%-' Af—l LECTURES s &r. &L /*m, ON THE ftiu*. -$/./r DIAGNOSIS, PATHOLOGY, AND TREATMENT OF THE DISEASES OF THE CHEST, BY W. W. GERHARD, M. D., MM Lecturer on Clinical Medicine to the University of Pennsylvania, Physician to the Philadelphia Hospital, Blockley, and to the Philadelphia Dispensary, &c. ^LII)I,AI?T "f> *;.£,$"* 74-: ■ PHILADELPHIA! HASWELL & BARKINGTON, 1842. * * » V • Entered according to the act of Congress, in the year 1842, by William W. Gerhard, M. D., in the Office of the Clerk of the District Court of the Eastern District of Pennsylvania. INDEX. Disease, artificial division of - Mode of studying ... Physical and rational signs, im- portance of combining - Diagnosis by exclusion, value of negative evidence, - - - Physical Examination, Basis of, and the attention necessary for acquiring a knowledge of - Source of error in Conformation of Thorax ... Mode of examining - Alterations of, and their causes - Percussion ------ Rationale - - - - - Pleximeter .... Mode of performing - - - Application to abdominal diseases Of the chest .... Regional division of chest in regard to..... Value of, in diagnosis Practical mode of acquiring Difference of resonance in healthy individuals .... Auscultation..... Mode of practising, - Relative value of mediate and im- mediate - Position of patient - Signs derived from - - - Vesicular and tubal sounds Mode of studying the sounds Explanation of bronchial respira- tion - - . - - Amphoric respiration - Rude..... Puerile..... Other varieties - - - - Resonance of the voice Rhonchi ...... Moist..... Mucous, crackling, gurgling Subcrepitant and crepitant Dry...... Sonorous and sibilant Friction sound, and metallic tink- ling - - - - - Their combination and connection with other physical signs Cough ....... Dry or irritative—sonorous Suppressed—laryngeal—loose or mucous—spasmodic 9 Expectoration - 9 Quantity of—colour—consistence and chemical composition—form 10 Odour..... Foreign matters mingled with 11 Thorax, Movement of the ... Signs of dyspnoea ... Frequency of inspirations in health 12 and disease - - - - 14 Pleurisy ------ 15 Definition of 16 Connection with diseases of the 17 parenchyma - - - - 19 Division of 19 Pathological changes 19 Their connection with physical 20 signs..... 21 Local functional signs 22 General signs - - - - Diagnosis—Prognosis 22 Treatment - - - - 24 Varieties .... 24 Chronic..... Latent - 25 Secondary and complicated 26 Bronchitis...... 26 Division of Acute . - - - - 26 Pathological changes 27 Mode of commencement and ter- 27 mination .... 28 Physical signs - 29 Local signs—cough — expectora- tion . - - - - 30 General signs - - - - 31 Duration of 22 Treatment of - 32 Of old men .... 32 Secondary .... 32 Chronic..... 35 Varieties..... 35 Common mucous catarrh - 35 Diagnosis - - - - 36 Treatment .... 36 Chronic catarrh with the glairy se- 37 cretion - - - - - Signs—treatment ... 36 Dry Catarrh . - - - Lesions — symptoms — physical 38 signs and complications - 39 Treatment 39 Peculiar varieties of Pertussis 40 Diagnosis 40 41 42 42 43 43 43 44 44 44 45 45 46 48 49 50 50 53 53 54 55 57 57 57 57 58 58 59 59 59 59 61 62 62 62 63 63 63 64 65 65 65 66 66 66 67 6 INDEX. Prognosis 67 Prognosis Treatment . 67 Duration • • Bronchitis depending on a consti Treatment tutional taint . 68 Pneumothorax General remarks . . 68 Physical signs Dilatation of tubes . 70 Diagnosis and prognosis • Varieties . 70 Treatment Diagnosis between phthisis . 70 Pulmonary Haemorrhage Emphysema of the Lungs . 71 Physical signs Pathological condition . 71 Tubercles of the Bronchial Glands Signs and symptoms . 72 Diseases of Heart Diagnosis—prognosis 73 General considerations . Treatment 73 Symptoms of Asthma .... 74 Causes of . . Diseases of lungs and heart simu Terminations of . lating . 74 Influence of ages, sex Nervous Asthma . 74 General diagnosis and prognosis . Causes exciting attacks . 74 Examination of Heart . Symptoms—Diagnosis—Prognosis 75 1. Position Importance of hygienic precautions 75 2. Size—extent of dulness Treatment 76 Impulsion Pneumonia 77 Sounds—normal—description of. Anatomical characters and division Bellows, rasping, sawing sound . into stages 77 Alteration of the rhythm . Physical signs 78 Intermittent action, congenital Signs of return . 80 Irregularity Local signs . , 80 Purring sound and sensation Secondary affections 81 Pericarditis, frequency of General signs 82 Physical signs of Prognosis—Duration 83 Local symptoms . Treatment 83 General symptoms of—obscure • Local pneumonia 86 Prognosis Asthenic do. 87 Effects—causes . Lobular pneumonia, or pneumo- Treatment nia of children 88 Hypertrophy of Heart Latent pneumonia, and pneumonia Varieties of the aged 90 Anatomical characters Secondary and intermittent 91 Causes . . . . Gangrene of the Lungs 92 Signs and symptoms Signs, local—physical—general . 93 Prognosis and termination Prognosis—diagnosis—causes 93 Diagnosis and prognosis . Treatment 93 Treatment Phthisis .... 95 Dilatation of heart . Pulmonary 98 Diseases of the valves Mode of attack . 98 Secondary affections Symptoms 100 Functional diseases of the heart . General, common, and pulmonary Pulse, Intermittence phthisis, and other tuberculai Angina pectoris . diseases 100 Diseases of Aorta Directly dependant upon the deve- Aortitis . . . . velopment of tubercles in the Symptoms . . . lungs . 102 Treatment Symptoms depending upon the ac- Aneurism of Aorta cessory diseases of the lungs Symptoms and air-passages 104 Treatment Of diseases of other organs 105 Endocarditis . . . . Physical signs 105 Symptoms Diagnosis 106 Treatment PREFACE. Since the year 1834, the author has been engaged in the practical teach- ing of Pathology and Therapeutics, especially the diagnosis and treatment of the diseases of the chest. To supply the wants of his class, and of others who felt an interest in the subject, he published in the year 1835 a short treatise on the diagnosis of thoracic diseases, embodying what was most im- portant in reference to the physical and general signs; this manual did not include the treatment, and was found upon experience to be less complete than was desirable. At the request of many of his pupils, he published a series of lectures, during the years 1840-1, in the Medical Examiner, which, with some additional lectures, are collected into the present volume. The form of lectures is, retained as the most convenient; some of them *s are condensed by a careful hand from the oral lectures of the author; the greater part, however, were written by himself, forming the substance of the course. They necessarily are less full than the lectures as delivered, and the illustrations are of course excluded, but they comprise the most import- ant parts of the subject, such as are most worth being remembered, and seem essential to a knowledge of the subject. For numerous errors of style the author must apologize, and hope that the form adopted by him, and the mode of publication, will be admitted as a sufficient excuse. The same apology is offered for those typographical errors which may strike the reader. The length of the lectures is very unequal, many of them in fact include several lectures, but it was thought unnecessary to break up the unity of a subject by adhering to the divisions which were originally required by the time and order of the course, not by a natural classification. Few or no references are made to authors; these seemed unnecessary, for the history of the diseases of the chest is so well known, that there is little difficulty in determining the source from which the recent discoveries have originated. The publication of the work of Laennec on mediate ausculta- tion gave precision to the history of a class of diseases in which it was before unknown, and, as was soon found, the labours of this admirable observer, far from diverting attention from the observation of the rational symptoms, rendered them more available for diagnosis. Andral, if not the first to discover the bronchial respiration, was the earliest to point out its value; but his most valuable labours as regards the diseases of the chest, are the complete history which he has given of their symptoms and pathological anatomy. The publication of the work of Dr. Louis on Phthisis was another important step in the history of pectoral diseases ; it developed the pathological ana- 4 PREFACE. tomy and symptoms much further than had hitherto been done, and rendered the diagnosis of consumption vastly more perfect. Since the publication of Dr. Louis's work, the additions made to the history of phthisis and pectoral diseases in general have been much less important if taken singly, but in the aggregate are far frtfm inconsiderable. The pulmonary diseases of chil- dren are much better understood, and are known to be more frequent causes of death than those of any other organ of the body; and amongst the affections of adults the pathology of phthisis has been studied in connexion with a general diathesis, or tuberculous predisposition, and not merely as a disease limited to the lungs. The therapeutics of phthisis have advanced to some extent, but in a less degree than the natural history of the disease. The diseases of the heart were but imperfectly known to Laennec ; later investigations, especially those of Bouillaud and Hope, have added more to their pathology than had been done for almost a century before. The therapeutics of these diseases have been, perhaps, more immediately im- proved by recent pathological investigations, than those of any other affec- tions. The lectures included in this volume contain the results of the author's ob- servation, derived indirectly from the different authors who have written on the subject, but in all cases verified at the bedside or in the amphitheatre. They are not therefore properly a compilation, which would require citation of authorities, but are immediately deduced from clinical observation. The plate which is attached to this volume is one drawn for Dr. Pennock of the Philadelphia Hospital, from a dissection made by him. He kindly permitted the author to use it for this volume. The form adopted in printing this volume may deceive the reader as to the amount of matter contained in it, which is about equal to that of an ordinary volume of four hundred pages. Philadelphia, 13 S. Ninth street, March, 1842. LECTURES ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE CHEST. LECTURE I. Uses of Classificalion in the Study of Disease- Signs. Comparison of Physical and General In the study of diseases of the chest, as well as those of other cavities of the body, the clas- sification adopted for the convenience of the pupil must often be arbitrary and imperfect. Diseases which are naturally closely connected together, are separated into artificial subdivi- sions, while others which are essentially dis- similar are brought together in a manner which tends to lead the mind of the pupil from the study of their true relations; still, the artificial divisions which have been admitted for a long time, are in general the most easily recollected, and for purposes of study possess many advan- tages ; while the erroneous conclusions to which an artificial classification sometimes leads may be obviated by attention to real points of similarity, and the natural connexion may finally be re-established after it has been for a time broken up. There is thus a double task for the author or teacher: first, that of analy- sis, for the purpose of discovering and pointing out isolated facts; next, that of synthesis, or of bringing together those which present, in com- mon, strongly marked fundamental characters. Both of these tasks must be kept in new, or the true scientific connexions of disease may be forgotten, and the diagnosis will be merely local, and therefore imperfect, instead of being based on correct and enlarged data. The very division of diseases into those be- longing to the several cavities of the body, is, in a great degree, artificial; and although many of these affections are strictly local, or nearly so, there are others which are nothing more than evident shoots from a diseased root, which 1 extends itself widely throughout the body. In these cases the disease, when it shows itself in the chest, is readily recognised, and is taken as a sign of the general disorder. Sometimes the local disorder grows rapidly, and becomes the prominent malady; but in all such cases it is only a sign of a deeper and more extended mischief. The remarks which are applicable to the study of disease, are naturally extended to the means of discovering it. These are separated according to the various methods of investiga- tion resorted to, whether founded on the gene- ral symptoms, or the physical changes of the part; and they are more or less deceptive with- out a careful comparison, or collation of them, one with another. This is not done by a smat- terer in pathology or in diagnosis; hence, the conclusions attained by him are uncertain, and cast discredit upon medicine, and especially on exact diagnosis. The rules of true phi- losophy, as applied to medicine, do not differ from those of any other science. The same mental discipline, and the same rules of phi- losophizing are required; and, with equally ascertained data, the same degree of certainty may be acquired. We must, first separate a group of facts into detached elements, examine them in every practicable way, and then bring them together again, and reinstate them in a regular and natural order. In all departments of science, especially the natural sciences, with which medicine is so closely connected, we examine the objects of our research in two ways: first, as actually 10 PHYSICAL EXPLORATION. existing; and, secondly, as pa,st. The objects actually present, are known by evident signs; those past,are discoverable by the more obscure traces which they have left behind. We thus discern the modes of a disease, just as we learn the habits of a plant or an animal, from its foot- steps, or the remains of its food ; and we can, in either case, learn the peculiarities which have characterized them during life, or during the continuance of the diseased action, by the phenomena actually occurring, or the changes consequent upon them. We are therefore obliged to discriminate in the study of disease, between those phenomena which are actually going on, and those which have terminated and are no longer of mischief; this obviates many grave errors, and prevents a disorder from being confounded with the lesions which often constitute the proof of its cessation, or it pre- vents us from mistaking the actions which are in their nature mischievous, for those which are useful and salutary. The latter error is one of more frequent occurrence than the for- mer, for the severe diseased action may require for its removal a slighter, but more permanent deviation from *he healthy functions of the part. And although this secondary disorder would, if occurring singly, constitute a disease, it ceases to be one when it is merely a curative agent which exerts a favourable influence with the primary affection. These diseases are often very similar to blisters, or other powerful re- vulsive means, truly curative, and they then only become injurious when heedlessly med- dled with. The recognition both of the primary and se- condary disorders, is more easy in affections of the thorax than in those of other cavities of the body, from our possessing the advantage of two distinct modes of investigation. These are the altered functions, including both those of the viscera of the thorax and of the rest of the body, and the physical signs offered by the diseased organ. The general symptoms of thoracic diseases are learned in the same way as those of other organs of the body; but the physical signs, on the other hand, are so much more applicable to chest affections than to any other disorders, that they are, in practice, with a few exceptions, used only in the diagnosis of the diseases of this cavity, and are generally de- scribed with direct reference to the chest. This peculiar fitness of the physical signs for the stu- dy of pectoral diseases, depends upon the con- formation of the thorax and the structure of the organs contained within it. These are important viscera,—the lungs and heart, which are or- gans possessing different degrees of density, and constantly in motion; hence we may, from the examination of the thorax, not only ascer- tain the density of the organs when at rest, but we may, with great certainty, discover whether they act in a regular and natural manner, and what impediments interfere with their motion. These advantages are not offered by the viscera of any other cavity; for although the physical properties of them are sometimes sufficiently marked to enable us to detect variations in form, or in density of tissue, they are never suscepti- ble of sufficient motion to cause an audible sound by their own contraction, or by the passage of a fluid throughout their cavity. The physi- cal signs are, therefore, chiefly adapted to the investigation of the diseases of the thorax. Physical exploration is much more extended in its application when combined and com- pared with the rational signs, than if used alone. For in itself it teaches us rather the condition of organs as modified by disease, than the manner in which the disease forms, or the mode in which it advances. This is especially the case in the chronic diseases of the chest, which depend upon a general vice of the economy, for in order to distinguish dis- ease from health, by the physical exploration of the lungs and heart, it is necessary that a change should occur in the structure of the tissue,—and as this alteration is only brought about slowly and gradually, we cannot always decide whether the tissue is or is not diseased to some extent, if it be in a degree not sufficient to produce an important change in the conforma- tion^ the part. There is, therefore, no means of arrivirur to a correct conclusion in the diagnosis of pectoral diseases,other than a union of the two modes of investigation, which will then work together as two different ways of arriving at the same end. When physical exploration is properly understood, and compared with the symptoms, it will be found to be even more useful for its negative than its positive results, that is, it will be more useful as a means of showing that some diseases do not exist, or that a given disease is not arrived at a point of structural disorganization sufficient to endanger life, than as direct evidence of the mischief COMPARISON OF GENERAL AND LOCAL SIGNS. 