammatory action. The use of purgatives as Avell as of diuretics is calculated to procure considerable temporary alleviation under some of the above circumstances. The frequent co-existence of disease of the heart, often of a yet more hopeless * See Dr. Beatty's case, before alluded to; Dr. Frazer, cited by Dr. Stokes in the fifteenth number ofthe Dublin Journal of Medical Science; Dr. Graves, &c.—Author. diseases of veins, (General Observations.) 617 nature than that of the aorta itself, is never to be lost sight of in the regulation of our treatment, any more than in the formation of our prognosis. But though this complication may prevent us from entertaining any the most remote hopes of curing the disease, still much may be done to render the remnant of existence more endurable, chiefly by the exhibition of such medicines as tend to moderate and regulate the action of the heart; and amongst the most influential of these pal- liatives, according to the recent clinical researches of Dr. Lombard of Geneva, and in conformity with previous experience, are to be reckoned assafoetida, cam- phor, arid polygala seneka—remedies which, though peculiarly suited to those cases of palpitation or excessive action of the heart connected with nervous ex- citability, or dilatation and feebleness of the organ, are yet not inappropriate, even in those where the heart, though hypertrophied, has to struggle with an almost overpowering obstruction. To the debilitating system he is no less averse than Avas the late M. Dupuytren, and are most of the best recent British and American authorities. DISEASES OF VEINS. General observations on diseases ofthe veins and their functional derangement. Diseases of the veins were long much overlooked; but have of late years, or since John Hunter drew particular attention to them, been investigated with great success by a host of distinguished pathologists.* The lesions to which they are subject differ very considerably in many respects from those of arteries, in con- sequence of their dissimilarity of functions and structure. Thus there is nothing in their composition analogous to the middle or yellow fibrous and elastic coat of the last-named vessels, with its marked tendency to disease and destruction from the deposition of steatomatous and osseous particles; and as all the venous coats are of a nearly equally yielding nature, when dilatation ensues it assumes neither the form nor local magnitude of the ordinary or sacculated species of arterial aneu- rism, but rathei that of a general enlargement and flexous elongation of the trunk of the vessel in a considerable portion of its course as well as of its ramifications. The veins, moreover, are not exposed to the direct or pulsatile shock of the heart, and consequently the manner in which their enlargement is effected is very unlike that by which the arteries are dilated. Again, the veins are much more apt to contain puriform and other morbid matters than the arteries, both from a greater proneness, after slight injuries received, to take on and propagate the inflamma- tory action in a diffused form along their inner membrane; as well as from their connexion with the function of absorption, and their office of returning the blood from the various organs often the seat of disease. And farther, the blood coagu- lates much oftener, and more readily in the class of vessels which we are now considering, on account, probably, of its slower and more equable motion and its peculiarity of composition; and partly, it may be also, in consequence of a smaller supply of the nervous ramifications, and a loAver degree of vitality in their coats, * We refer particularly to the contributions of Baillie, Hodgson, Brodie, Meckel, Otto, Davis, Travers, Lawrence, Dance, Ribes, Breschet, Carmichael, Velpeau, Marechal, Rochou.x, Bland'in, Bouillaud, Lee, Gcndrin, Piorry, Louis, Cruveilhier, Carswell, Ward, and Andral. For a great proportion ofthe facts in the summary of venous pathology, here presented to the reader, we are indebted to the Anatomie Pathologique ofthe last-named author (vol. ii. sect. 3.) an invaluable work, which should early be put into the hands of every medical student.—Au- thor. Vol. II.—78 618 phlebitis, (Anatomical Characters.) as well as from their greater proneness to the effusion of coagulable lymph, and the more frequent presence of pus, either of which may constitute a nucleus for the commencement of the transformation. The functional derangements of the veins which, in conformity Avith the ar- rangement we have hitherto adopted, should precede their inflammatory and organic changes, have been already in part noticed in previous portions of this treatise, when speaking of the preternatural pulsation of the jugulars and veins of the extremities, and the remittent humming sound heard in the neck, &c. A continuous buzzing sound has occasionally been perceived in this last situation, and also beloAV the sternal ends of the clavicles, where an aneurism of the aorta presses on the venous trunks in the upper outlet of the chest—and any other tumour similarly placed would probably have the same effect. The veins throughout the body are sometimes, moreover, in an unnaturally re- laxed condition, their caliber being modified to an unusual degree by variations of temperature; and they are farther liable to be greatly over-distended, and even rendered varicose over the abdomen, legs, arms, &c, by the obstacle to the re- turn of their blood which exists in cases of organic disease of the heart, or of pres- sure on any of their great trunks. But on these states, as being for the most part only symptomatic of disease in other parts, it is unnecessary here to dwell. PHLEBITIS, OR INFLAMMATION OF VEINS. Anatomical characters.—Secondary purulent deposites in organs.—Secondary organic inflam- mations and symptomatic fever.—Causes.—Phlegmasia albadolens.—Treatment of phlebitis and phlegmasia dolens. There has been the same difficulty in determining what anatomical proofs are to be admitted as decisive of the existence of phlebitis, as in the case of arteritis already treated of. The veins are even more prone to reddening by sanguineous imbibition than the arteries, both on account of their structure, and also of the greater quantity of blood generally contained in them in the moribund state, and after death. The hue thus imparted to them is, as we should expect from the colour of the blood within them, of a darker tint, and generally penetrates deeper, often entirely pervading their several tissues. Anatomical characters. To establish indubitably the existence of venous in- flammation, there must co-exist with redness of a lighter (more pinkish or browner) tint than that just spoken of, distinct vascular arborizations, or fine ca- pillary injection in their walls, along with infiltration of their structure, the effu- sion of coagulable lymph or pus, or the existence of ulceration on one of their surfaces. The lymph so poured out may occupy either the exterior of the vessel, and so lead to its agglutination to surrounding parts, or else be poured out into the substance of its coats, or rather between them into the connecting cellu- lar membrane, and so give rise to their morbid thickening; or finally, into its cali- ber, when, if in considerable quantity, it will necessarily obstruct the passage of the blood; or, if more thinly spread over its interior, it will assume the form of a false membrane lining its sufface; and it is susceptible, under both these circum- stances, of becoming at length organized into cellular tissue. It is thus that veins which have once been the seat of inflammation, are occasionally found con- verted into dense and impervious cords, whilst the office is supplied by collateral trunks in a state of preternatural dilatation. When the effusion is of a purulent nature, it may likewise exist in any ofthe three situations just indicated. If on the outer surface, the cellular membrane in Avhich the vessel lies imbedded may phlebitis, (Secondary Inflammation.) 619 • ^fh6 .seat of extensive suppuration; when it takes place, on the contrary, mio tne cavity 0f the vein, it often co-exists with a coagulum of blood, by which tne circulation through the vessel is stopped. The purulent matter is sometimes actually enveloped in the clot, and when thus situated has been supposed bv An- dral occasionally to originate within it, either by a process of transformation or of secretion; a supposition, however, which is still by many looked upon not only as merely hypothetical but unnecessary. As to the pus so often found in the interior of the veins, it must be recollected that its source is frequently quite independent of inflammation of the coats of these vessels, being introduced into the torrent of the circulation either from ulce- rated surfaces, or purulent deposites in other organs through which they pass, or from which they arise. Thus the veins returning the blood from an inflamed or cancerous uterus, from dysenteric ulcerations of the intestines, from a suppurating portion of the brain, from carious bones, or from joints or stumps in which the suppurative process is going fonvard, very frequently contain such matter. In many instances the puriform matter, whether it be kept up by the veins in the «U*r just indicated, or secreted from their lining membrane, or finally sepa-1ft4#*H»y rated directly from the blood contaminated or altered in its constitution, is sub- sequently, as M. Dance, Rose, and others have shown, deposited in distant points of the system, as the serous cavities, the lungs, liver, spleen, joints, and cellular membrane, and more rarely in the kidneys, and even in the heart. The quantity of these deposites is probably, in some instances, still farther augmented by a pro- cess of suppuratory inflammation, excited by the presence of the pus, (or con- taminated blood) in the capillaries of the organs to which it is carried, as the pain occasionally felt during life, and the softening redness or ulceration of the adja- cent tissues, sometimes observed on dissection, seem sufficiently to evince. The lungs and liver, and especially the former, are the organs into which these secondary purulent infiltrations most commonly take place. They usually pre- sent themselves in the form of deposites, varying in size from a pea to a Avalnut, or somewhat larger, disseminated through the structure of those viscera, which are generally unnaturally red in their immediate vicinity. They