11 already done to the organs. The positive evi- dence derived from physical exploration is so simple and easily discovered, that after ac- quiring a certain familiarity with it, little at- tention is required to discover the full value of the signs; the negative evidence, on the other hand, is much more difficult, for a thorough knowledge of the means of examination, and much practice in using them, are required to pronounce with certainty as to the existence of slight alterations of a part, or the absence of decided structural change. But when the ne- cessary familiarity is acquired, the certainty of the knowledge obtained from this source is such, that we may rely upon its negative evi- dence as confidently as upon its positive signs, especially when compared with the indications derived from the general symptoms. The great value of the negative evidence of physical exploration depends upon its cer- tainty. The process of reasoning which ren- ders negative evidence of value in diagnosis, is called reasoning by way of exclusion; but, although it is of great utility when skilfully applied, it is useless unless a disease is an- nounced by positive signs when it exists, and then we may look upon the absence of these signs as a proof that it is not present. If, on the other hand, the signs themselves be doubtful,the absence of them is of course no proof that the diseasedoes not exist; or if these signs be of such nature that we can ascertain them with ex- treme difficulty, they lose the advantages of serving both as negative and positive evidence. Now, in the diseases to which physical ex- ploration is applicable, this is not the case. The signs are, in general, very easily ascer- tained, and are always, under similar circum- stances, the same; hence they may be used in the way of exclusion with great confidence; that is, when they are not discovered by one who is familiar with the means of exploring them, they may be confidently said not to exist. This negative evidence, as I have already stated, is useful in two ways: first, as evi- dence that there is no disease; secondly, as evidence that there is no great change of struc- ture. The first requires that the general symp- toms should agree, as it were, with the physi- cal signs, in proving the integrity, or the com- parative soundness of the part. The second requires that the physical signs should be, to a the general symptoms. But, as this seeming discrepancy is applicable only to the degree of the alteration, and not to its nature, there is, in fact, no real contradiction between the two means of examination. On the contrary, they will be found, when compared together, to ac- cord singularly in the principal deductions which are drawn from each of them. The extent of application of the physical means of exploration is, perhaps, novel to many persons who are not familiar with the beauti- ful application of the laws of diagnosis, by way of exclusion, in which the certainty of the physical signs renders them even more useful, than in other cases in which a precision which approaches mathematical correctness is requir- ed ; but this very certainty may render them an occasional source of error with those who are neither accustomed to their use, nor per- fectly familiar with the ordinary symptoms of disease. That is, an art which is evidently based upon fixed physical laws, may lead to error when the data upon which the problem of diagnosis is founded are not perfectly settled, although the process of reasoning may still be the correct one. But, the abuse of a certain method of observation does not constitute a real objection to its employment; it merely proves that it is necessary to surmount the first difficulties which attend its acquisition. The great importance of the comparison o\ the general symptoms and physical signs has become more apparent with the more general employment of physical exploration, as a really practical aid to diagnosis. The earlier writers on auscultation, especially Laennec, were ra- ther disposed to separate physical from symp- tomatic diagnosis: this error depended upon the novelty of the art, and the overstrained efforts to extend its application,—but as phy- sicians became more familiar with it, and had opportunities for testing its merits, it was placed on its real footing, and regarded as the most useful of all symptoms taken singly, but as neither the only class of symptoms to be relied upon, nor as superseding the general sio-ns. We are indebted to the French patho- logists for pointing out the necessity of com- parison of all the symptoms of pulmonary dis- ease, and of connecting this comparison with their succession or order. It is a subject largely insisted upon in the writings of Andral, ZZlZlZoZZlteTo] ol^ven'by |but one which was most completely developed 12 PHYSICAL EXPLORATION. in the lectures of Dr. Louis. It afterwards received much attention from Dr. Stokes, and others, who have occupied themselves with the study of pectoral diseases. Although it is not at this time necessary to in- sist upon the truth of the physical signs to those who are conversant with their use, their certain- ty may still appear questionable to a few who are not practically acquainted with them. As these signs are based upon the settled laws of physical science, and in fact involve some uni- versally admitted principles, the only reason for doubting their accuracy is a want of due knowledge on the subject. But as a certain acquaintance with them is necessary to appre- ciate the evidence upon which they depend, I may properly enough point out what is included under the terms physical exploration and phy- sical signs. Physical exploration includes the modes of ascertaining the changes which occur in the physical structure of organs; these changes we appreciate by the alterations of form, and by the sounds produced in the inte- rior of the body by the motion of solids, or of elastic or non-elastic fluids, or by the resonance which is yielded by the surface when tapped or struck by the finger. This latter mode of examination obviously depends upon the differ- ent density of organs, and in the cavity of the thorax, chiefly upon the existence of air, and the percussion is more or less clear or dull, as the quantity of air contained within the thorax is greater or less. The alterations of form are few in number, and are readily learned; but the signs dependent upon changes in the sounds produced by the passage of the air and of the blood within the thorax, or the resonance of the air when thrown into motion by the act of speaking, seem comparatively difficult, and involve more complicated phenomena. The same remarks are applicable to the signs of percussion, which are not a little difficult; but in either case, the sounds are regularly and uniformly the same under similar circum- stances. The difficulty in learning the phy- sical signs consists in two distinct points; first, in the acquisition of the sounds themselves, considered as simple phenomena; secondly,in the knowledge of the condition of. the organs which corresponds to these sounds. The sounds themselves require not only to be learned well enough to be understood, but they must be fixed so thoroughly in the mind that no room should be left for mistaking one for another. This demands time, attention, and organs of hear- ing which are not physically incapable of dis- criminating between sounds which at first may seem nearly similar. The first difficulty is surmounted; there still remains the other, which requires a knowledge of many circum- stances which are connected with the pathology of the disease. These are those which relate to the physical condition of the organs or the pathological anatomy of the parts, and to the functional action of the organs which is ne- cessary for the production of most of the sounds. Hence the knowledge of the physi- cal means of exploration requires no little time and attention, and cannot be learned in a care- less or hasty manner. There is, therefore, this impediment to the study of the diseases of the chest, and of phy- sical exploration, that the act itself is a matter of difficulty, and requires more labour than is willingly bestowed upon it. The whole pro- cess of investigation requires this attention; even the manual or mechanical precautions ne- cessary to be taken, are not to be learned at the first trial, but require time in the performance of this art, like that of every other; for the ear and hand are not at first capable of the delicate and varied actions necessary for the satisfactory exploration of the thorax. But, although the apparently complex nature of physical explo- ration may prevent many from attempting its study, the difficulties which at first present themselves are readily enough removed by pa- tient and laborious attention, and are more than compensated by the certainty which results from a mode of investigation based upon fixed physical laws. Every step in the acquisition of this knowledge is appreciable, and in pro- portion as it becomes more accurate, the diag- nosis of disease assumes a new character,which is never acquired when confined to the func- tional symptoms. This is true even at pre- sent, when the comparison of local and general symptoms to which I have just alluded has rendered the latter much more clear, and their value better defined. The physical signs have served as a point of departure, with which to compare the rational symptoms, and have thus rendered the latter more easy of recognition, and more positive in their relations with the internal lesions of the thorax. This is so ob- viously the case, that a glance at the works of COMPARISON OF GENER AL AND LOCAL SIGNS. 13 any of the later writers upon the subject is sufficient to show that the rational signs have become of more practical service for the study of diagnosis than they have ever been before, and that many of these symptoms have been investigated with a care which was never be- fore bestowed upon them. Some symptoms, it is true, have fallen into comparative neglect, because they are no longer of decided utility in diagnosis, but the greater number have de- rived new value from their connexion with the physical signs. As the diagnostic characters of the diseases of the chest are composed of several distinct sets of symptoms, they may be studied after each class of symptoms has been separately learned, or the diseases themselves may be first observed, and the symptoms analyzed as they present themselves at the bedside. The former method is naturally adopted in a sys- tematic treatise, or course of lectures; the lat- ter belongs more properly to clinical or demon- strative medicine,—a subject of which I treat more at large in another place. As the object of the present series of lectures is not only to explain the mode of application of these me- thods of investigation to the study of disease, but to teach the methods themselves, it re- solves itself naturally into two parts. The first part will contain the explanation of the physical signs, and teach the method of ac- quiring them which 1 have found most conve- nient for the pupil. In connection with this portion of the lectures, I shall treat of those functional symptoms which are immediately connected with the organs of the thorax, and are therefore most conveniently studied at an early part of the course. The second part will be devoted to the study of individual diseases in connection with their symptoms and treat- ment. The series will thus comprise, as nearly as my time will permit, a complete history of the modes of exploration'used in the diseases of the thorax, and of those diseases themselves. The difficulties which attend the study of pectoral diseases, depend more, however, upon an imperfect method, than upon the subject itself, and may be obviated in a great degree by adopting an order which is in harmony with the natural connexion of these signs. In all essential particulars they are readily under- stood when they are pointed out by one who is practically familiar with them; one who is yet unpractised becomes embarrassed when he examines a patient without the aid of an ad- viser. Signs which are really different are sometimes confounded together, and those which are mere varieties of the same species are thought to be perfectly distinct. If the signs are well characterized sounds, their dis- crimination should always be easy, and error would be impossible. That is, the correspon- dence between the sounds in certain physical conditions is necessarily exact, and the chances of error depend upon an erroneous interpreta- tion of them. The interpretation is very dif- ferent from the recognition of the sounds, and necessarily includes more data and more com- plicated reasoning; but there can be no reason for not detecting a sound connected with the chest; it should be at least as easily recog- nised as the tone of voice or spoken lan- guage ; it does not require any peculiar nicety of organs, or a finely cultivated musical ear, but merely a good organ, and the attention necessary for observation of any natural phe- nomena. I shall endeavour to arrange the physical signs in such an order as will facili- tate this part of your study, and shall explain the method of acquiring them which you will find most convenient. The great secret is to give great attention to the signs at first, and fix each one in your mind as you go on. If you content yourselves with detecting them when pointed out to you, and merely under- standing the differential characters without actually knowing them, you will gain but little, and you will never acquire the knowledge of them which is practically useful. The best method of avoiding the habit of careless ob- servation, is to dwell long upon each sign at first, and afterwards connect it with others which are closely related to it, and are met with either in the same or in other patients. The whole matter will in this way be ren- dered singularly easy. LECTURE II. Conformation of Chest—Circumstances influencing if—Mode of Examination— Mensuration—Succussion. My first lecture was designed to prevent a frequent source of error, which often produces either an obvious or a concealed influence upon the mind. This is a desire to lay too much stress upon a single set of symptoms, to the neglect of others, and to examine a disease of a part of the body as if it were nearly or alto- gether unconnected with the same or with dif- ferent disorders which attack other organs and tissues. In commencing, therefore, a course of lectures which are founded upon the posi- tive evidence of anatomical lesions, and of the corresponding physical signs, I would put you upon your guard against too anatomical a view of the subject, too exclusive a study of lesions, and warn you against allowing the results of disease to be confounded with disease itself, or the physical signs which constitute the key to so many important researches, from being mistaken for actual diagnosis. It is the de- - ductions from the whole of the physical signs and functional symptoms which constitute the diagnosis, not the naked examination of a sin- gle set of them. This may seem a matter which is too trivial to attract much notice; but in practice it is of much moment, and the er- rors which I have seen from a neglect of it are frequent, and very readily committed. It may seem to you that this is reasoning against myself, as it were, and attacking the subject upon which I lay so much stress; but, in pro- fessing to give a course of lectures on diagno- sis and treatment, I am necessarily led to an enlarged study of pathology, and to the* view of the subject which seems to me most con- sistent with facts,—that is, one embracing the relation of the phenomena one to another. I am also unwilling that you should diminish the value of positive observation, by drawing any inferences which the actual state of the subject will not fully warrant; this would be the case, if, at the commencement of your stu- dies, you fall into a contracted, imperfect mode of reasoning. After warning you thus earnestly against the abuse of the physical signs, I may proceed to point out the best method of avoiding or overcoming the difficulties which you meet with at the commencement of your studies. They depend in a great degree upon the want of fixed starting points from which the study of the subject may begin. These points are readily enough learned by those who possess the advantages of examining for themselves, after the sounds have been pointed out by their teacher; and they are, perhaps, less necessary for you. This is not the case with many of those who may read, but do not hear these lec- tures ; and it is therefore necessary to explain fully the best mode of learning the sounds,— that is, of acquiring a sufficient number of sounds to serve as a point of departure, and guide for subsequent study. This method supposes that the sounds are analyzed and se- parated into their elements, and requires at first more than an ordinary share of attention; but the whole time required for learning the art is much shortened, and the subject greatly simplified. Most of these initial sounds may be disco- vered in the healthy body,—that is, sounds sufficiently similar to those you meet with in disease, to enable you to recognise them when they are heard; and if these are thoroughly learned, the remaining sounds, which are the most easy, are quickly acquired. You will find it to your advantage to follow very nearly the process which I shall point out, for the purpose of simplifying those sounds; for al- though it is not indispensably necessary for you, it is highly useful, and really will shorten the time and attention required in their study. In studying the physical signs, I follow as nearly as possible the most natural method, re- serving to myself, however, the privilege of deviating from it as often as may be advisa- ble. The physical signs, properly speaking, may CONFORMATION, MENSURATION, ETC. 15 be classed under the heads of alteration in the conformation of the thorax, resonance of the chest on percussion, and the sounds yielded by respiration, or produced during the act of coughing or speaking. These constitute the signs which may be regarded as strictly phy- sical. There are some other signs, which, although less important, are, to a certain ex- tent, classed among the physical signs; they belong more properly to the conformation of the thorax, than to any other division: under this head I shall treat of them. These are, succussion, or giving to the patient a sudden shake, to ascertain the presence of air and li- quid in the cavity of the pleura, which is rarely practised, and is, in the majority of cases, both totally unnecessary and highly disagreeable to the patient; palpation, or examining the chest by placing the hands upon it, and pressing them carefully along the lateral portions of it. CONFORMATION OF THE THORAX. The thorax, it is well known, resembles an irregular truncated cone. It is flattened on each side, and presents numerous inequalities, depressed in one part, and elevated in another. For the convenience of study, it is usual to examine it anteriorly, posteriorly, and laterally. Of these surfaces, the lateral, or the axillary, are the most regular,—the posterior, the least so. The walls of the thorax do not represent precisely the space occupied by the lungs and heart; for the liver, spleen, and stomach, en- croach slightly upon the lower part of the ca- vity. This is particularly the case with the liver, which rises on the posterior part of the chest, nearly half an inch higher than the cor- responding boundary on the left side. On the whole, the lower boundary may be repre- sented by a line drawn from the spinous pro- cess of the twelfth dorsal vertebra, to the lower bone of the sternum : on the left side the boun- dary begins also at the twelfth dorsal vertebra, but passes at a distance of half, or at least one- third of an inch higher, until it reaches the precordial region. The lower boundary of the chest, as thus defined, is not always the same, as the size of the liver is of course variable, and the dimensions of the thorax are necessa- rily influenced by this circumstance. This line is not followed with perfect regularity, especially on the left, side, where the heart passes a little beyond the limit of the adjoin- ing part of the chest. At the upper boun- dary, the difference of the two sides is less; on the right it sometimes rises a little higher than upon the left, from the greater de- velopment of the muscles and bony parietes of the thorax on that side; but this difference is, in general, so slightly marked, as scarcely to attract attention. The lungs extend a little beyond the clavicles, especially during the act of full inspiration, not exceeding half an inch. At the posterior part of the chest, the upper boundary is formed by a line drawn from the upper doisal vertebra, outwards and down- wards towards the point of the shoulder. When the conformation of the thorax is per- fectly normal, it presents an irregular plane on each of its four sides; but the angles of these planes are sufficiently rounded to retain a ge- neral conoidal shape. Each side of it offers several elevations and depressions; at the an- terior part these correspond with peculiarities of form of the viscera, and are really formed by the parietes of the chest; but the irregulari- ties of form at the posterior part are owing, in great part, to the muscles, and to the scapulae. The clavicles form a ridge, which is slightly arched ; the space above them is therefore de- pressed, except the patient be extremely cor- pulent, or labour under a disease of the lung or pleura. Beneath the clavicle, another de- pression, but one much shallower, exists; it extends to the lower part of the second rib. The space below this depression is slightly and regularly convex as far as the upper edge of the liver; at that level there is, in many persons, on the right side, a slightly depressed line, which corresponds with the interval be- tween the liver and the lungs. On the left side, in young persons, there is often a promi- nence corresponding to the heart; this is slightly marked, and never decided, as it is in cases of real disease of this organ, or effusions within its investing membrane. The lateral portions of the chest are regu- larly bulging from the apex to the base; and as the walls are here thinner than elsewhere, and nearly without muscles, the external form corresponds nearly to the lungs. The posterior surface is rendered irregular by the scapulae; but at the part uncovered by this bone its form is nearly as regular as that of the other portions, gradually widening 16 PHYSICAL EXPLORATION. towards the base of the chest. A slight de- pression, or gutter, exists on each side of the spine, for the reception of the dorsal muscles. The lower and posterior portions are often di- lated from effusion into the pleura, and yield to the pressure of liquid with great readiness. The upper part is not changed in conforma- tion, except the quantity of liquid be very large. The contraction of the chest is also extremely obvious at the lower portion after the absorption of pleuritic effusions. In children the form of the chest is much more rounded than in adults; and in women, although the exterior seems more irregular than in males, yet the proper bony parietes are much more regularly formed, and are more conoidal in form. The conformation of the chest, it is well known, is often characterized by individual pe- culiarities. Thus, some individuals are called chicken-breasted, from the prominence of the sternum, and others present a well-marked de- pression at the lower portion of this bone, which is sometimes congenital, and at other times is caused by trades or occupations which oblige the followers of them to work in a con- strained posture,leaning forwards; this is par- ticularly the case with shoemakers, who nearly all present this depression after working at their trade for a few years. Other individuals, who are thin, and of a feeble constitution, offer a remarkable contraction of the parietes of the chest; but, in all these cases, the contraction is more or less general, instead of being confined to a single part of the chest.