differ from ordinary abscesses in being neither encysted nor concentrated into one place. According to M. Dance, the affected portions present, in their earliest stage, the appearance of local sanguineous infiltrations; these subsequently have a very dark firm nucleus in their centre, which gradually becomes white and soft, and assumes all the cha- racters of true pus. Whether the increased vascularity which surrounds these depo- sites is to be considered their cause or consequence, admits of dispute. M. Dance, like Mr. Arnott, is persuaded that whenever purulent deposites of this kind take place, phlebitis and an altered state of blood arising therefrom, have ahvays pre- ceded and led to them. Their occurrence in the liver, in connexion with injuries of the head (in which phlebitis, originating either in the injury done to the soft parts or to the bone, appears to be the connecting link,) had long ago attracted the attention of surgeons, but Morgagni had the merit of showing that the other vis- cera were not exempt from similar secondary disease in those cases. Phlebitis is often attended with marked inflammation of the membranes of the brain; and in several instances the eye has been rapidly destroyed, the cornea becoming opaque and the whole globe red and swollen, and eventually bursting or becoming totally disorganized; several examples of this destruction of the eye in the puerperal state have been recorded by Dr. M. Hall and Mr. Higginbottom; and it has also been known to take place after the tying of the saphena, and after the inflammation and obliteration ofthe jugular vein. An inflammatory condition ofthe organs from which the veins spring, or through which they make their way, become, not unfrequently, on the other hand, commu- nicated to the coats of these vessels. This has been particularly observed, in re- spect to the cutaneous surfaces in which the local inflammation arising occasion- ally from even very slight injuries is, in certain states of the constitution, readily imparted to the lining membrane ofthe veins, and through their medium give rise 620 phlebitis, (Causes.) to dangerous diffuse cellular inflammation. M. Ribes, in particular, speaks of having met with an inflammatory condition ofthe veins, characterized by redness, thickening of their coats, and a pseudo-membranous effusion lining their cavity, in cases both of simple and phlegmonous erysipelas; and Andral has noticed a simi- lar appearance in the vena portae, in connexion with disease of the liver and intes- tines. Thus, then, it appears, inflammation of the veins may either be the cause or the consequence of inflammation in other organs; and from the rapidity with which the diseased action spreads along their inner coat, and the facility of transport or morbid products in these vessels, it is evident how important a part they must needs play in the propagation of diseases; and even their obstruction, though it may form a barrier against the farther transmission of the contaminating matters, be- comes in its turn the source of a new set of evils, painful swelling of the parts beyond such obstruction, general dilatation ofthe collateral and subordinate veins, or even obliteration of many of the latter by the coagulation of the blood within them. The local signs of phlebitis, when so superficially seated as to fall ufrer9r**the cognizance of our senses, are pain, greatly increased on pressure, swelling, stiff- ness, and occasionally redness, in the course of the vessel, generally extending upwards towards the heart in the direction of the current, more rarely spreading downwards, or in both directions. Where it has supervened on a wound in the vessel, as after the operation of venesection, a minute quantity of pus generally makes its appearance at the aperture; and after the inflammation has begun to abate, and the swelling at the surrounding cellular membrane has decreased, the indurated vessel may be felt rolling beneath the finger like a cord knotted at in- tervals. The formation of matter is generally preceded by flying pains in different parts ofthe body, and accompanied by well-marked and repeated rigours. The accompanying fever, especially in the advanced stage of the affection, is of a low or typhoid kind, characterized by great prostration, irritability, and anxiety, a very rapid pulse which soon becomes feeble and occasionally intermittent, hurried breathing, frequent nausea, meteorism, and tenderness of the abdomen, black sordes on the tongue and teeth, and muttering delirium, with a Avild haggard look, and yellowish or discoloured skin. Such at least is a picture of the more aggra- vated cases as they draw towards their fatal termination. This form of fever, which bears a close resemblance to that induced by the injection of putrid matters into the veins, seem to occur especially in those cases where the purulent secretion becomes freely mingled Avith the blood so as to deeply alter its constitution, but doubtless may depend also in some degree in other cases on the rapid diffusion of the inflammatory process along the inner lining of the vessels. Mr. Arnott, how- ever, has proved satisfactorily that the former is much the more influential cause ofthe two, for the worst general symptoms very frequently occur where but a ATery small portion of the vein is in an inflammatory condition. The larger the vein affected the greater is the danger, generally speaking, as the chances of its speedy obliteration and of the insulation of the purulent effusion and arrest of the inflam- matory process are much less. Causes. Phlebitis very rarely originates spontaneously, but may be almost inva- riably traced either to some injury done to the vessel itself, or else to the commu- nication of inflammatory action from some contiguous tissue. Amongst its more ordinary causes may be enumerated all those operations in which veins of a cer- tain magnitude are either wounded or tied, of which but too many examples pre- sented themselves a few years ago, from the practice then prevalent of attempting to obliterate varicose veins by the knife or ligature. Instances of it are also not unfrequently afforded by the simple operation of venesection, especially where the lancet has been either blunt or dirty, or recently employed in operating on some diseased part, or where the incision having been made transversely, the orifice has long remained gaping or exposed to the air, or the limb been too freely used before phlebitis, (Phlegmasia alba dolens.) 621 the wound has perfectly healed. The state of the health has also a marked influ- ence m predisposing to the diseased action in question, and thus very slight injuries, which would have no ill effect in a healthy constitution, are often sufficient to induce this formidable disease in the irritable and unsound. Again, whether the suppura- tive or adhesive action shall predominate, and consequently the degree of danger at- tending the case, depend in a considerable degree on the previous state of the pa- tient. It has appeared to M. Gruveilhier that operations or injuries affecting bones are peculiarly apt to be followed by venous inflammation. He has very often de- tected it after amputations in connexion with profuse suppuration Avithin the shaft of the bone, and along with the purulent deposites in distant organs already spoken of; and remarks that a large proportion of the patients operated on in the Hotel Dieu, are cut off more particularly by lobular pneumonia thus induced. The fatal erysipelatous inflammation of new-born infants seems occasionally to depend on suppuration Avithin the umbilical vein, from the injury done to the cord after birth. Phlebitis is farther known to originate in exposure to cold, either by a curreiHof air directed against the limbs, or by standing long in cold damp situa- tions. *TPn instance where gouty inflammation was transferred to the coats of a varicose vein is upon record. One of the most frequent of the causes of phlebitis is indubitably the existence of ulcers, either on the surface of the body or in its interior, as in the bowels, uterus, &c. We knew of an instance where the care- less introduction of the pipe of an enema syringe, so as to injure a tumour seated within the rectum, gave rise to a general swelling of the lower extremity and well-grounded suspicions of the existence of inflammation of the femoral vein; and a French writer mentions a similar result from the introduction of a catheter into a diseased bladder. Pressure, if firm and long-continued, as by a tumour, a ligature round a limb, or other external cause, has likewise in many cases suf- ficed to induce inflammation in a subjacent vein, a circumstance the knowledge of which has been taken advantage of by Mr. Travers to effect the obliteration of varicose veins. Phlebitis in the superficial veins of the leg has ensued even upon a blow on the skin. Phlegmasia alba dolens. Inflammation of the internal and external iliac and femoral veins has often been found to exist in puerperal cases, in connexion with the disease of the lower extremity, commonly known under the name of Phleg- masia Alba Dolens. This affection, Avhich commences within from one to five weeks after delivery, is characterized by a very painful elastic swelling of the limb, which, though unnaturally hot and exquisitely tender, is of a pale colour, whitish and shining. Unlike ordinary oedema, it does not pit on pressure. From the stiffness of the part, and the impairment of the functions of its nerves, the power of motion is almost or altogether lost. The affected leg is often twice the size of the other, the swelling generally reaching its height Avithin forty-eight hours from its commencement, and being for the most part preceded by rigors and a sense of uneasiness in the loins, lower part of the belly or groin, and more rarely by well-marked peritonitic symptoms. Sometimes, but rarely, both limbs are affected, either successively or together. There is commonly much fever, a rapid pulse, with headach, thirst, foul tongue, and nausea. The acute stage is generally over in about a fortnight, but the limb often remains SAVollen and feeble for a length of time after, and we have seen it continue so for life along with painful varicosity of the superficial veins and great suffering from all prolonged exercise or standing. In a very few cases the pa- tient has been cut off in the early stage by the violence of the accompanying general symptoms. This affection was described