— When it depends upon disease it is much more local, and is caused in nearly every in- stance by pleuritic adhesions, which draw the walls of the chest towards the lungs. En- largement of the chest, beyond the natural average, is nearly as frequent as contraction. When it coincides with a general development of the body, and evidently depends upon a stout and large frame, it is of course indicative of health, rather than disease. The morbid dilatations, properly so called, are local, either limited to a part, or to the whole of one side of the chest; on this account they are readily recognised. They depend either upon an anormal development of these organs, or upon dilatations caused by effusions of air or liquid into the serous or mucou3 cavities of the chest. The comparison of the two sides is requisite, in order to recognise dilatations or contrac- tions of the chest; and the thorax must be ex- amined throughout in nearly every position, so that its true and relative dimensions may be ascertained. It is not necessary that the chest should be exposed in order to examine its conformation, although this is much more convenient than to inspect it when covered. When no objec- tions exist to exposing the chest, the patient should be placed in a sitting posture, or remain erect; if that be impossible, he should lie upon his back, and quite straight, so that the light may fall upon his chest: a cross light may of course give rise to error. The patient should then remain at rest, with his arms lying quietly by his sides, or slightly crossed, if the posterior part of his chest be examined; in this way the whole of the anterior or posterior surface may be taken in at a glance. An examination of this kind is, of course, not practicable, in cases of women, or of patients who are sweating profusely: under such circumstances, you must content yourself with the partial inspec- tion which is practicable when the body is more or less covered by clothing, and you may aid in this examination by passing the hands lightly over the thorax. The examination by the touch is especially convenient for the poste- rior and lateral parts of the chest,where the mor- bid dilatation is generally most considerable. The examination by the touch is called pal- pation, but I do not think it at all necessary to multiply terms in the description of the me- thods of physical examination. Palpation, then, is nothing more than the examination of the chest by means of the touch ; it aids the sight, and often may be substituted for it when the patient is too thickly covered. The hand forms, as it were, a kind of natural callipers, and will give very accurate results. If you examine the lateral and inferior portions of the chest, you may place the whole palmar surface of the hand upon it; if the anterior and upper portions be examined, the fingers may be passed lightly over it. In this way you can detect any abrupt deviations from the natural conforma- tion, but a general and moderate rise or depres- sion cannot be detected except by the sight. If you cannot resort to this means of investi- gation, you must content yourselves with the other physical signs. • CONFORMATION, MENSURATION, ETC. 17 Dilatation of the chest is necessarily pro- duced by all diseases which give rise to en- largement of the pulmonary vesicles, or to dis- tention of the pleune. Those which act upon the pleura? are inflammation, the products of which are serum, lymph, and purulent matter, or dropsy, in which the secreted fluid consists merely of serum. The effusions arising from pleurisy are nearly always confined to one side of the chest, take place rapidly, and are much more local than those of hydrothorax, which extend over a large surface, and are not con- fined to a single lung. Hence the pleuritic distention begins chiefly at the base of the lung, and extends upwards, involving the whole of one side only in those cases in which the quantity is extremely great. Pericarditis gives rise to dilatation from the same cause as pleurisy, and the prominence follows very nearly the shape of the pericardium, and is therefore somewhat triangular, the small ex- tremity upwards. The extreme dilatation which takes place in severe cases of pleurisy, in which the whole side of the chest is en- larged, elevates the shoulder, and gives the whole body an inclination towards the healthy side. This is often evident when the patient walks or sits in the erect posture. The effu- sions of liquid in the serous membranes give rise to the most decided, and, as it were, abrupt prominence of the chest; which the dilatation produced by enlarged vesicles is, in general, less decided, or, at least, more gradual. It gives rise to a more equable and moderate bulging of the chest, than that from effusions of liquid into the serous cavities. Of course it is most marked near those parts of the lung where the vesicles are most frequently dilated,—that is, along the anterior portion of the chest, on each side of the sternum ; but, if it involve a large portion of the lungs, the shoulders are some- times elevated, and the space above the clavi- cles becomes prominent, instead of offering a slight depression, as it does in the natural state. Contraction of the thorax is a consequence of many diseases in which pleurisy has occurred, either as a primary or secondary lesion ; but it is most marked in cases of primary pleurisy, especially where the quantity of effused liquid has been large. Tn the secondary pleurisy which follows or accompanies phthisis, contraction almost invariably takes place, and usually occurs near the summit of the lungs, so that the natural depressions, both above and be- low the clavicle, are exaggerated. Some- times the depression reaches to the lower portions of the lung, as in ordinary pleurisy. The latter variety usually follows those cases of phthisical pleurisy which have commenced in the ordinary way, and in which the develop- ment of tubercles takes place rather late in the disease, after the inflammation has ceased, or at least has diminished. The general rule holds good, that contraction is evidence of pre- vious pleurisy,—the exceptions are nearly all of a doubtful nature. In a few rare cases the tissue of the lung contracts from the partial or complete cicatrization of a cavity, or of an inflammation, although the attendant pleurisy may not be sufficiently extensive, or the adhe- sions strong enough to account for the depres- sion. In these cases we are bound to admit that the pressure of the atmosphere has filled up the vacuum which would otherwise have been left. In the depression which follows pleurisy, it is true that the process is somewhat similar, as I shall show when speaking of this disease, but it is less strictly physical, and more dependent upon the contractile power of the adhesions. The absorption of the effused liquid in pericarditis does not give rise to a de- cided depression; it sometimes exists, but only in a slight degree. I have given to you the general indications derived from an examination of the form of the thorax, and rely, as you may observe, chiefly upon the results which are derivable from the sight and touch. In a few cases the chest may be measured on the two sides, in order to estimate the difference in the semi-circum- ference more exactly, by passing a tape around the thorax, from the extremity of the spinous process of a vertebra, then marking the point corresponding to the middle of the sternum, and afterwards comparing the two parts ex- tending from the sternum to the spine together. The seventh or eighth dorsal vertebra is the most convenient for this purpose. The mea- surement which is thus obtained is, of course, correct; but it applies only to those cases in which the difference is very evident, unless the dilatation occurs in the left side. In the latter case the increased dimensions are readily per- ceived ; for the right side is naturally larger than the left, and the difference is more or 18 PHYSICAL EXPLORATION. less according to the habits which the indi- vidual may have of exercising the right arm, more than the left: a difference in favour of this side would therefore be comparatively of little moment. Mensuration is therefore of little value. There is another mode of exploration which is termed succussion ; it belongs to this part of the course as properly as to any other. I use the term merely to explain to you the method of per- forming it, not to advise you to resort to it. The method itself is sufficiently simple, and consists merely in placing the hands on the shoulders of the patient, and giving him a sud- den jerking motion. If both air and liquid are contained in the cavity of the pleura, a gurgling, almost a splashing sound, is pro- duced. There are other methods of investiga- tion which are sufficient to make this state of things perfectly evident, so that we need not in any case resort to succussion. LECTURE III. Percussion—Rationale—Mode of Performing—Pleximeter—Division of Chest into Regions—Value of Percussion. We now come to a highly important part of the subject—this is, percussion, or the method of estimating the density of the viscera con- tained within the thorax, by tapping lightly upon its surface. The rationale of this is very simple: The lungs occupy the greater part of the thoracic cavity, and are filled with air. If percussion be made upon them when removed from the body, they yield a very clear sound, especially if a solid yet elastic body be laid upon them, which may receive the impulsion of the striking body, and prevent it from sinking into the soft pulmonary tissue. Now, this elastic body, or sounding-board, exists naturally in the thorax, and is formed by ribs and carti- lages; and a light tap upon their surface, that is, on the exterior of the chest, gives a clear, full, hollow sound. When the patient is thin, and the skin is very sensitive, he will not bear a smart tap without inconvenience; and, on the other hand, if he is very corpulent, or if the subcutaneous cellular tissue be infil- trated with serum, the sound will be quite dull, and will not truly represent the condition of the internal organs. In order to prevent this chance of error to the observer, and incon- venience to the patient, we interpose an addi- tional elastic body between the chest and the end of our finger. This interposed body is called a pleximeter, and was invented by Dr. Piorry. Its only utility is to increase the body of sound, by giving more resonance to the elastic parietes of the chest, and to pre- vent the direct impression of the fingers upon the chest of the patient. Though the ribs are an excellent natural pleximeter, they are too sen- sitive at times, and at others are rendered use- less for physical exploration, by the softer sub- cutaneous deposits. By applying an artificial pleximeter we not only increase the fitness of the natural sounding-board, if we may so call it, but we bring it into play, by compressing, and, as it were, thrusting out of the way the tissues which impede its vibrations, and then we gain the important advantage for our- selves and our patients of preventing pain, or perhaps of increasing the disease. The only method of performing percussion which is now practised, is that by means of the plexi- meter. It has so many advantages over immediate percussion, or the striking with the ends of the fingers directly upon the chest, that it is much better fitted for every purpose. The pleximeters'used are various; that is, those that may be used; for, practically, they are reduced nearly to the most natural plexi- meter, that is, the forefinger of the left hand. But if you choose, you may make use of a piece of gum elastic, of ivory, or of metal. You take this in the fingers of the left hand, and hold it firmly upon the chest, after- wards percussing in the usual way with the right hand. If it be not applied firmly against the chest, a clacking sound is immediately produced by the air which is interposed be- tween the instrument and the skin : this clack cannot be entirely obviated, for the tap upon the instrument will of course give rise to sound. If the material be very dense, the sound will be sharp and decided, and interfere a little with the pulmonary sound, that is, the reso- nance developed by the tissue of the lungs; for this reason there are some advantages attend- ing the use of the gum elastic pleximeter, ra- ther than an ivory or metallic one, which is harder, and of course gives rise to more sound. The elastic instrument was, I believe, first proposed by Dr. J. B. S. Jackson, of Boston, and is the most convenient. You can readily enough make one for yourselves, by taking a a common piece of gum elastic of the flat kind, about a quarter or a third of an inch thick, and about two inches square, that is of a size con- venient for holding in the fingers. The density of gum elastic is more nearly similar to that of the chest, than a harder material, which is an additional reason for its employment, as it 20 PHYSICAL EXPLORATION. contributes to give it a clear, uncomplicated sound. The gum elastic pleximeter is simple, but all of you are provided with one which is much more simple, and which you see me resort to— it is the forefinger of the left hand. In thin persons, the finger is even more bony and elastic than the ribs ; in those who are fatter, or whose hand is remarkably stout and cover- ed with a thick skin, the finger loses its elas- ticity, and is not so well fitted for the office of pleximeter. Still, under ordinary circum- stances, it is the best one which you can em- ploy, and is superior to any of the ordinary artificial instruments, from its ready adapta- tion to different parts and irregularities in the chest. The finger may in this way be placed behind the clavicle or below it, and be brought very near the lung, which could not be done with a broad and flat plate : any single limit- ed spot may be examined in the same way with great ease. This natural pleximeter may be used in two ways: you may apply the dor- sal or palmar surface upon the chest, and of course tap upon the reversed side; if you ap- ply the palmar surface upon the chest, the dorsal side upon which the percussion is made is firm, and gives a sharp clear sound; it is much better, therefore, for the accurate appre- ciation of slight deviations from the natural standard. The palmar surface is occasionally more convenient, especially when it becomes necessary to apply the finger to the depression behind the clavicle,—it is of course better for this purpose that the finger should be curved to fit this depression; hence, percussion must be made upon the palmar surface. Much of this nicety in the mode of applying the finger which serves as a pleximeter, will be found to be unnecessary, and may be dispensed with after a little practice ; the shape of the hand and fingers of the observer will, however, have some influence on the position which will be found in practice most convenient. The most difficult part of percussion is not, however, the application of the hand which serves as a pleximeter; this is very soon ac- quired. Much difficulty, however, is often met with as to the method of tapping or strik- ing with the right hand upon the pleximeter finger. You may use for this purpose either one finger or several, but you will find that for children, and for persons who are very thin, and whose chests are therefore tender, a sin- gle finger will be most convenient. Whether you use one or more fingers, the essential part of the process is to hold the hand as firm as possible, and to give the greatest possible elasticity to the wrist. The motion should therefore be performed in the wrist, and not in the shoulder or elbow; if you strike with the whole arm, however gently it may be, you are apt to give the patient pain, and you are sure to deaden the sound. The sound depends upon the elasticity of the wrist, and if the fingers be suffered to remain in contact with the plexi- meter, or the thorax, a moment longer than is necessary for the percussion, the sound will be proportionately obscured. The slowness of the motion is a frequent error with those who are slightly acquainted with physical exploration. They are apt to pause as soon as the finger touches the surface, and allow it to remain in contact with the part, this is altogether wrong. It is at first difficult to acquire the perfect free- dom of motion which is essential to elastic, clear percussion; still, it is perfectly practica- ble, with a little perseverance and experience. If you use a single finger for purposes of percussion, there is little difficulty in hold- ing it in the proper position. Either the fore or the middle finger of the right hand may be selected as the percussor; you then bring it, as nearly as possible, into the form of a light mallet or hammer, and make the second and third phalanges serve as the head of the ham- mer ; of course, they must be flexed at right angles with the first phalanx, and must be re- tained firmly in that position, otherwise the form of the hammer is lost. The extremity of the finger should be as nearly at right angles with the hand as possible, otherwise the tap is not made with the extremity of the fingers, but the pulp, which is a matter of essential consequence, as the pulp of the fingers is soft, and non-elastic, and deadens the sound. If the thorax be covered with fat, or the parietes be infiltrated, it is necessary to percuss more strongly than is possible with a single finger; in that case bring the three middle fingers of the hand together, and allow them to rebound together after striking upon the plexi- meter; they thus give a more forcible impulsion, and a sound nearly as clear as if a single finger PERCUSSION, RATIONALE, MODE OF PERFORMING, PLEXIMETER, ETC. 21 were used. Indeed, you will generally find this method the most convenient for the examina- tion of the chest, although, as I have al- ready stated, a single finger is the best per- cussor in cases of children whose chest is thin and very elastic, or in those whose thorax is very nearly in the condition of that of children, from emaciation. Although when you use several fingers, your tap is of course stronger than if a single one be employ- ed, you will find in either case that it is not the force, but the sharpness and quick- ness of the impulsion, which produces the sound. A hard blow causes so much clacking sound against the finger that it proves a source of error, and renders the full resonance of the chest more difficult to draw out. Plain and easy as these directions are, pro- bably not one of you will at first practise them correctly; you will find that the elasticity of wrist, and light, clear tap, are learned but slowly, and after many efforts. There is, however, an easy method of improving your knowledge of percussion: repeat the operation frequently upon yourselves, at night, when you have removed your outer clothing, and all is quiet around you, a slight difference in sound then becomes perceptible, and the causes Which render it dull are evident, and you thus learn to avoid those errors which are embar- rassing from their apparent trifling insigni- ficance. Notwithstanding all your care, you will not make equal progress in this matter; to acquire a perfect facility, a light and rather thin hand, and a correct ear, are requisite; if you have not these advantages, you will expe- rience more difficulty,—but with more practice and more attention, it may be overcome. An instrument has been contrived by Dr. Bioelow, of Boston, for percussion. It is a piece of whalebone or elastic wood, covered at the end with a ball of velvet or buckskin; the ball is nearly an inch in diameter: it is a very good instrument if any accident should deprive you of the full use of your fingers: the objec- tions to it are, of course, the trouble and com- plexity of its use; hence Dr. Bigelow himself advises it merely in hospital practice, where you have a large number of patients to exa- mine, and your fingers sometimes suffer from constant tapping. If you use this instrument, tap with the ball upon the pleximeter, which should be made of gum elastic. While I was at Paris, an ingenious friend of mine imagined an instrument for measuring the sound of percussion. It was to consist of a percussor somewhat similar to that of Dr. Bigelow, but inclosed in a large stethoscope. The percussor was to be set in motion by a spring and wheel, as in watches, and the ear to be applied to the stethoscope in the usual way during the action of the instrument. The idea was ingenious, but the practical applica- tion of it almost impossible. Any contrivance to assist the senses in diagnosis must be ex- tremely simple, or it will be practically use- less; and, as a general rule, you will do much better to trust to your hands alone for the per- cussion of the chest. Percussion is applicable to the study of ab- dominal as well as thoracic diseases; indeed, it is largely applicable to the exploration of many diseases of the former cavity. The ab- domen contains solid viscera, such as the spleen and liver, and tubes filled with gas or liquid. The gaseous contents are much more abundant than the liquid; hence the sound is clear over the greater part of the abdomen from the gas retained in the alimentary canal. If the quan- tity of gas be increased, you necessarily have an increased resonance on percussion, and the converse is, of course, true; this fact enables you to estimate the effusion of liquid in the pe- ritoneum, the enlargement of the solid viscera, and the distension of the cavity of the intes- tine with a large quantity of gas, which causes a tympanitic resonance. The same manual method of percussion is applicable here as in the exploration of the thorax; but, in general, you will find that a very light tap, with a sin- gle finger, is the best, especially in those cases in which the gas is contained in the larger intestines, and therefore approaches very near to the surface. Percussion of the abdomen is always prac- tised when the patient is lying upon his back, and the surface of the abdomen therefore placed in the situation most convenient for examination; but in the thorax you vary the position,—that is, you vary it in all those cases in which the patient