by Mauriceau so far back as the end of the seventeenth century; though, it is true, pathology is still litigated, and the theories which have been framed to account for its nature and origin arc very various. Puzos and Leveret fancifully ascribed it, in consequence probably of its colour, to the translation of the milk to the limb; White, and Brandon Trye, to rupture of the lymphatics, or their obstruction by the pressure of the head of the foetus against the brim of the pelvis; and Dr. Hull to a general inflammation 622 phlebitis, (Phlegmasia alba dolens.) of the whole limb, its muscles, cellular membrane, and inferior surface of the true skin, and occasionally extending even to its great vessels, along with a rapid effusion of serum and coagulable lymph into the sub-cutaneous cellular tissue. Dr. Davis, M. Bouillaud, and Dr. R. Lee, have endeavoured to show that the affection is altogether dependent on phlebitis, asserting that the iliac and femoral veins are invariably found, either containing pus, or thickened and contracted, or plugged up by a coagulum of blood, or by plastic lymph; and the last-named author believes farther, that the inflammatory action is ahvays imparted to the veins in question, by the uterine vessels in a similar state. According to M. Dance likewise, phlebitis has very often its origin in inflammation of the uterus after delivery; but Velpeau supposes it to commence rather in suppurative inflam- mation of the pelvic articulations, and the subsequent introduction of pus from this source into the veins by absorption. Many pathologists, however, are still averse, and we think with reason, to ascribing such an exclusive influence to the veins in the production of the SAvelled leg of lying-in women, believing that they are only implicated in common with, or even subsequently to several other tissues, more especially the sub-cutaneous cellular membrane, the inferior surfsffie'of the cutis vera and the superficial nerves; for the swelling here, unlike that induced by the ligature of a vein, most frequently begins in the groin, labium, and thigh, and afterwards spreads downwards, in place of always manifesting itself first in the distal extremity of the limb, and it is accompanied, moreover, by an acute neuralgic tenderness diffused over the Avhole surface, and not met with in the same degree in cases of pure phlebitis, in which the pain and sensibility to pres- sure are more localized in the course of the vessels. Again, in phlegmasia dolens the swelling is not cedematous, but from the quantity of coagulable lymph poured out it is tense and elastic, and when the disease is fully formed rises immedi- ately after pressure, and cannot be evacuated in almost any degree by puncture or incision; and finally, the type of the accompanying fever is very dissimilar to that in indisputable phlebitis, and the rate of mortality is incomparably lower.* An affection of the lower extremities, somewhat similar to phlegmasia dolens, has been occasionally noticed after abortion, and likewise in connexion with can- cerous ulceration of the uterus, or after the removal of polypus from that organ, in elderly women,f and even in individuals of the male sex an analogous swelling of the limb has sometimes presented itself when individuals Avere labouring under inflammatory or organic diseases of the organs within the pelvis, as the rectum or bladder. Thus, Dr. Charles Forbes and Mr. Holberton have each recorded an instance of its occurrence in young men in the advanced stage of phthisis, where it probably had its source in ulceration of the large intestines, and to the commu- nication of the inflammatory action to the veins. To Dr. Tweedie the merit is due of fixing the attention of practitioners on an inflammatory and very painful swelling of the limb, occurring in or after fevers.}: It had previously been cursorily alluded to by Dr. Cheyne, of Dublin, and similar instances have been recorded more recently by Drs. Graves and Stokes.} It differs, as Dr. Treedie has pointed out, from the passive oedema of the lower ex- tremities, also occasionally one ofthe sequelae of protracted fever, in being ushered in by rigors and renewed febrile symptoms, in generally attacking but one leg, which becomes exquisitely tender, and in commencing commonly'in the upper part of the thigh and thence extending downwards, and in not retaining the impres- sion of the finger. The swelling, like that in the puerperal state, is colourless. * See Dr. Johnson, in No. XXII. of the MedicoChirurgical Journal, and in previous num. bcrs; also Dr. Graves's Lectures. t Lawrence, in Medico Chirurgical Transactions, vol. xvi. t Ed. Med. uud Surg. Journ. vol. xxx. p. 258. § The earliest notice of it we have met with is Mr. Bellol'a case, as detailed by himself in Fcirier's Medical Histories and Reflections, vol. iii. p. 187. phlebitis, (Treatment.) 