is well enough to change his posture at pleasure: if he be too feeble for this, you must, of course, examine him in any way that happens to be practicable. In ordi- nary percussion your object is to place the pa- 22 PHYSICAL EXPLORATION. tient in such a position that you may render the parietes of the chest as tense, and conse- quently as elastic as possible; the muscles must therefore be put upon the stretch, and the skin drawn tightly backwards. In percussing the anterior part of the chest, the patient should sit upon a chair; or, which is still bet- ter, stand erect, and throw the shoulders slightly backwards, so as to render the pecto- ral muscles tense; for the posterior part of the chest the position should be reversed; the pa- tient must lean forward, and' cross his arms strongly, to draw the scapulae from the spine, and throw out the arch of the back. To exa- mine the axillary region, the arms should be raised above the head. The chest may be percussed at first in a cursory way on each side, to gain a general idea of the condition of the viscera, and afterwards you may proceed to the details, and compare the sonorousness of different parts of the lungs and of the heart. The lungs are not equally sonorous throughout their whole extent; for as the clearness of the sound depends upon the large quantity of air contained in the vesicles, and the small quan- tity of solid matter, a difference in the relative proportions of these parts will give rise to va- rious degrees of resonance ; thus, the sound is most clear wherever the vesicles are most nu- merous, and the larger bronchial tubes, whose walls are thick and firm, are least developed; for the thin parietes of the vesicles present no obstruction to the vibration of the air contained within them, but the hard walls of the bron- chial tubes offer a very decided obstacle. Hence, if other things be equal, the sound may be stated to be most clear at the lower part of the chest, and along the anterior margin of the lungs, while it is comparatively dull at the summit and root; in the rest of the lungs the sound is intermediate, neither dull nor clear. Where the lungs are so situated as to overlap the more solid organs of viscera contained in the chest, the sound is but moderately clear, becoming more dull as the thickness of the so- lid organ is greater than that of the lungs. This is the case both with the liver and heart, and is a fact which is analogous to the phe- nomena observed in a diseased state of the lungs, where a lesion which renders the deeply seated parts of the pulmonary tissue more so- lid, makes the percussion dull over the cor- responding parts of the lung. The dulness of sound is observed, notwithstanding the superfi- cial portions may be perfectly pervious to the air. The relative quantity of bronchial and vesi- cular tissue gives rise to the modifications in the clearness of the sound in percussion to which I have alluded, and the resonance of the vesicular structure is quite different from that which would be caused by the same quantity of air contained in a single bag, or large vesi- cle. If the air contained in a large number of scattered vesicles were collected together, and percussion were made upon the sac which con- tains it, the sound would be drum-like, or tympanitic. This character is actually ob- served in certain morbid conditions of the chest, but is never similar to the healthy sound, which is more deep and hollow, but at the same time less gaseous. The difference between the two varieties of the clear sound will be appreciated at once if you examine the chest, and then percuss downwards until you come to the hollow viscera of the abdomen, which yield the tympanitic resonance very different from the hollow sound, which you may call vesicular. After you have gained a general idea of the resonance of the chest, you should proceed to a more thorough examination of the various portions of it, one by one. For this purpose, it is convenient to divide the chest into regions or parts. These may be the anatomical divi- sions corresponding to the exterior of the chest, as the clavicular, scapular regions, &c; or you may use terms expressive merely of the fractional parts into which the surface is divided, such as thirds, fourths, &c. For most purposes, the latter method has seemed to me to be the most convenient. When you wish to be more exact, you may subdivide these regions, or you may, in addition, desig- nate them by a reference to their anatomical relations; but if you divide the anterior and posterior surfaces into three parts, and the ax- illary into two, you will find it sufficiently minute for most purposes. The anterior sur- face may be divided, therefore, first, into an upper third, extending from the summit of the lung to the lower margin of the second rib, and of course including the anatomical subdivisions of post-clavicular, or the space above the cla- vicle ; clavicular, or that corresponding directly to this bone; and sub-clavicular, or the region PERCUSSION, RATIONALE, MODE OF found immediately beneath it. This portion, in general terms, may be said to correspond with the summit of the lung, and is of great interest to the physician; for it is the ordi- nary seat of tuberculous diseases, which of course render the sound dull; and occasionally of pneumonia, which produces the same effect in a more marked degree; and, thirdly, of em- physema, which renders the sound preterna- turally clear. The middle third extends from the lower margin of the upper division to the space between the fourth and fifth ribs; it is less interesting for practical study, for its dis- eases are, for the most part, such as begin in the upper or in the lower third, and extend themselves to the middle, than those which commence in it. Emphysema, however, is often more developed about the middle of the lung than in any other part of this surface. The lower third extends from the boundary of the second to the lower margin of the chest; it is the usual seat of pleuritic effusions and of hydrothorax; in both of these diseases the liquid extends itself gradually from the poste- rior parts of the chest, towards its anterior margin, rendering the lower portion dull. In the healthy condition the sounds of per- cussion are not equally sonorous in all parts of the anterior part of the chest; in children the lower third is decidedly the most sonorous; in adults the middle is generally the clearest. In women you will find it difficult to compare these various portions together, for the mammae in- terfere so much with percussion that it is ex- tremely difficult to examine the middle third in a satisfactory way. The heart is another cause of dulness of sound at the interior part of the lower third on the left side. The praecordial dulness extends from the space between the fourth and fifth ribs at the sternum to the nip- ple, generally passing a little within this part. On the right the dulness is bounded by a line which follows the middle of the sternum ; the lower part of the heart rests upon the dia- phragm. The axillary or middle surfaces are divided most conveniently into two portions, by a line drawn nearly through the middle of the axil- lae. The sound in these parts differs in a very slight degree, and is throughout extremely clear, from the almost complete absence of the more solid parts of the lungs, and the remark- able freedom of this portion of the chest from PERFORMING, PLEXIMETER, ETC. 23 muscles which necessarily deaden the sound to a greater or less degree. If the posterior part of the chest be divided into thirds, these portions are still more unequal than they are at the anterior part. The upper extends from the top of the lungs to a line passing along the spine of the scapu- la, prolonged to the vertebrae. This, like the summit of the lungs at its anterior part, is the common seat of tubercles, which are more fre- quently developed here than at any other por- tion. Percussion is, however, so difficult at this part of the lungs from the thickness of the muscles, that its results are not of great value to beginners. Under all circumstances the sound is but moderately clear, becoming duller towards the external margin. The mid- dle third extends from the lower margin of the upper, to a line drawn at right angles to the spine from the lower angle of the scapula. The natural sound is here much more clear than in the upper third, especially near the spine, where the scapula does not interfere with it. Upon the scapula the percussion is necessarily dull. The lower third corresponds to the largest mass of pulmonary tissue; and, from the conformation of the ribs, gives a re- markably clear sound in children, whose tho- rax is elastic. In adults, the greater firmness of the ribs and muscles, and the greater indu- ration of the ligamentous and cartilaginous tis- sue, renders this sound less hollow; still it is always comparatively clear. This portion of the chest, with the middle third, is the usual seat of pneumonia; it is also the commencing point of pleuritic effusions,—hence, in dis- ease it is often dull, when the rest of the chest is comparatively clear. After you have examined the chest in a cur- sory manner, the regions must be examined comparatively,—that is, each part should be compared with the corresponding one upon the opposite side at the same points. For pur- poses of convenience I generally begin at the summit of the lung, at the anterior part, and then pass downwards towards the diaphragm, percussing both over the ribs and in the inter- costal spaces, and always placing the finger of the left hand parallel to the ribs; this gives you the sound corresponding accurately with the portion of lung which is immediately be- neath your finger, or very little more than the sound corresponding with that space. If you 24 PHYSICAL EXPLORATION. percuss across several ribs, the sound is more difficult to appreciate, as it is produced by a much larger portion of the lung, and is there- fore of little value, except for the facility which it gives you of gaining a general idea of the condition of the lungs. If you are at all doubtful about the sound, I would advise you always to compare the two sides together in very quick succession, while the impression of the sound is still fresh in your senses, and re- peat the percussion until you are satisfied whether there is, or is not a real difference. In a certain proportion of diseases of the lungs, the signs of percussion, united with the general symptoms, are sufficient for the diag- nosis; or, if combined with the other physical signs, they are sometimes perfectly character- istic of the disease without the aid of the ra- tional symptoms. You must remember, how- ever, that percussion indicates merely the rela- tive density of the lung, and is not sufficient for the diagnosis of most of its diseases with- out the aid of other means of investigation. The signs of percussion, although compara- tively few in number, are often of more value than any others, for their evidence is positive as far as it is applicable, and indicates with perfect accuracy the density of the tissue be- neath the spot upon which the percussion is made; but as the causes which influence the density are numerous, they are not explicable without the comparison of other symptoms. Percussion is, therefore, of all the signs of pulmonary disease, the most strictly physical, and of course the most mathematically correct. Percussion is not confined to the diseases of the lungs; for as these organs surround the heart, the sound is clear as far as their tissue extends: hence, the size of the heart is mea- sured by percussion of the lungs, rather than of the organ itself. It is, as we shall after- wards see, one of the most certain methods of learning the size of the heart. The practical mode of acquiring percussion is of more interest to yon than the mere detail of the signs derived from it. Like all the means of pectoral investigation, percussion may be learned in two ways,—that is, either on the healthy or the diseased subject. Those of you who observe patients on a large scale, and have sufficient time to examine at your own leisure the cases which I point out to you, will learn percussion chiefly from pa- tients, and, as it were, in connection with other signs. But this is not always the more con- venient method : it is not at all fitted for those whose sense of hearing is not acute, or who may not possess the necessary facilities for studying disease among a large collection of patients. If your ear is to be educated as well as your hand, you will cause no little un- easiness to your patients in your attempts to gain, little by little, a familiarity with the sounds. You will be sure to percuss much too smartly for their comfort at least, and you may possibly aggravate the symptoms of their diseases. Always, therefore, learn on your own persons; or if several of you unite together, and form little clubs for mutual per- cussion, you will get on much more rapidly. For the healthy chest presents every shade of percussion, from complete flatness to the most perfect sonorousness, and you may thus accus- tom yourselves to every variety of sound. At first you should examine the parts of the chest where the sounds are most distinct; and for this purpose it is best to select a young per- son, and, if possible, one who is rather thin,— then, by percussing first on the middle of the side of the chest near the sternum, and after- wards on the region of the liver, you may gain a correct idea of the difference between perfect flatness, and the full, clear, pulmonary sound. This should be repeated frequently, until a good idea of the difference of these sounds is impressed upon the memory, and, above all, upon the senses. The same points of extreme flatness and sonorousness will explain the dif- ference between the tapping with a single fin- ger, and the deeper, but less sharp sound pro- duced by decided percussion with several fin- gers. These comparative points should be examined on several individuals of different ages, and different degrees of flatness or thin- ness, until a correct idea of the average sounds is acquired. After the extreme degrees of sound have been repeatedly heard, the in- termediate characters may be learned by per- cussion of the precordial region, where the sound is dull, but in the healthy subject not completely flat. There is also a little dulness of sound at the summit of the lungs; on the right side, in most individuals, it is a little less clear than upon the left. The repeated exami- nation of these parts of the chest will not only give you a correct idea of the sounds them- _____PERCUSSION, RATIONALE, MODE OF selves, but will train your ear and hand to the manual performance of percussion. 1 have pointed out to you the great accuracy of the signs of percussion, and their uniform dependence upon the same physical condition of the lungs. It matters but little whether the disease is seated on the surface of the lung or in the internal parts of it; the quantity of air is necessarily diminished by every harden- ing of the tissue, which is sufficiently extensive to compress one or more lobules. Whenever the obstruction is sufficient to form an altera- tion in the sound perceptible to our senses, it may be readily recognised. The induration is perceptible enough, when three or four lo- bules become impervious to the air, but it cannot be recognised with certainty if limited to a less extent. The deeper seated lesions are rather more obscure than those nearer the surface, as the air-vesicles which intervene be- tween the ear and the indurated portion, of course give rise to a clear sound, but it is less full and hollow than it is when the lung is completely free; for the plain reason that the mass of sonorous, that is, of aerated tis- sue, beneath your finger, is less considera- ble. A compression of the lung necessarily acts much in the same way as an induration of its parenchyma; hence effusions into the pleu- rae, or even into the pericardium, compress the pulmonary tissue, and render it less elastic,— that is, they diminish the size, and expel the contents of the air-cells. The compression which is at first produced does not give rise to as great a degree of dulness as the induration of the pulmonary tissue, for the whole tissue remains pervious, and is merely a little less dis- tended with air than usual; but in advanced ca- ses of effusions into the pleura the flatness may be more complete than under any other circum- stances, for the compression, although slow, may be carried to such a point as to alter the structure of the pulmonary tissue completely, and flatten it against the spine. In the peri- cardial effusions the compression is never so great as to destroy the resonance, except im- mediately around the liquid, 1 PERFORMING. PLEXIMETER, ETC. 25 Life has nothing to do with the clear- ness or dulness on percussion,—for in the lung removed from the dead body you will find precisely the same condition of things un- der the same circumstances,—and you may readily verify the fact for yourselves, if you attempt to make the examination of the body of an individual dead of a disease which alters the structure of the lung,—or you may resort to the same experiment, by producing a change in the structure of the lung by artificial means, such as injections of wax into the bronchial tubes, or of liquids or of air into the serous cavities, when the percussion is flat; if, on the other hand, you distend the vesicles by inflating them with air, the percussion immediately be- comes extremely resonant. You will find that in healthy individuals there is often a considerable difference in the sounds of percussion. I have already alluded to some of the causes of this difference, which may be perfectly external to the chest, and con- sist in accumulations of fat or serum beneath the skin; or, on the other hand, they may de- pend upon a want of resonance in the thoracic parietes, and arise from the partial ossification of the cartilages. There is a third class of patients who offer less than the average de- gree of resonance of the chest; in these indivi- duals the lungs contain less air than usual, and are apparently more firm and more similar to cellular tissue. The chest,on the other hand,may be more resonant than the average, from either a real dilatation of the vesicles of the lungs, or from the patient being greatly emaciated, with- out much disease of the lungs themselves. You will find but one way of overcoming these difficulties,—and that is, to examine the chest in many patients until you acquire a knowledge of the average clearness or dulness of sound, and of the circumstances which modify it without the developement of positive disease of the lungs. These accidental circumstances are altogether dependent upon ordinary acous- tic principles: elasticity and thinness of the parietes of the chest favouring the clearness of sound, and thickness and rigidity of them pro- ducing a contrary effect. LECTURES IV. AND V. Auscultation—Modifications of 1 We now come to the most important and extended means of physical exploration,—that is, auscultation, or the act of hearing and inter- preting the sounds produced in the chest during the act of respiration, or of coughing or speak- ing, or caused by the action of the heart. Per- cussion teaches us merely the density of the tissue of the lungs; but auscultation goes much farther, and not only indicates the phy- sical density of the tissue, but the functional play of the organs, and the obstructions which impede the passage of the air in the lungs, or of the blood in the heart. Hence the signs of auscultation are much more functional than those of percussion; they are developed by the patient himself, and of course cease with the termination of life. They are more complicated in their nature than the signs of percussion, and are less positive, because they may be modified by a greater number of circumstances: but when these are taken into the account, the deductions from auscultation are quite as con- clusive. The mode of practising auscultation is ex- tremely simple; you may apply your ear di- rectly to the chest, or you may interpose be- tween it and the thorax of the patient a solid or flexible tube; hence auscultation is either immediate or mediate. As the sounds are produced by the patient, and not by your hand, as in percussion, you have thus far a very easy task; but you will find it of more difficulty when you come to the sounds them- selves, and to their interpretation. Some, in themselves, are not easily learned; but others are difficult, only because they differ one from another by slight shades, and may therefore readily be confounded together. For most purposes, immediate auscultation, or the direct application of the ear to the chest, is preferable to the use of a conducting tube. Those who are perfectly habituated to the ex- ploration of the chest, prefer this method in the great majority of cases, on account of its greater rapidity and facility of application, for Respiration and Voice—Rhonchi. there is no previous preparation necessary, nor is there any difficulty in passing the ear ra- pidly over the chest. But in those portions of the thorax, where the space for the applica- tion of the ear is extremely limited, such as the clavicular regions and the axillae, or above the mammae in females, the stethoscope, as the conducting tube is called, will be found pre- ferable. Besides these reasons of mere expe- diency, the sounds themselves are sometimes better characterized, or at least better limited in immediate auscultation ; this is the case with the heart, and even with the lungs; for, as the