623 mnliSUP?hfi(i-aluCUteneous veins are occasionally much dilated,* and the power of moving the limb almost totally lost It has been viewed by the author just named a> an acute inflammation of the cellular tissue, demanding very active local anti- pmogistic treatment It has, though very rarely, gone on to suppuration, and is occasionally as remarked by Drs. Graves and Stokes, complicated with inflam- mation of the cavities of the joints. A similar swelling has also been noticed in the upper extremity, in conjunction with intense pain and inflammation in the cel- lular tissue about the breast. Treatment of phlebitis. From the state of depression which commonly exists, general blood-letting is rarely admissible. The free and repeated application of leeches over the inflamed portion of the vein constitutes the chief part of the treatment, with which the use of mild aperients and diaphoretics is to be combined, and, m severe cases, the antiphlogistic influence of calomel in combination with opium or antimony, or both, ought early to be had recourse to; digitalis has like- wise been recommended, but it is of such more dubious efficacy. The affected part should be placed in the position most favourable to the return of its blood, and an emollient cataplasm applied; or if more agreeable to the pa- tient's feelings, an evaporating lotion, or water dressings, may be substituted. The local vapour bath, which has found recently so able an advocate in Dr. Macart- ney, would seem, from its soothing and relaxing influence, and from leaving the part free from all pressure, peculiarly suited to these cases. The proposal of Mr. Hunter to effect the obliteration of the vein by means of pressure Avith firmly-applied compresses above the point of inflammation, has not, we believe, been generally successful, though it is still occasionally practised in France with another view, that of preventing the passage of the purulent matter into the general current ofthe circulation. Where there is great sinking, bark, wine, and diffusible stimulants, together with beef tea, jelly, and other light nutriment may be requisite, even while the local depletory treatment already recommended is being put in practice. In phlegmasia dolens, no less than in pure phlebitis, the early and frequent topi- cal abstraction of blood, by the application of leeches in large numbers (20 to 40,) over the femoral vein, as it passes from underneath Poupart's ligament and along the inside ofthe thigh, is the leading indication, along with which assiduous fomenta- tions are generally advantageously combined, though to some patients cooling ap- plications are more soothing. From the known influence of mercurial ointment in moderating erysipelatous inflammation, its trial has been recommended also in phlebitis, and in the acute cellular inflammation so often connected therewith; and in consequence of the morbid state of sensibility of the cutaneous nerves which marks phlegmasia dolens, and the peculiar inflammatory swellings of the limbs after fever, Dr. Graves has been led to combine it with one-eighth part of the extract of belladonna, applying them on lint over the whole extent ofthe limb, whilst he, at the same time, freely exhibits opium internally (iv to vi grains in the twenty-four hours,) or Dover's powder, and endeavours to promote the secretions and slightly to affect the system by the Hydrarg. cum Cret& given thrice a-day. When the disease in the limb has passed into the chronic or indolent state, blisters, frictions, and bandaging are to be had recourse to, in order to promote the absorption ofthe remaining swelling. * The distention of all the minute cutaneous veins was probably the source of the bluish tinge ofthe skin, in a case of phlegmasia dolens recorded by Dr. Stokes—Author. 624 varicose veins, (Causes.) VARICOSE VEINS. Causes, effects, and treatment. The irregular knotty enlargement to which the veins, especially the more super- ficial ones, which are least supported by external pressure, are liable, may ori- ginate in any permanent obstruction in their course, whether from inflammation in the vein itself or pressure on its outer surface; as, for instance, by the gravid uterus, a diseased liver, indurated glands, aneurismal tumours, &c., or, if more general over the body, in obstacle to the passage ofthe blood through the heart or lungs, or in universal relaxation ofthe coats of these Aessels. The veins arising from a cancerous part, or one in a state of chronic inflamma- tion, are usually much dilated, and the appearance so produced forms an impor- tant feature in the external physiognomy of such morbid states. Obliteration of the deeper-seated veins by inflammation of their parietes, by tumours, malignant diseases, &c, give rise to an unnaturally swollen and prominent condition of those near the surface, and thus a valuable indication of disease in internal organs, out of the reach of immediate examination, is occasionally afforded.—Thus, for in- stance, in obliteration of the superior cava, as has been remarked by Reynaud, the intercostal and mammary veins are seen dilated and freely anastomizing with those from the head; whilst if the cava inferior, or vena portae, is obstructed, the epigastric and external abdominal veins are greatly enlarged. The vena cava, azygos, and other internal veins have occasionally been found in a varicose state. A similar condition of the jugulars in the neighbourhood of the clavicles has sometimes, on insufficient examination, led to an erroneous suspicion of arterial aneurism. Varix was supposed by Mr. Hodgson to be connected Avith rupture ofthe valves of the veins, but this opinion has not been borne out by later anatomical exami- nation. (Stanley.) Where, however, the dilatation is already considerable, the valves will obviously no longer be capable of fulfilling their natural office of pre- venting the retrogade motion of the blood, and the ill consequences of their dis- eased state must then necessarily be much augmented. When varices of the legs are very large, the assumption of the erect posture has been known to give rise to fainting, in consequence of the sudden Avithdrawal of so large a quantity of blood from the centre of the circulation and from the brain, as was exemplified in a case recorded in Lower's work on the heart The enlargement of the caliber of the \-eins may be accompanied either by thickening or thinning of their parietes, or by both states at different points. The dilatation may either take place pretty equably throughout a considerable extent of their tube, which acquires, moreover, a tortuous outline from the simultaneous elongation of the vessel, or else may present here and there sacculated protube- rances, or may be divided into loculi by septa crossing their interior: and farther, these cells occasionally communicate by numerous small apertures Avith the sur- rounding cellular membrane, a state of things analogous in some degree, as Andral has remarked, to the natural structure of the spleen, and Avhich is not unfrequently found in haemorrhoidal swellings, though these may also consist in the simple dila- tation of one or more veins. A spontaneous cure of varicose veins, especially the sacculated variety, has oc- casionally been effected by the supervention of a slight inflammatory action in their Avails, the effusion of lymph, the coagulation of the contained blood, and the consequent obliteration of their caliber. Varicosity of the veins necessarily gives varicose vf.ixs, (Treatment.) 625 rise to serious obstacle to the return of blood, and, consequently, to oedematous swelling, weight, numbness of the parts from which they arise, to inaptitude for active exercise, tendency to chronic inflammation in their coats, and to bursting of the vessel at its most prominent part, and hence to serious or even fatal haemor- rhage, as well as to very obstinate sores on the extremities. Ireatment of varicose veins. The palliative treatment has now almost en- tirely superseded the attempt at radically curing the disease by ligature, or cutting across, or excising a portion ofthe A'essel, as practised a few years ago at so much risk even of life. Where the varicosity exists in the loAver extremities, incompara- bly its most frequent seat, the person should avoid walking much, and still more standing long at a time; the limbs, when at rest, being kept in the horizontal posture, and the vessels at all times supported by elastic bandages, or laced stockings. Where a sub-inflammatory state ofthe vein, or surrounding cellular membrane, has been accidentally induced, leeches and evaporating lotions, Avith aperients, a cooling diet, and perfect rest, will commonly afford speedy relief. Indeed, the im- portance of a temperate and rather dry diet, Avith a view to keeping the quantity of the circulating fluid moderate, along with attention to whatever may serve to improve the tone ofthe system generally, and consequently, also, in some degree, that ofthe diseased vessels, and the promotion of a due performance ofthe excre- tory functions, are, in a chronic disorder like this which rarely admits of a perfect cure, obviously points ofthe first importance. When sudden haemorrhage occurs, the person must instantly be placed in the horizontal posture, and a compress and bandage applied over and below the aper- ture, so as to arrest the farther escape of the returning blood. When ulceration ensues, the Avater dressing, or black wash (calomel and lime-water,) covered with oiled silk to prevent evaporation, and retained by an evenly applied bandage continued from the foot upAvards, form the best local applications. Where there is much thickening of the coats of the vein the tincture of iodine has been em- ployed by Mr. Guthrie with advantage. Mr. Mayo is still an advocate for obliteration of the vein, by the formation with caustic of a narrow transverse eschar of the integuments across its course, by means of which the adhesive inflammation is excited in its coats, and for the most part, according to his experience, Avithout any serious accidents. Some other practitioners prefer having recourse to the effects of pressure by means of any hard substance firmly retained for some days, by tightly drawn adhesive plaster, or bandage, along the traject of the vein. We apprehend that the cases where either of these proceedings will effect a complete and permanent cure are rare, seeing that so many branches are commonly implicated, and that there is usually a marked tendency to the recurrence of the disorder. A plan which has recently been employed by Mr. Colles with considerable success, and which has the advantage of being unattended with danger, is to make permanent but mode- rate pressure on the saphena, where it is about to enter the femoral vein, by means of a spring compress so applied as to diminish the ordinary Aoav of blood through the superficial veins, and compel the deeper seated ones to a supple- mentary action. In varix of the scrotum Mr. Wormwald has succeeded in affording relief, by drawing the lower portion of the skin through a metal ring, so as to reduce the quantity of blood circulating in the part; Avhilst M. Breschet advocates the more hazardous practice of obliterating the varicose veins, Avhether in the cord or scrotum, by the graduated pressure of a screw forceps, Avhich soon produces an eschar at the point of application, and adhesive inflammation of the walls of the vessel and consequent obstruction of its canal. Vol. II.