instrument covers but a small space, and is perfectly isolated from the rest of the chest, the sound which is produced in the li- mited portion covered by its extremity, is alone conducted to the ear,—and that coming from the adjoining parts of the thorax is not heard, or at least is so feebly heard that it does not materially interfere with the result. When we apply the ear, we place the large surface of the head in contact with the chest, and as the bones of the chest and head are tolerably good conductors of sound, we hear the sounds of a larger portion of the lung than is desira- ble, and acquire less precise notions. But when you wish to examine rapidly a large portion of the chest, you will gain much time from this very circumstance, and take in at once the sounds from a large space, such as a whole lobe of the lung, or nearly so; and if you are really familiar with the sounds, they can be analysed and distinguished one from another, though heard at the same time, just as several instruments can be recognised in the same piece of music played by a complete or- chestra. For ordinary purposes, therefore, im- mediate auscultation is much to be prefer- red. When you use an instrument for conducting the sound from the chest to the ear, you will be obliged to take more precautions. This in- strument is called a stethoscope, and is nothing more nor less than a tube of light wood, such as AUSCULTATION, ETC. 27 cedar; the extremity which is to be applied to the chest, is hollowed into the form of a cone, the apex of which terminates in the tube, and, of course, serves as an ear trumpet to conduct the sounds. The substance of the tube, although a comparatively good conductor of sound, is of much less service than the column of air; for an ordinary flexible ear-trumpet in which the sound is conducted exclusively by the column of air, is an excellent stethoscope. The diameter of the base of the cone should be from an inch to an inch and a quarter ; if it be much larger, the sounds are confused, and the instrument loses its greatest advantage, that of concentrat- ing the sound within a limited space; if too small, the sound is not loud enough. The es- sential point in the construction of a stethoscope is, that its cone should be deep and well hol- lowed out, at least an inch and a half or two inches deep, as is the case with several of the instruments which 1 now show you. The length of the tube may vary from four or five inches to a foot; six or seven inches will be found to be of a very suitable length for most purposes. The ear piece should be slightly convex or flat, or you may have a nipple- shaped projection, to insert into the ear; it should be of the same material as the rest of the tube, and not of ivory, as is often the case. Your ear should not be so near the chest as to expose you to the inconvenience of immediate auscultation, nor so far removed from it as greatly to diminish the intensity of the sound, for the sound becomes more gradually less and less loud in proportion as the ear is further removed from the part of the lung in which it is produced. A flexible tube, that is an ordinary ear trum- pet, about eighteen inches long, with the open end brought nearly to the form of the extremi- ty of the stethoscope, is the best instrument for the examination of the sounds of the heart, as it does not conduct the impulse to the ear, hence the sounds alone are heard without the impulsion, which renders their analysis more difficult. Dr. Pennock of this city, who has devoted great attention to the diseases of the heart and their signs, was the first to introduce the flexible tube for this purpose, instead of the ordinary stethoscope. 1 do not wish to detain you longer with the description of the mere instrument of hearing, which you may procure from any turner, but 1 must give you some cautions respect- ing the mode of application of the stetho- scope. If you apply it directly upon the chest you must take great care that the end be placed flat upon the skin, without inclining to one or the other side, as the sounds are both modified and lessened by the admission of the air be- tween the thorax and the tube. Indeed it is better not to place the instrument immediately upon the skin, but upon an under garment of muslin or flannel; this fills up the interstices between the tube and the surface, and prevents pain from too strong a pressure. The cover- ing must be thin and not stiff, hence starched linen and silk are both improper, as they give rise to a rustling sound, and obscure the respi- ratory murmur. The position of the patient for auscultation should be similar to that already directed for percussion, but the muscles and skin need not be drawn as tensely upon the ribs, for the pressure of the ear or the stethoscope against the chest will supply the effort performed by the muscles, and bring the parts as closely together as is desirable. The signs derived from auscultation are di- vided into those of the respiration, of the voice, and cough, and lastly, of the heart. The signs of the respiration include both the modi- fications of the natural sounds produced by disease, and the rhonchi, or the new sounds, which are totally unlike those heard in the normal state. The latter class of signs are simple, and readily learned ; the former are more important, and are produced by deeply seated alterations of the substance of the lung, producing a change in the density of its tissue. These signs are always attended with corresponding alterations in the percussion, and the resonance of the voice, which depend upon the same changes in the vesicular struc- ture, and in the permeability of the bronchial tubes. They are thus learned, a3 it were, in connexion; and the signs of the respiration are strengthened or disproven by the correspond- ing changes in the voice and the percussion. Hence you will find it more easy to acquire them than it otherwise would be, for you may verify for yourselves at every step of your ex- amination, and gradually acquire confidence in your powers of discrimination. The morbid alterations of the respiration are well marked in extreme cases, but gradually 26 PHYSICAL EXPLORATION. pass into the characters of the healthy respira- tion ; hence there is but one way of learning these signs. First to acquire the signs when strongly characterized, and then to proceed to the cases in which the modifications of respi- rations are but slight. In the diseased sub- ject you will find that the strongly marked signs are very easily recognised; and many of you, who follow my practical demonstrations with sufficient attention, will naturally begin your study by the examination of patients who present these signs. Still, the facility for ex- amining individuals in health is so much greater, that I should advise you all to fami- liarize and train your ear by the attentive study of those sounds presented by healthy individuals which approach most nearly to the signs of disease. And you will find that the character- istics of the radical sounds exist both in the healthy individual and in many diseased con- ditions. These characters in healthy individuals are founded upon the peculiarities of the sounds in different parts of the chest dependent upon the differences in the tissue. The lungs consist of tubes conducting the air to vesicles in which the arterialization of the blood takes place. The sound of the air entering the ve- sicles is different from that caused by its pas- sage through the tubes; and the former is therefore known as the vesicular sound, the latter as the tubal or blowing sound. The ve- sicular sound is often called a murmur, from its softness and diffusion over a large space, and cannot be produced unless the vesicles are healthy, or nearly so. If you keep up artificial respiration in an animal stunned by a blow on the head, or suddenly killed, and apply your stethoscope upon the exposed lung, the mur- mur is heard very distinctly during the inspi- ration, so that you have direct evidence that the sound is produced by the passage of the air into the vesicles; the vesicles, however, empty themselves in a noiseless manner, and the expiration is therefore nearly unheard. The tubal or blowing sound is quite different in its character; it is evidently produced by the passage of the air through tubes, and is heard very evidently both in the inspiration and expiration,—and is, in fact, much more distinct in the latter. The cause of this dif- ference seems to be the different manner in which the air impinges upon the vesicles and tubes. During the inspiration the ter- minating point is of course the air vesicles,— and the air, if forced into them with tolerable rapidity, produces a sound; this is the same, whether the impelling force be the pressure of the atmosphere, upon the column of air in the bronchial tubes, when the parietes of the chest are elevated by muscular action, or to the force communicated by the bellows, when artificial respiration is carried on. The sound is in part owing to the vibration of the air, and in part to the noise produced by the dilating of the vesicles themselves. At least, the sud- den dilatation of a partially collapsed ve- sicle is, in all probability, attended with sound, caused by the membranes; for, when the parietes of the vesicles are thickened, the sound probably becomes louder and more distinct. It is a point, however, which is dif- ficult to decide, and one that is of little practi- cal moment,—for, admitting either explanation, it is equally necessary that the vesicles should be clear, and that the air should pass freely into them from the adjoining tubes. Theexpira- tion produces a faint, vesicular sound ; almost no sound in those portions of the lungs where the vesicular tissue is not traversed by bron- chial tubes of a certain calibre. This proba- bly depends upon the gradual manner in which the pressure upon the vesicles expels the air from them into the larger tubes through which itmay readily pass towardsthe exterior: as the air is forced out from the vesicles very slowly, and of course not in a regular stream or cur- rent, they contract without sound. The ve- sicular murmur is compared to various sounds not very like to it; but it can be learned only in one way,—that is, by listening to those portions of the chest in which it exists in the greatest purity, especially towards the lower and lateral portions of the lungs. The mur- mur will be found to vary in intensity in differ- ent individuals : in some it is always feeble, and in others comparatively loud. It is loud- er in those persons of a nervous temperament in whom the necessity for rapid respiration is greatest, than in stouter individuals. It is also stronger in women and in children than in men and adults. The vesicular sound is in- deed so much louder in children, that the term puerile respiration is used as synonymous with loud and full vesicular sound. AUSCULTATION, ETC. 29 In most persons, the dilatation of the vesi- cles is obviously incomplete, except in forced inspirations, and in some is much more so than in others. This imperfect dilatation is rather more marked at the lower portions of the lungs than the upper, probably from the longer course and smaller size of the bronchial tubes, which require a more powerful effort to pro- duce their full distension. The tubal respiration is often called bron- chial, from its production in the larger bron- chial tubes,—or tracheal, from its develop- ment in the trachea,—the term tubal being thus confined to the most intense degree of this sound. In the healthy individual this may be heard in a very marked degree at the trachea, immediately above the sternum, and the air is then heard very easily as it passes through it, both in the inspiration and expiration. The sound is always blowing, and very different from the vesicular murmur; this character is best marked in the expiration. The cause of this difference will be very obvious to you if you attend to your own respiration; you will find then, if you breathe rapidly, that the ex- piratory sound, which is heard out of the chest, is much louder than the inspiratory, and is produced in the upper portion of the bronchial tree, and in the nasal fossae, where the air passages are large, and the ra- pidity of motion of the air is greatest. It is for this reason, in the trachea the respiration is most decidedly tubal, or if you choose to use the term, tracheal. It gradually becomes less and less so as you approach more nearly to the parts of the lungs where the vesicular struc- ture is most abundant, and contains tubes of the smallest calibre, and most removed from the surface. You may thus analyze the dif- ferent sounds heard in various parts of the re- spiratory passages; you will find then the blowing sound only at the trachea, and the ve- sicular only at the lower parts of the chest,— while at the roots of the lu«gs there is a mix- ture of the two varieties of sound, and the ve- sicular is combined with the blowing sound. Passing from the root of the lung you will find a gradual diminution in the loudness of the bronchial sound,—but it is still heard as far as the summit, and much more distinctly on the right side than on the left. The difference in the two sides arises from the anatomical struc- ture ; for the tubes leading to the upper part of the right lung are shorter and larger than those going to the left, on which side the large bronchus passes under the aorta,'and is there- fore much longer and more tortuous than upon the right. The larger but shorter tubes of course approach much more nearly than the longer and smaller ones to the physical condi- tion of the trachea, in which the air circulates with such freedom as to give rise to the loud- est double blowing sound. The louder blow- ing sound exists on the right side, both at the anterior and posterior part; hence a given amount of induration of structure, which may tend to increase the loudness of this sign, will be much more perceptible on the right side than on the left,—while, on the other hand, in the state of health, a perfectly natural peculi- arity may be mistaken for disease. The blow- ing sound, if it be heard only on the right side, must be well characterized to become a sign of disease, and is not of much value unless combined with other corroborative evidence. This difference of respiratory sound on the two sides of the chest dependent upon the dif- ferent structure of the ,lungs, was not pointed out previously to some researches which I un- dertook upon the subject, at the Children's Hospital of Paris, about eight years ago. My attention was called to the subject by the ob- servation made by my lamented friend Dr. Jackson of Boston, who laid great stress upon the characters of the expiration observable in commencing phthisis, and other diseases at- tended with consolidation of the lung. His remarks upon the early development of the blowing expiration in commencing phthisis, were perfectly well founded; but at the com- mencement of his researches he was sometimes led into error from not making due allowance for the difference of the two sides dependent upon peculiarities of conformation. In the study of the respiration you have a plain course to follow: examine as often as you can the region of the trachea, and then the lower and vesicular portion of the lungs, and thus fix in your minds the difference between the two leading varieties of the respiration, or the tubal and the vesicular. Some of you find this study a matter of some difficulty, while others can seize the distinctive characters at their first effort. You must not be in doubt as to the cause of this difficulty when it exists; it arises in part from a less acuteness of hear- 30 PHYSICAL EXPLORATION- ing, but much more from a defect of attention, which you may readily supply by your own efforts; and, rely upon it, you know no- thing of auscultation until you have mastered this subject. After the best marked sounds are learned, you may proceed to those parts of the chest in which you will hear the two va- rieties of the respiration at the same time; you then analyze their peculiarities, and may ask yourselves at each moment whether you have a clear idea of both sounds, as they are heard together. The same process should be re- peated in different individuals of various ages, sex, and conformation; and you will find that although they present numerous shades of dif- ference, the radical features are the same, and must always be the same, for they depend on known principles of acoustics. In connexion with this part of your studies, you may properly enough accustom yourselves to the shades of difference offered by the parts of the lung, where other viscera, such as the heart and liver, occupy a portion of the space beneath the ear, and you may in this way learn the abrupt manner in which the respiration gene- rally ceases at the level of the lung. During your examination you should direct the patient to breathe with different degrees of rapidity, sometimes quite naturally, and at others much more quickly, so as to force the air into the vesicles. In the examination of diseased in- dividuals we follow nearly the same order,— and, after placing our ear for a moment upon the chest of the patient while breathing in a quiet and regular manner, we usually direct him to make a forced inspiration, which clears out the mucus in the bronchial tubes, and sup- plies a full proportion of air to each vesicle. In cases of disease of an acute character ob- structing a portion of the lung, there is no ne- cessity for directing the patients to breathe ra- pidly, as the obstruction in the diseased part of the lung causes the respiration in the rest of the pulmonary tissue to be much exagge- rated or puerile. After the radical characters of tracheal or bron- chial respiration,which differ merely by a shade, of the vesicular respiration, and of the rude re- spiration, which is intermediate to the two lead- ing varieties are learned, you may proceed to the study of the morbid alterations of the respira- tory sounds. These are classed according to their greater or less accordance with the natu- ral characters of the respiration. I will begin with the most strongly marked. This is the bronchial respiration, and its varieties, which include the cavernous and amphoric respira- tion. The bronchial respiration, as it occurs in a diseased lung, is essentially the same with the tracheal respiration of the healthy chest. The bronchial respiration is developed by causes which harden the parenchyma of the lungs, and destroy the vesicular texture: these are the infiltration of the tissue of the lungs with blood and plastic lymph in pneumonia, the compression of the lung by pleuritic effu- sions, and the deposits of various anomalous productions, such as tubercle and cancer, in the tissue of the lungs. If the induration be seated around the larger bronchial tubes, the bronchial respiration is much louder than in the portions of the lung where the tissue is chiefly composed of vesicles, for the essential cause of this sound is the passage of the air through the tubes; the induration of the sub- stance of the lung is merely a favourable cir- cumstance which developes the sound where it is not generally heard, or increases it in those parts of the lung in which it exists naturally. The bronchial respiration is produced then part- ly by the obliteration of the vesicles, and partly by the closure of the smaller tubes. Hence, the air in passing through tubes of a certain size is suddenly interrupted and repelled from their sides, because their terminating branches are closed. This repulsion produces sound, and increases the blowing respiration, which is heard most loudly when the air, instead of diffusing itself throughout the vesicular tissue, is, on the contrary, forced through the larger bronchi, which are converted into closed cy- linders, from the occlusion of their branches by the progress of the disease. The bronchial respiration is often accounted for in the following way: The passage of the air in the tubes is, under ordinary circum- stances, not attended with sound; as the surrounding tissue is a bad conducting medium, and deadens the sound. When this tissue is rendered more solid, the sound already pro- duced in the. tubes becomes audible, and is conducted to the ear. This explanation is va- lid only to a certain extent; the bronchial sound exists only in a slight degree in the natural state, for a tube through which the air is con- AUSCULTATION, ETC. 31 stantly and equally drawn during the respira- tion, gives rise to a very faint sound, but if the tubes passing into it be cut off, the passage of the air is at once hurried, and by its friction against the parietes of the bronchus gives rise to the usual bronchial sound. In disease, therefore, the blowing sound is very often much louder in those portions of the lung where it does not exist naturally, than over the trachea or the larger tubes, which are almost immediately beneath the ear; and this extreme loudness de- pends upon the circumstance to which I have already alluded,—that is, the sudden reflection of the column of air from the interrupted tube. The large size of the tubes is, however, as I have already stated, a circumstance highly favourable to the development of bronchial respiration; and if the tubes be superficial, the influence of size becomes more obvious. If the tubes be enlarged, while the paren- chyma remains healthy, the respiration is bronchial, but to a less degree than if the tissue be hardened, and the tubes retain their usual calibre; for the induration is a more effi- cient cause of bronchial respiration than sim- ple enlargement of the tubes. The bronchial respiration is not perfect ex- cept when the induration of the pulmonary tis- sue is complete; this takes place in a few cases of phthisis, and in pleurisy with large deposit of lymph, but is much more frequent in pneu- monia than in any other disease, for in none other is the hardening of the tissue so perfect: this sign is therefore one of the best indications of the second stage of inflammation. In dila- tation of the tubes the respiration becomes very bronchial when the surrounding tissue is indurated, that is; when complicated with pneumonia. The bronchial respiration, then,is produced by the passage of the air through tubes of the mid- dle and larger size in an indurated lung, and also by the enlargement of these tubes. The ca- vernous respiration is another variety of sound which is closely analogous to the bronchial respiration, and depends upon the passage of the air into a cavity communicating with the bronchi. For physical purposes this cavity may be considered as a mere dilatation of the bronchus with which it communicates; but as the termination of the tubes themselves is never so abrupt as the morbid cavity, the air in the bronchial respiration proper is gradually dif- fused through the tissue, and is slowly lost,— but in the cavity it is abruptly reflected from the walls of the excavation, and therefore seems to be more circumscribed, and comes from a limited point. This diffusion of sound in the one case, and concentration in the other, constitute the difference between these varia- tions, and they therefore run into each other by insensible shades. As the line of distinc- tion is an arbitrary one, it is sometimes impos- sible to discriminate between them, but it is not generally a matter of much practical mo- ment, for the signs of a cavity generally be- come more and more distinct in proportion to the duration of the disease, and the doubtful usually become clear in a short time. The amphoric respiration is a modification of the same sound, but is more unlike the bronchial respiration. It is produced by the passage of the air into a large cavity with firm walls. If the communication between the cavity and the bronchi be free, the expiration is also loud, and the sign differs from the ca- vernous respiration in one respect only—it is fuller and more musical, somewhat similar to the sound caused by blowing into a glass or metallic vessel. Both the inspiration and ex- pectoration are blowing, and there is no trace of the vesicular murmur. If the communica- tion with the bronchi be interrupted, or too small to allow of the free passage of the air, the inspiration alone is distinctly heard, as the air passes out of the cavity too slowly to pro- duce much sound. The common cause of am- phoric respiration is a large tuberculous cavity near the surface, and surrounded by indurated lung. It may also depend upon perforation of the pleura; in which case the amphoric tone is extremely well marked, as the cavity is much larger than one formed in the lungs, and its walls are large and elastic. If the amphoric respiration depend upon a gangrenous cavity, it is generally less marked than in tuberculous excavations, as the surrounding tissue is usually soft, and is therefore a bad conductor of sound. We now return to the bronchial respiration as our standard of comparison, and pass from it to the vesicular murmur, reversing the order we have just followed. The varieties of the respiration intermediate between the vesicular murmur and the true bronchial respiration, are 32 PHYSICAL EXPLORATION. very numerous, but they are properly enough classed under the general designation of rude, or rough respiration, which is applied to those varieties in which the vesicular murmur is still retained, but the blowing sound is at the same time more developed than is natural in the part of the lungs where it is heard. It may be attended with a feeble or an increased loud- ness of the vesicular murmur. When this is more feeble, the obstruction to the air occurs about the smaller tubes, and gradually com- presses them; when loud, the morbid deposit is situated rather in the course of the larger tubes than at their terminating branches, which still receive their full supply of air while the respiration becomes blowing from the increased conducting power of the hardened tissue. The rude respiration is one of the most interesting varieties of the respiratory sound, for it occurs in those varieties in which the lesion is not yet much advanced, and a portion of the pul- monary tissue remains permeable to the air; hence it is a sign of the earlier stages of phthisis, of the commencement of pneumonia and of pleurisy. It is a sign which you will learn with some difficulty, because both the primitive varieties of the respiration are pre- sent, and they can only be separated by a care- ful analysis. From the rude respiration we naturally re- turn to the vesicular murmur; which may be exaggerated, or enfeebled, but still retain its essential characters. The exaggerated or pu- erile respiration, generally depends upon dis- ease in other portions of the lungs than those in which it is heard. The healthy portions then perform double duty, and arterialize more than their proper share of blood. From the occurrence of puerile respiration in a part of the lung of a patient who labours under dysp- noea, we can very often determine that some obstruction must exist in other parts of the lungs; and from the knowledge of the acute and chronic diseases which generally give rise to this obstruction, we can with tolerable cer- tainty discover the nature of the lesion. The respiration is rendered feeble in disease, either by the compression of the vesicles from effu- sion upon the exterior of the lung, or the de- velopment of solid matter in the parenchyma, or lastly, from obstruction of the smaller tubes. There are some other varieties of the respi- ration, which it were difficult to bring within a systematic description; they should be learned after the leading varieties have been first stu- died. They generally arise from slight changes in the condition of the vesicles or smaller tubes, and sometimes from the mode in which the re- spiration is performed, but rarely depend upon important organic changes in the lung. They may be reduced to the following: 1st, the in- complete or interrupted respiration; in this va- riety the inspiratory sound seems to be arrested before the air passes completely into the vesi- cles; it arises from two causes,—a nervous spasm, and a partial thickening or congestion of the smaller tubes. It is a peculiarity which is often observed when we examine for the first time a nervous, sensitive patient, who is alarmed by the exploration of the chest; and it is sometimes met with in the infiltrated or con- gested state of the lungs which attends the forming stage of tuberculous disease, as well as certain varieties of bronchitis. 2d. The rustling sound of the respiration is one of the character- istics of emphysema, in which the vesicles di- late and contract with difficulty, and seem to produce sound rather from the rustling of the membrane, than the air which impinges against it.—There are other and slighter deviations from the natural tone of the respiratory mur- mur; but, although they are very obvious to an experienced eye, yet they are neither suffi- ciently permanent nor well marked to be re- duced into a systematic classification. The varieties of the respiratory sound cor- respond with varieties in the resonance of the voice, which often are nearly as well charac- terized; still, the natural tone of the voice has so much influence upon its aptness for vibra- tion, that the signs are not always as perfectly distinctive as those of the respiration. In the ordinary act of speaking the voice vibrates throughout the chest; and if the hand be placed upon its parietes, a slight tremour is very per- ceptible; if you apply your ear to it, you will hear a thrilling, but distant and confused sound. This sound becomes louder, and is brought nearer to the ear, if you listen near the summit of the lungs, especially on the right side, or at their root; and if you then place the stethoscope upon the trachea, you find the re- sonance loud, and the words pronounced nearly as distinctly as they are by the mouth. In fact, the voice is conducted by the column of air, and then articulated words seem to enter AUSCULTATION. 33 the ear from the trachea. This distinct and loud resonance at the trachea is pectoriloquy; and it is in this situation very perfect, espe- cially if the voice of the individual be naturally clear, and rather shrill. At the sternum, and at the root of the lungs between the scapulae, the resonance is less perfect, and the voice seems to enter the ear less completely than in pectoriloquy; it is therefore not quite so well characterized a sign, and is called, from its po- sition, bronchophony. In the rest of the lung the resonance of the voice is gradually less and less as you pass from the bronchi to the vesi- cular structure, where you hear nothing but a faint vibration. There is, therefore, a uniform relation be- tween the voice and the respiration, the reso- nance of the voice being greatest when the blowing sound of respiration is most intense. In disease the same proportion exists; a cavity gives rise to cavernous respiration in breath- ing, and to pectoriloquy in speaking,—and a consolidated lung, especially around the large bronchi, produces bronchophony and bronchial respiration. The same relation exists between a mere loud resonance of the voice and rude respiration, and between the ordinary vesicular murmur and a slight thrilling vibration of the voice. In cases in which the murmur is en- feebled, the resonance of the voice is less; but sometimes there is a low, purring sound, com- municated to the ear as well as the hand, which is analogous to the rustling sound of emphysema, and depends upon the same causes. The blowing respiration may continue very loud when the resonance of the voice has be- come quite feeble, for an accumulation of mu- cus may be forced aside by a full inspiration, but cannot be thrown out of the way by the act of speaking, and therefore obstructs the vibra- tion of the column of air: in these cases it is not, however, totally destroyed, for the sound is cbnducted by the hardened lung from the neighbouring tubes. When a cavity in the lungs is very large, there is, of course, amphoric respiration at the same time. You will then find amphoric reso- nance of the voice, which often scarcely dif- fers from pectoriloquy: that is, if the cavity be not much larger than a hen's egg, and its walls remain firm. But if the cavity increase much beyond this size, the resonance of the voice is extremely metallic, or has a clear ring- ing sound, which, like the respiration, is very similar to that produced by speaking in a glass bottle without quite closing its mouth. But when the large cavity is situated in a soft permeable portion of the lung, the ampho- ric respiration may be obscure, like the reso- nance of the voice under the same circum- stances. The bronchial respiration which results from pleuritic effusions, differs so slightly from the other varieties, that it is usually not separated from them, but the resonance of the voice which takes place under the same circum- stances, is very different. Its vibration is very great, and is so peculiar that the sound is called egophony, from the bleating tone of the voice, somewhat similar to that of a goat or sheep. This is not an invariable result of pleuritic ef- fusions, but it is produced in all cases in which the effusion is sufficient to compress the lung without entirely flattening it out. If the quan- tity of liquid happens to be very great, but the lung stiff and more solid than usual from pre- vious inflammation of its substance, its ego- phony continues longer than it otherwise would do, and rarely ceases during the course of the disease. The signs of the voice are learned by the same process as those of respiration. After having acquired a good general idea of the cha- racters of the respiration, you should examine them in connection with the signs of the voice, confirming or disproving one by the other, and then practising percussion, which will throw additional light upon the subject. You need not, of course, restrict yourselves to the healthy subject, but you may also study those cases of diseased lungs in which the diagnosis is com- paratively easy from the functional signs, such as examples of decided phthisis and pneumo- nia, and then search for cavernous and bronchial respiration, with the connected signs of the voice and percussion. The cavernous resonance of the voice in pec- toriloquy was the first physical sign discover- ed by Laennec. He happened to place some paper rolled up into the form of a cylinder upon the chest of a patient, in order to feel the pulsations of the heart, when he was surprised to find that, during the act of speaking, the voice of the patient seemed to enter his ear. He examined immediately the chest of a large 34 PHYSICAL EXPLORATION. number of patients in the same way, and de- tected the same phenomena in a great number who were evidently labouring under advanced phthisis ; the cause of this was afterwards found to be cavities in the lung communicat- ing with the bronchial tubes. Pectoriloquy was divided by him into three varieties, the perfect, the imperfect, and the doubtful ; in the perfect, the voice seemed to pass through the stethoscope (which Laennec always used) to the ear, in the second to enter the tube, and in the third the resonance was quite confus- ed. These distinctions are of little value and rather tend to confuse your ideas. The following table will give you the rela- tion between the voice and the respiration. Amphoric Respiration, Amphoric Resonance of Voice, Cavernous Respiration, Pectoriloquy, Bronchial Respiration, Bronchophony, Rude Respiration, Strong Resonance of Voice, Vesicular Respiration, Slight Thrilling of Voice. LECTURE V.—Concluded. The Rhonchi. There is a set of sounds produced by the respiration in certain states of disease of the chest, which are totally unlike the sounds heard in health. These sounds are called the rhonchi; and they are produced by impedi- ments to motion, either of the lungs upon the ribs, or of the air in the bronchial tubes. Those which belong to the lungs proper are caused by obstacles to the passage of the air through the bronchial tubes; these are the most inte- resting and important of the class. There is another set of rhonchi, which arise from the friction of the serous membranes in the chest, and are common to both the lungs and the heart. They occur when the effu- sions in these membranes consist chiefly of lymph which coats the surface of the serous tissues sufficiently to cause a slight creak- ing sound. This creaking or friction sound in the pleura, takes place during both inspiration and expiration, but especially at the com- mencement of the expiration, when the ribs first begin to sink down, and the pleura is drawn rather rapidly over them. It is not limited to a single spot, but shifts about with the dilatation and contraction of the chest; and is generally most evident about the lower an- gle of the scapula, and often extends from that point across the axilla to the sternum. It is a sign which is proper to pleurisy, either pri- mary or secondary; and it is in general readily recognised after the bronchial rhonchi are known, especially if the friction be sufficient to give to the parietes of the chest a thrilling motion, which may be felt by the hand. The rhonchi, properly so called, are divided into the moist and the dry. The moist rhon- chi are the mucous, including the gurgling of cavities, the sub-crepitant, and the crepitant. The dry rhonchi are the sonorous and the sibi- lant, to which may be added the dry crepitant. The moist rhonchi are caused by the resist- ance offered by a liquid in the tubes or vesi- cles to the passage of the air; the liquid forms bubbles of various sizes, and their suc- cessive breaking is the chief cause of the rhon- chus. The dry rhonchi are produced by real thickening or spasmodic contraction of the mucous membrane, which gives a musical tone to the respired air; they are most evident in the expiration, while the moist rhonchi are for the most part heard during the in- spiration. The rhonchi are not necessarily per- manent, except the crepitant rhonchus; for the obstructions forming mucous rhonchus, or the thickening of the larger tubes may be removed for a time, in many cases, by an effort of coughing. The mucous rhonchus is the loudest of the moist rhonchi; it is caused by the breaking of bubbles of tolerable size contained in the larger tubes; the sound is readily enough recognised, and is scarcely ever mistaken, even on a first examination. This is the sound which is often audible at a little distance from the chest of the patient, especially if it extend over a large portion of the lungs. The mucous rhon- chus is heard wherever there is an abundant secretion of liquid into the larger bronchi; now this generally arises from the second stage of bronchitis, but it is quite common in phthisis and the third stage of pneumonia; and the blood which is poured into the bronchi in haemop- tysis, may give rise to the same phenomena. The mucous rhonchus is generally heard both in the inspiration and expiration, as the air re- turns with sufficient force from the lungs to agitate the liquid, and form bubbles. There are two varieties of the mucous rhon- chus, which are almost peculiar to phthisis; these are the dry crackling, produced by the softening of the thick, pasty matter of tubercle, which gives a peculiarly dry and sharp sound, and the loose, but concentrated gurgling of a cavity. Any disease which gives rise to a ca- vity in the substance of the lung, will produce this cavernous gurgling; hence it may arise from gangrene of the lungs, pneumonia, or even a dilated bronchus. But as cavities de- pend much more frequently upon phthisis than 3fi PHYSICAL E XPLORATION. any other cause, probably nine-tenths of those which you meet with, may be referred to soft- ened tubercles. The gurgling differs from mucous rhonchus merely by its greater con- centration; it is in this respect that,like the other signs of cavities, it is distinguished from those of the bronchi; and it passes into mucous rhonchus by an insensible gradation. You may place, therefore, the dividing line between the mucous rhonchus of small cavities, and of the bronchi, where you please. Large cavities can never be mistaken. But there are some cases of dilatation of the bronchial tubes which extend over a considerable portion of the lung, in which the secretion of liquid is abundant, and the mucous rhonchus very similar to that of an ordinary cavity. The liquid gurgling is heard both in the inspiration and expiration, for the air is reflected from the sides of the ca- vities during expiration, and of course causes an almost continuous rhonchus. You will find that both the crackling and gurgling are liable to disappear, although the cavity re- mains ; for the liquid secretion may be for a time suspended, or the matter may be expec- torated, and the walls of the cavity remain dry. The subcrepitant rhonchus differs from the mucous in two respects: the bubbles are finer, and they break in a more gradual and regular succession. The rhonchus is therefore con- fined to the smaller tubes, through which the air passes rather slowly, and the bubbles nearly fill up their calibre. It is heard in various parts of the lungs, but much more frequently at their lower and posterior part than else- where, for the liquid accumulates there in the smaller tubes more than in any other part. The subcrepitant rhonchus is heard very faintly during the expiration. The crepitant rhonchus is the most import- ant of the moist rhonchi. It is either fine or coarse, the latter variety differing very slightly from the subcrepitant. When the crepitant is fine, it is pathognomonic of the first stage of pneumonia; and it is then produced in the ve- sicles of the lung, and perhaps in the small tubes which ramify through the lobules,__but when it is extremely fine, the sound is proba- bly strictly vesicular, and seems to depend upon two causes, the breaking of the minute bubbles of thick mucus, and the dilatation of the thickened and stiffened vesicles. If the crepitus be rather coarse, it seems to arise more from the smaller tubes than from the;vesicles, although this is a point which is not suscepti- ble of a rigorous demonstration. A crepitant rhonchus is a sign which is connected with the parenchyma of the lungs, and can never occur in the larger tubes; and it is not produced by other diseases of the parenchyma than pneu- monia, because it is only in the latter disease that you will find the thick, viscid secretion, and the stiffened, yet still dilatable condition of the vesicles. The crepitant rhonchus is strictly confined to the inspiration; the air does not pass in the expiration with sufficient ra- pidity to break the tenacious liquid. The cre- pitant rhonchus generally forms trains of bub- bles, something like the successive explosion of a small train of wet powder; and the sound is compared to various trivial noises, such as the crackling of salt, the rubbing of a lock of hair; but, like all the signs of auscul- tation, nothing out of the body gives a correct idea of its character. You must, therefore, learn it in patients labouring under pneumonia; and if you have not opportunities for examin- ing cases in connection with persons who are familiar with the physical signs, I would ad- vise you to select a case in which the pneumo- nia is advanced to the second degree, and the general symptoms of the disease accord with the physical signs. In such cases your diag- nosis of the disease may be regarded as quite certain; and you may trace the crepitant rhon- chus as it proceeds from the interior of the indurated lung towards the exterior. There are certain sounds connected with the pleurae which are similar, as I have already stat- ed, to the moist rhonchi. These are two in num- ber,the friction sound, and the metallic tinkling which is heard generally when the external air communicates with the cavity of the pleura, but is occasionally observed in cases of large cavities in the substance of the lung. The fric- tion sound differs in some cases very slightly from the sub-crepitant, and I have sometimes been puzzled to discriminate between them ; of course 1 do not allude to the, well character- ized variety, in which there is a thrilling mo- tion extending along the chest, and felt as well as heard, but to those cases in which the fric- tion is very slight. The deposit of lymph is then generally very small, but such is not ne- cessarily the case, for there may be little fric- THE RHONCHI. 