—7«* 626 affections of the veins, (Depositions.) MISCELLANEOUS AFFECTIONS OF THE VEINS. Spontaneous perforation and laceration ofthe veins and of their valves.—Obliteration of their cavity.—Calcareous deposites.—Phlebolites,—Fatty tumours.—Gaseous effusions. The veins, in addition to the lesions already alluded to, are farther liable to perforation, Avith or without previous ulceration, softening, or Avasting of their coats. The vena cava has been known to be burst or larcerated during violent muscular struggles and falls from a height. A similar event is said to have oc- curred in the rigors of an ague, and in a delicate female, mentioned by Portal, under the action of the cold bath. Large veins are occasionally penetrated from without inwards by the spreading of malignant ulcerations from adjacent parts. The valves of the veins likewise are sometimes found lacerated or perforated, and when, in this state, they are often entangled in their fragments shreds of coagulated blood and of lymph—appearances for the most part indicative of pre- vious inflammation ofthe lining membrane. Independent of their obstruction by an inflammatory tumefaction of their coats, effusion of lymph, and coagulation of the blood within them, the veins are farthei exposed to obliteration by the pressure of contiguous aneurisms and other tu- mours against their external surface. Their obstruction, hoAvever induced, is the usual source of partial dropsies, as one of the limbs, abdomen, the side of the face, &c, as Bouillaud has ably demonstrated several years since. Calcareous depositions are occasionally, though rarely, met with in the Avails of the Areins, and there is reason to believe that a pre-disposition to their forma- tion is, sometimes at least, the consequence of preA-ious inflammation. Both Morgagni and Baillie had seen them in the vena cava; Beclard in the femoral vein, Avhen in contact Avith the corresponding artery, Avhich Avas in an ossified state; and Dr. Macartney and Andral in the external saphena. The last-named author speaks of instances in which concretions of this kind, formed in the Avails of the vessel, push the lining membrane before them, and thus project into the cavity, attached at length only by a narroAv pedicle; and he suggests the possi- bility of the phlebolites, or loose pisiform, or oval concretions occasionally found within the veins, varying in size from a grain of millet to a pea, having their origin in this manner by the eventual separation of the slight remaining adherence. He suggests that they may also occasionally have their source in the coagu- lation of the blood and subsequent vital processes carried on Avithin the clot; an opinion which has likewise been advocated with his usual ability by Dr. Cars- well, as well as by Tiedemann, Otto, and Errhman. A small"coagulum first forms, and in the centre of it appears a firm nucleus Avith concentric layers. This becomes gradually denser, the red part of the blood being absorbed, and calcareous matter deposited in the interior, till all the lamellae have at length undergone the ossific change. The most frequent seat of these concretions appear to be the veins of the pelvic viscera, and the sub-cutaneous ones of the lower extremities. Fatty tumours have been met Avith in the walls of the veins projecting into, and nearly obliterating their passage; and Andral speaks of having, in one instance, detected hydatids Avithin the pulmonary veins of a man Avho had died of organic disease of the heart, but Avas not aware of any similar case on record in the human subject. In horses, hoAvever, and others of the loAver animals, the occurrence of various species of entozoa Avithin the blood-vessels is by no means \ery rare. affections of the veins, (Fatly Tumours, etc.) 627 There is reason to believe that gaseous matters have been secreted in some very rare cases into the cavity of the blood-vessels during life, or else that they have separated spontaneously from the blood in a morbid state.* The vast ma- jority of instances, however, in which such products are discovered on dissection, have their source in incipient putrefaction. * See Dr. Mollan, in Dublin Hospital Reports, vol. ii. p. 329, and Dr. Reid, in the Transac tions of the King and Queen's College of Physicians, vol. v. For examples of the secretion of air into the cellular membrane and serous sacs, see Valsalva, Ruysch, Frank, Laennec, Andral, Rebolle de Gex, and other authorities cited by Dr. Graves, in the twelfth number of the Dub. lin Medical Journal.—Author. THE END OF VOL. H. 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