37 tion when the effusion is large, especially if the lung be separated from the pleura by se- rum, which prevents the two surfaces from coming much into contact. The best method of distinguishing the slighter variety is to at- tend to the manner in which it follows the act of respiration; in the true sub-crepitous rhon- chus the bubbles break regularly, and follow the passage of the air; in the slight friction sound there is not this regularity, and its po- sition is never as permanent; there are be- sides, generally, some collateral circumstances, such as the existence of the sub-crepitant rhonchus in other parts of the lungs, which will aid in distinguishing the two sounds. The metallic tinkling is a peculiar sound produced by the escape of bubbles of air from beneath a stratum of liquid, situated in a cavi- ty whose walls are firm and elastic. The li- quid must occupy only a portion of the cavity, the upper part remaining filled with air. It was supposed that the sound was caused by a drop of liquid which fell from the upper sur- face of the fluid. Dr. Bigelow, of Boston, sug- gested the explanation which is now common- ly received, that the sound is not caused by the fall of a drop, but by the bursting forth of a bubble of air from beneath the liquid. This is the case, but it is not necessary that the air should be driven forcibly through the bron- chial tubes ; a very small portion of air contained within the liquid is sufficient to give rise to the tinkling. The sound is called tinkling, because it is somewhat simi- lar to the light tinkle produced by striking with a pin or some other light piece of metal upon a glass vessel. It is always heard in connexion with the amphoric respiration, which depends upon the physical condition necessa- ry to produce it. The sound, therefore, is not of great practical value. The dry rhonchi are the sonorous, sibil ant, and the dry or rustling crepitant; the latter of these is of very little value, and hardly differs from the rustling sound of the respiration, to which I have already alluded. They are, for the most part, heard chiefly during the expiration, and are caused by temporary or permanent thickening of portions of the mucous membrane of the larger or smaller tubes. In the large majority of cases they are heard in the earlier stages of bronchitis, before secretion has occurred, or in the chronic stages of this disease in which the secretion is not sufficient to remove the swelling of the membrane. But they may depend upon a purely spasmodic state of the bronchial tubes, for there is no doubt that these tubes are occa- sionally subject to spasmodic action. The sonorous rhonchus is generally very loud and well marked ; few of you have ever heard it, without recognising it merely from description. It is a loud cooing sound, some- what similar to that caused by drawing the bow slowly over the bass string of a violin, or to the cooing of pigeons. The sound may be compared most exactly to the note of the vio- lin, but the rhonchus itself is so peculiar from its deep musical tone, and so unlike any other sound heard in the chest, that you will scarce- ly mistake it. It is most frequent along the upper part of the lungs, both anteriorly and pos- teriorly, and cannot be produced except in the larger bronchial tubes, for the smaller ones do not yield so deep a note. In acute bronchitis, and even in the chronic cases of this disease, this rhonchus is so fugitive that it sometimes ceases and returns almost with every act of respiration. But you will generally find it in some portion of the lungs, although it may not remain long in a single spot. It is, how- ever, not always so moveable. In the nume- rous cases of secondary bronchitis which at- tend the diseases of the lungs and various acute disorders, the sonorous rhonchus is frequent, but it is not found in the most severe and dangerous cases of these disorders, or at least not exclu- sively. It is in all cases a sign of bronchitis, and when not connected with the moist rhon- chi, generally indicates a mild form of the dis- order. The sibilant rhonchus bears the same rela- tion to the smaller tubes, that the sonorous does to the larger; it is a low, whistling sound, heard during the expiration, generally very short and variable in situation. Of course you will find it in those portions of the chest where the bronchi are rather small, and, at the same time, are not subject to congestion or ac- cumulation of secretion,—that is, at the ante- rior margin of the lungs. The sibilant rhon- chus is chiefly heard in the various stages of bronchitis without effusion, especially in the chronic dry catarrh, and the secondary bron- chitis of typhoid fever. Both these dry rhonchi are easily learned from this description alone, for they have* a 38 PHYSICAL EXPLORATION. sufficiently close analogy to the sounds which are selected as objects of comparison. Thus the deep bass note and the musical tone are quite characteristic of the sonorous rhonchus, while a whistling and slightly musical sound are equally characteristic of the sibilant. The latter rhonchus is even more moveable than the sonorous, and is extremely irregular in its time of re-appearance. The mucous, sub-crepitant, sonorous, and sibilant Thonchi are sometimes heard combined together in a variety of chronic catarrh, at- tended with asthmatic paroxysms ; they were then sometimes called by Laennec the " song of all birds,—cantus omnium avium." More frequently, however, you will find two at least of these rhonchi present at the same time, as the sonorous and sibilant, the mucous and the sub-crepitant; a dry may be combined with a moist rhonchus. This depends upon an obvious cause; the various portions of the mu- cous membrane may be affected to different de- grees, and in one part secretion may have com- menced, while another remains turgid and dry; besides the secretions tend to accumulate at the posterior and inferior part of the lungs ; hence you will find the moist rhonchi some- times in this position, when the same inflam- mation gives rise merely to a dry rhonchus elsewhere. The rhonchi may also be connect- ed with other physical signs, as the bronchial respiration and resonance of the voice ; and it is sometimes a matter of some difficulty to dis- tinguish them. This is especially the case with the bronchial respiration and the sonorous rhonchus ; one not accustomed to these signs may easily mistake one for the other when they occur singly ; and if combined, the sono- rous rhonchus may mask the bronchial respi- ration to an inexperienced observer, for both these signs are chiefly heard during the expi- ration, and there is a certain degree of simila- rity between them. The only certain distin- guishing mark is to examine the part of the chest by percussion; if this be flat it will prove that there is bronchial respiration wher- ever the tubes are large ; if both bronchial res- piration and sonorous rhonchus are present at the same time, the flat percussion is so far use- ful that it indicates the more important sign. The chances of error, therefore, become ex- tremely small, and are still more diminished if you attend to the musical tone in the sono- rous rhonchus; this does not characterize the bronchial respiration, which is a pure blowing sound. After having gone through the description of these sounds you will be tempted to make the same remark which has often been repeat- ed to me. That is, that the difficulty is not in understanding the description of the sounds, but in acquiring the habit of rapidly and readi- ly recognising them. To be practically use- ful you must distinguish them with certainty, and you must do this without great loss of time to yourself, or the fatigue to your patient which necessarily results from a protracted ex- amination. If you are tempted to lay too much stress upon your newly acquired know- ledge, you may perhaps be tempted to fall into the errors against which I have warned you at the beginning of the course, that is, of trusting too much to your physical diagnosis. Now, you must avoid both these errors, and you will do this by the same means ; that is, by making your diagnosis by the general symptoms, and merely adding the physical examination to this as a matter of instruction, until you are sure of your Own progress. Those of you who follow my demonstrations will not need this caution, because each step is pointed out, and every part commented upon as it presents itself. The caution is designed for those who trust chiefly to their unaided ex- ertions ; these are, under ordinary circum- stances, sufficient, though necessarily attend- ed with more trouble, and requiring more time. I shall bear these remarks in mind when de- scribing individual diseases, and will group the physical and general signs together, that one may mutually assist the other. There are another set of symptoms which are not physical, yet are so local in their cha- racter that they should be described beforeyou proceed to the study of special diseases ; these are the cough and expectoration, which may properly form the subject of another lec- ture. LECTURE VI. Cough—Expectoration. Cough is produced in diseases of the thorax from two causes—the accumulation of liquid in the bronchial tubes, and the sympathetic irrita- tion caused in the larynx by pain or stricture in the chest. In the former variety, the cough is useful, and is productive of relief to the patient, in the latter it is often a cause of aggravation of symptoms. The true excretory cough occurs only in the diseases of the bronchial mucous membrane, and of the parenchyma of the lungs which directly communicate with this mem- brane. The irritative cough takes place not only in the earlier stages of inflammation of the bronchial tubes, and of disorders of the paren- chyma and serous membranes which do not communicate with the bronchi, but it is also a frequent dependent upon diseases of the heart, and even of the stomach, and in many cases is caused by a disordered condition of the nervous system, which is totally foreign to the chest. You perceive, therefore, that the causes of the irritative cough are extremely various, and that the cough itself, in many cases, throws but little light upon them. I shall now attempt to define to you the va- rieties of cough and of the expectoration, which are closely connected together. The dry or irritative cough. —The term irri- tative may properly enough be applied to this variety, which is nothing but a short and quick cough,—that is, a short and rapid expiration, which is the essential character of cough. The term dry cough is so well known as the desig- nation of this variety, that it is universally un- derstood. It is followed by no real secretion; there is sometimes an expectoration of the small quantity of mucus which is naturally found in the fauces and bronchi. The diseases of the lungs in which it occurs, are the early stages of phthisis and certain cases of serous inflamma- tion. It is also an attendant upon the elonga- tion and inflammation of the uvula, and may cease abruptly after its removal. In diseases of the stomach and bowels, and in affections of the mucous membranes of the abdomen as well as in peritonitis, the same variety of cough is observed. Indeed, you may generalize the subject much farther, and say that the short, dry cough, is the most frequent form of irritative cough, and the most persistent; and that, al- though in itself it is of no moment, it is often the sign of a commencing disease of the tho- rax. On the other hand, your knowledge of the circumstances which give rise to a dry cough, must lead you to look for other causes of it than the diseases of the chest,—and after your physical examination has taught you that there is no important lesion in the thorax, your next object will be to examine other por- tions of the body, and ascertain whether some disease of the abdominal viscera, or a mere nervous irritability, will not account for this cough. There is another variety of cough which is not very unlike the dry; that is, the sonorous cough: this is always loud, and at times very ringing and clear, so as to be heard at a consi- derable distance from the patient. This variety belongs to many morbid conditions: it is found in the chronic dry catarrh, but chiefly in the earlier stages of ordinary acute catarrh, before secretion has commenced. In its most marked degree, however, the sonorous cough is not in- dicative of diseases of the lungs, but of many and various conditions of this morbid nervous action; and, as you may readily suppose, it is most apt to occur in young girls, who are much more subject than any other class of individuals to diseases attended with deranged nervous ac- tion. Hence the cough is very irregular in its indication; and although when it is of recent occurrence and short duration, it is nearly al- ways connected with disorder of the bronchial tubes,—yet, when chronic, it is most frequently either a true nervous cough, or an attendant upon chronic diseases of the larynx, especially those in which there is a morbid growth which projects into the rima glottidis, and acts as a constant cause of irritation. This cough is therefore rather a matter which must exercise 40 PHYSICAL EXPLORATION. your sagacity, than a correct indication of any special disease. The suppressed cough is, like the dry, a short cough; but it is checked by a voluntary effort of the patient; for as the act of coughing is, to a certain extent, independent of the will, a pa- tient may arrest the violent expiration if he be aware that it will cause him much pain; hence the cough becomes suppressed in serous inflam- mations of the chest, where there is little or no secretion from the bronchi, and the pain is much more considerable than in ordinary cases of disease. In pertussis, the fear of exciting a violent fit of coughing will frequently cause it to be suppressed. In the early stages of pneumonia there is very little secretion into the bronchi; hence the necessity for cough and ex- pectoration is but slight, while the accompany- ing pleuritic inflammation acts as in cases of simple pleurisy, and suppresses the cough. The laryngeal cough is various in its charac- ter ; still, as it depends upon thickening or ul- ceration of the larynx, the tone of the cough is stridulous and somewhat stifled; at times, al- most whistling. In the advanced ulceration of the larynx, which constitutes laryngealphthisis, the cough is alternately loud and whistling, and again almost aphonic. This variety of the cough is attended with a peculiar alteration of the voice. The loose, or mucous cough, is well known as the cough which attends the resolution of acute bronchitis, and is therefore of favourable prognosis in this disease; it is connected with a free secretion into the bronchial tubes, and is of course accompanied by mucous rhonchus, and generally by expectoration. As there are many diseases in which there is an abundant liquid secretion into the bronchial tubes, the mucous cough is very far from being confined to bronchitis; it occurs also in the advanced stages of phthisis, in the third stage of pneu- monia, haemoptysis, &c. Hence, like most of the varieties of cough, it becomes useful as a sign, chiefly when combined with other symp- toms. In certain cases of large cavities from phthi- sis or gangrene, the cough sometimes is not merely mucous, but it is loud and rattling; that is, as it is caused by the free agitation of the air in a large cavity, it partakes of the charac- ters of the cavernous respiration, and differs in being much louder and more gurgling from the ordinary mucous cough. The spasmodic cough is the last variety of cough which is sufficiently characterized to ad- mit of a separate description. The type of this variety is found in pertussis, in which disease the cough is more decidedly spasmodic than in any other. But there are numerous other cases of disease, especially lesions situated about the larynx, which are attended with a severe cough, returning in paroxysms, and sometimes accom- panied with a noisy, whooping inspiration. Although it is most frequent in obstructions about the larynx and upper part of the trachea, the enlargement of the bronchial glands will often give rise to it, and the peculiar cough is sometimes a valuable diagnostic sign in an affection which is always obscure. In certain cases of asthma the cough recurs in paroxysms which are often attended with a noisy inspira- tion. In general terms, you may state, cough does not bear an accurate relation to the extent of the pulmonary lesion; frequently the cough seems to be almost in inverse proportion to the mass of parenchyma involved in the disease. For if a large portion of the lungs be rendered unfit for the performance of the respiration, the patient cannot make the forcible expiration ne- cessary to produce a decided cough. It is rather a sign of laryngeal and tracheal irritation, than of deep-seated pulmonary disorder. The cough is of less value as a sign in the aged than in those enfeebled by disease, or than in other patients, for in them it may be wanting through- out the whole course of a grave disease: the same remark is applicable to young children, who cough much less frequently than those who are older. In diseases of the lungs in ge- neral, the cough may completely cease if the brain becomes seriously involved; for a cerebral disorder renders a patient unconscious of the irritation, which, under ordinary circumstances, would give rise to severe cough. Secondary inflammation of other organs, as the stomach and bowels, sometimes produces a similar effect, but to a much less degree: this is in accord- ance with the general pathological law, that a severe intercurrent inflammation will obscure, and, to some extent, replace the symptoms of the primitive affection. THE EXPECTORATION. The expectoration is less frequent in diseases COUGH--EXPECTORATION. 41 of the chest than the cough; but its signs are more definite, and in some cases they afford very accurate indications of pulmonary disease. As a general rule, the sputa come from the lining membrane of the bronchial tubes, and from cavities or softened portions of the paren- chyma, which communicate directly with the bronchi. Hence, their value as positive signs is chiefly confined to the diseases which affect the mucous membranes of the chest. The sputa, however, may contain other liquids be- sides the ordinary secretions of the mucous membranes, such as blood, tuberculous and calcareous matters. The secretion of liquids in the bronchi is necessarily independent of the will, but the expectoration is a voluntary act. It is per- formed imperfectly when a person is averse to making the necessary muscular exertion, on ac- count of the pain it may give him, or other reasons; there are no sputa when the feebleness of the patient prevents his making an effort. For similar reasons, children below the age of six years do not expectorate; they do so but rarely until the age of puberty. In very old people the expectoration is rare, and not pro- portioned to the extent of the disease. When the sputa are not copious, they are chiefly expectorated in the morning, on waking from sleep, during which they accumulate in the bronchi. When the sputa are copious, but the expectoration causes pain, they are also retained in the lungs until a paroxysm of coughing comes on, and they are discharged in large quantities. Except in the cases above mentioned, the sputa are rarely wanting during the whole course of a disease, but they do not usually assume their characteristic appearance until the disease is sufficiently advanced to be recog- nized by the more certain physical signs. In some exceptional cases the sputa are pathog- nomonic, when the physical signs are doubtful, on account of the remote situation of the lesion or the state of the surrounding tissue. 1. Of the quantity of the expectoration.—It is small when it does not exceed a wine-glass- ful in the twenty-four hours; moderate, when from two to six fluid ounces; large, from six ounces to a pint, and very large if more than a pint. In descriptions of the sputa, it is advi- sable to state the quantity. 2. Of the colour.—The saliva and the mucus 5 of the bronchial tubes are transparent; and may be more abundant than usual. A higher, or rather more prolonged degree of inflammation of the bronchial mucous membrane, gives a whitish colour to the sputa, if the catarrh pass into resolution; or, if it assume a chronic form, the sputa' are yellowish, and frequently of a greenish tinge, and altogether opaque. In acute inflammations of the air-vesicles and of the minute bronchial tubes, the sputa are at first transparent and colourless, but soon become tinged of an orange hue, or they are rust-colour- ed or of a bright scarlet colour. In inflamma- tions of the lungs, with great prostration, the sputa are brownish, of a mahogany colour, or like that of stewed prunes. 3. Consistence, and chemical composition.—In general, the sputa, if colourless, are thin and very liquid; those that are yellow and opaque, are thick, and flow less easily. The shining transparent sputa of pneumonia are more viscid than any other, are often heaped up in the cen- tre of the cup, and adhere strongly to its sides. In one variety of chronic catarrh, and in some affections of the tonsils, the matter expectorated is very small in quantity, and almost solid. The sputa frequently consist of two parts, one more solid, and the other nearly of the con- sistence of water. If much air be mingled with the sputa, they are light and frothy. The chemical nature of ordinary bronchitic sputa scarcely differs from that of the healthy mucus of the bronchial tubes, but if the inflammation be more advanced, the sputa are more opaque, and become more albuminous. The increasing thickness of the sputa is a sign of a tendency to resolution in acute bronchitis, which is but slightly influenced by the mucous expectoration of its earlier stages. When pus is mixed with the mucus, the consistence is immediately in- creased ; the thick pasty sputa which occur in advanced stages of phthisis, in which the softening is very rapid, are very consistent, but adhere together less intimately than the sputa of pneumonia, 4. Form.—When the sputa are composed of simple mucus from the bronchial tubes, they run together, and form a mass which is per- fectly homogeneous,—and when they become albuminous, they offer no peculiar form, but are generally composed of two parts—one con- sisting of the whitish opaque mucus, which, in the form of shreds, is diffused through the 42 PHYSICAL EXPLORATION. mass of the liquid, and the other more transpa- rent. In some cases of bronchitis, especially of the chronic varieties, in which the sputa are more albuminous than in any other, the matter is moulded into the form of the smaller bronchi, and is expectorated in little cylinders, which are dif- fused through the secretions of the larger tubes. The viscid,transparent sputa ofpneumonia,blend together perfectly well, and form a mass which is with difficulty separated into smaller parts; and the sputa, both of the early and later stages of this disease, are so nearly similar to those of different stages of bronchitis, that they can scarcely be distinguished from them. The form assumed by the expectoration of phthisis is similar to that of bronchitis in its early stages: after softening has been completed, the sputa are moulded in the cavities, and form ir- regular, rounded masses, with loose cottony edges; these constitute the nummular sputa; when the softening is very rapid, the sputa run together, and lose their nummular form. The sputa, in gangrene of the lungs, retain no pecu- liar form, but vary according to the consistence of the matter in different cases of the disease. 5. Odour.—Transparent sputa are without decided odour; the thick, yellow liquid has generally a faint, nauseous smell, which is very marked in cases of phthisis. Gangrene of the lungs is distinguished by a peculiar fce- tor, sometimes gangrenous, at other times resembling the smell of moist plaster. Occa- sionally, a variety of chronic catarrh and one of tuberculous phthisis, in its advanced stage, are attended with foetid expectoration. Of the foreign matters mingled with, the se- cretions of the bronchial tubes.—Pus is often intermixed with the mucus secreted in bron- chitis, phthisis, and the latter stages of pneu- monia, when the sputa are said to be muco- purulent. Sometimes a portion of the pus is uncombined, and sinks to the bottom of the mass. Blood may be intimately combined with the sputa, as it is in pneumonia, when it communicates a general rusty or reddish tinge to them; or it may be mixed in streaks with the mucus, and still retain its florid red colour; or, lastly, it may be unmixed with the bron- chial secretions, when it constitutes haemopty- sis. The tuberculous matter may sometimes, though rarely, be detected in the sputa under the form of minute yellowish opaque grains, not often exceeding the size of a pin's head; this appearance coincides with the softening of the tubercles. Calcareous matter is sometimes, though rarely, observed when the tubercles are dry and contain much of the salts of lime. Portions of gray or dark pulmonary tissue have also been expectorated, after separation from the adjacent tissue. In cases of jaundice or pneumonia, complicated with disease of the liver, the sputa are sometimes tinged with bile. I have seen the expectoration composed almost entirely of pure bile from a fistulous opening between the liver and the lungs, following a wound of these organs. I have confined these remarks, on the expec- toration chiefly to the text of a short work on physical diagnosis which I published a few years since. They might be much extended; but as the subject is one to which I shall be obliged frequently to recur when speaking of individual diseases, I do not wish to annoy you with unnecessary repetitions. Still, it is essential for you to acquire some idea of the general characters of the expectoration. The best method of examining the sputa is to direct the patient to spit in a white or transparent vessel,—a common tumbler will do well enough for this purpose,—and then inspect them within a few minutes after they are discharged. The chemical analysis of the sputa has thus far led to few or no practical results; for the characteristic distinctions between the various forms of mucus, albumen, and pus, are ex- tremely slight. Indeed, it is not necessary for you to investigate, or rather to attempt to in- vestigate, these slighter differences in the ex- pectoration, which were at one time regarded as important. Amongst these, are the numerous tests between pus and mucus, which were sought in order to decide upon the distinctive characters of phthisis and catarrh; all these were found more or less fallacious: the best are the most simple,—that is, the yellow, puru- lent colour of the expectoration, when pus is mixed with the mucus, for it is rarely found in a separate state. This very admixture is one of the reasons which must make it impossible to discriminate in all cases, as to the mucous or purulent character of the expectoration. The whole subject is now placed in its proper light: the expectoration furnishes us with a most va- luable secondary means of diagnosis, but one COUGH--EXPECTORATION. 43 less important than many other methods of in- vestigation that have now come into general use. There is another class of symptoms which may be almost classed among the local signs of thoracic diseases,—that is, the mode in which the movement of the chest is performed during the act of respiration. In reference to this part of the course I shall content myself with quoting the observations contained in the work to which I have previously alluded. You will better understand their value by a reference to the numerous illustrations which I give you on this subject. ON THE MOVEMENT OF THE THORAX. In health, the act of inspiration is performed partly by the elevation of the shoulders and ribs, and partly by the depression of the dia- phragm. The passage of the air through the nostrils does not cause them to dilate evidently. When the respiration becomes difficult, the different muscles, whose action concurs in re- spiration, act irregularly, and much more forci- bly than in a state of health. When there is dyspnoea, without pain in any part of the tho- rax, all the muscles concerned in respiration act with increased energy. The nostrils dilate widely, the shoulders and ribs are forcibly elevated, and the diaphragm depressed. In acute diseases, the degree of the dyspnoea is nearly commensurate with the extent of the pulmonary affection. In chronic diseases, this is by no means the case. There are even some instances in which there is extreme dyspnoea, but no appreciable lesion of the lungs. When there is aeute pain in the sides of the thorax, or at the diaphragm, from inflammation of the serous membranes, the parts of the chest nearest to the inflamed pleura move less than they do in a state of health. The motion be- comes free as soon as the pain subsides. If effusion of liquid occur into the pleura or the pericardium, the motion of the ribs at the cor- responding part is impeded by the mechanical distension, though there be no acute pain. When the liquid is absorbed, and false mem- branes unite the two surfaces of the pleura, the dilatation of the diseased side is always im- perfect. The diminished motion of the side of the chest, most affected in phthisis, depends upon the adhesions produced by the frequent inflammations of the pleura. The number of the inspirations is generally from twelve to sixteen in the minute; but when the lungs or the pleura are much inflamed, the inspirations may increase to thirty or forty; and, when the disease is extremely violent, the number may be as high as sixty or seventy. This extreme frequency is most remarkable when all the serous membranes of the chest are inflamed at the same time. In acute dis- eases, the frequency of the inspirations is at first nearly proportioned to the violence of the affections; when they have lasted a certain time, the patient seems to accommodate him- self to a diminished supply of air, and breathes less frequently. The respiration of children affected with diseases of the chest is very fre- quent, especially when the lobular pneumonia has extended to a large portion of both lungs. When the extreme frequency of the respiration in acute diseases has ceased, the inspiration remains more hurried than usual; sometimes it is performed in as short a time as the expi- ration—after which apause ensues. In health, the time required for the inspiration is twice as long as that of the expiration, both in chil- dren and adults. LECTURE VII. We now come to the study of individual dis- eases of the chest. These may occur in the substance of the lungs and heart, or in their investing or lining membrane. The affections of the upper portion of the respiratory system are also closely connected with those of the thorax, and will require at least a passing no- tice. Both lungs and heart offer an investing and a lining membrane, which are more frequently inflamed, or otherwise affected, in connection with the parenchyma, than separately. Never- theless, these inflammations are sometimes met with in an isolated form, and it is then that they are most readily studied; afterwards the more frequent, but more complicated forms, may be analyzed, and you may separate the symptoms belonging to the different parts. The study of special diseases may begin with the inflammation of the serous or of the mucous membranes. In the present lecture I have determined upon deviating somewhat from the ordinary course, and shall commence the study by the examination of the serous mem- branes. These are the most simple of all the tissues composing the lungs, and the symp- toms of many of their diseases are nearly as regular and readily learned as their pathological lesions. Still, in all such cases, you must be- ware of the difficulty into which an imperfect study of the subject may sometimes lead you; for in diseases of the chest, more than in any others, a partial analysis, and a limited diag- nosis, may become the sources of error. You must prosecute your examination until you have arrived at the knowledge of all the symp- toms; otherwise the physical signs may limit your views, instead of extending them, and you may rest satisfied with the discovery of a single disorder, instead of taking into your esti- mate the numerous diseases with which it may be complicated. This is a common error with those who are commencing the study of aus- cultation ; they are apt to be too well satisfied with a partial discovery of the symptoms, and nsy. to forget that many other things may be con- cealed which a more thorough examination would explain. Pleurisy, as you well know, is an inflamma- tion of the serous membrane involving the luno-s; it is very regular in its progress and symptoms. Like the other inflammations of this tissue, it is sometimes simple and readily diagnosticated, and at other times is singularly complex, or perhaps consecutive to other disorders of a different and more constitu- tional character. For example, it may be con- nected with tuberculous diseases in several ways: first, tubercle may be developed in the adherent and more cellular portion of the serous membrane, and the inflammation may directly coincide with this development; in these cases the tuberculous deposit is formed, as it were, by the same process as the inflammation, and apparently by the same action of the vessels. In other cases the pleurisy is consecutive to the tubercles already formed in the lungs; in a third variety the pleurisy may attack an individual in good health, and afterwards give rise to the tuberculous deposit, partly from the general shock given to the constitution, and partly from the determination of the diseased action towards the lungs. This latter variety usually occurs in persons of a tuberculous tendency; but it may also prove a purely accidental cause of tu- bercles, and take place in those whose consti- tution is not previously tainted by this diathesis. Pleurisy also occurs in a more acute form as a complication of affections of the parenchyma of the lungs, when the latter approach the sur- face of the organ invested by the pleura. Pneu- monia is the disease of the lungs which most fre- quently gives rise to this form. There are some other lesions producing the same effect, which are, however, of rare occurrence, viz., gangrene and scirrhus: when these approach the surface of the lung, they cause inflamma- tion of the serous membrane, with an effusion of lymph,—this inflammation being in almost all cases preservative, as the adhesion which PLEU takes place prevents an effusion of the morbid matter into the cavity of the pleura. We have, then, three principal varieties of pleurisy,—1st, simple pleurisy; 2dly, pleurisy complicated with a deposition of tubercular matter; 3dly, pleurisy complicated with acute lesion of the parenchyma of the lungs. The pathological changes connected with ordinary pleurisy are regular in their progress, and proceed, step by step, with the symptoms, which afford us a means of measuring the in- tensity of the inflammation. The first change which takes place is the injection of the membrane, caused by an en- largement of its vessels, which, in the natu- ral state, do not transmit the red globules of the blood. These vessels are situated in the sub- jacent cellular tissue, and are disposed in an immense number of branches, which are inter- locked in various directions, and form a com- plete net-work. In the midst of this, there are numerous bright red points, apparently formed by minute extravasations of blood from the vessels. Almost simultaneous with this increase of vascularity is the development and effusion of lymph. This is at first deposited on the serous surface in minute points, which are scarcely visible, but may be readily detected by the touch. These points, as they become more numerous, gradually collect into groups, which, finally coalescing, form a continuous mem- brane. This deposit of lymph has received the name of a false membrane, and is more abun- dant at the lower portions, where it is in some cases as much as a fourth or even half of an inch in thickness, while at the upper portion it seldom exceeds the eighth of an inch. The character and amount of the effusion vary ac- cording to the form of the disease, and the con- stitution of the individual affected. In cases of local pleurisy, especially if occurring in ro- bust persons, the amount of serum effused is very small, while there is a considerable depo- sit of lymph; the same also occurs in persons who are not robust when the inflammation is confined to a small portion of the membrane. On the contrary, if the patient be thin, and of a lymphatic temperament, and the inflammation diffused, the effusion of serum will be very great, with but a slight trace of lymph. The thin and serous part of the effusion tends to ;ISY. 45 diffuse itself over the surface of the pleura, gravitating to the most dependent portion, and shifting its position with the movement of the patient. When, however, it is principally composed of lymph, it is confined to the part of the lung which is affected, and exhibits no such tendency. The serum increases in quan- tity as the disease advances, and decreases with its decline; but the lymph is more persistent in character, and, instead of being removed, be- comes organized, and assumes the character of a serous or cellular membrane, according to the circumstances in which it is placed. When the inflammation continues for a considerable length of time, a secretion of pus takes place, and the serum is entirely replaced by purulent matter. The lymph in this case being bathed in pus, is modified in colour by its assuming a yellowish hue. When the serum is abundant, the lower portion of it is turbid, while the up- per portion is clear. This results from the greater specific gravity of the lymph, in conse- quence of which it settles to the bottom of the fluid. During the recovery of the patient, the fol- lowing changes are observed to take place. As the serum is absorbed, the pressure of the atmosphere forces the parietes of the chest towards the lung, and adhesion takes place be- tween the two surfaces of the pleura. As the lung is compressed against the spine, and in that position is covered with a coating of lymph, it remains permanently flattened, and cannot rise to meet the ribs. In those cases in which the pleurisy is slight, and the effusion very small, there is either no contraction of the chest, or it takes place to a very slight degree. The con- traction is not entirely permanent; the lung after being compressed, does again expand to a certain extent, and rises partially towards its original form. The adhesions become gradually organized during this process, and new vessels are formed in the lymph. The particles of blood are de- posited in the lymph under foan of dots, and gradually collect in trains or streaks; vessels are afterwards formed around the blood, which then finally inosculate with the original vessels of the subjacent serous tissue. The contraction of the chest is not great when the serum is but moderate in quantity; but in cases of abundant effusion, the contraction is equally well marked 46 DISEASES OF THE LUNGS. with the previous distension. The alteration of conformation, therefore, is a purely patholo- gical state, and corresponds accurately with the quantity of liquid exhaled. If, therefore, the effusion be limited, it does not produce a very decided dilatation or subsequent contraction: a less quantity than a pint is scarcely appreciable; a quart gives rise to a very decided alteration in the shape of the chest, and larger quantities distend it sufficiently to incline the body to- wards the sound side. In the same way, if the contraction which follows pleurisy be very great, the body is inclined towards the diseased side. The nature of the liquid is not always the same; the greatest portion of it consists of se- rum in the early or inflammatory conditions of the disease. This is mingled with flocculi of lymph of various density, which seem to be de- tached from the surface of the pleura. In the chronic varieties of the disease, the liquid con- sists almost exclusively of purulent matter, al- though at first the serum is merely tinged with pus from a small admixture of globules with it; but as the disease continues, the purulent glo- bules become gradually more and more abun- dant, until the liquid consists nearly of pure pus: the pleurisy is then often called empyema. It is in these cases that the distension of the chest is greatest. In the early stages of some cases, pus is mixed with the serum and lymph in small quantity, giving the liquid a slightly yellowish tinge; but, as a general rule,.it is quite transparent, but of a light greenish yellow colour. In a few instances it coagulates spon- taneously immediately after death, becoming a mass of tolerably dense albumen. In a num- ber of cases it contains blood in small quanti- ties, and occasionally, although rarely, the pro- portion of blood is large. These varieties in the exhaled fluid belong to the same disorder, which is in all these cases inflammatory; but the product varies according to the general condi- tion of the individual's previous health,and other circumstances difficult to discover. In general, the product of inflammation of the pleura, and other serous membranes, is most consistent and most highly animalized when the patient is strongest, and the disease most violent. These changes are very regular, and give rise to an equally regular succession in the phy- sical signs. When the inflammation is severe, and the effusions very large, these signs are pathognomonic of the disease; but when it is small, the physical characters are so far useful, that they either confirm the indications of the functional signs, or prove that the disease is not advanced beyond a certain point. When the effusion of serum takes place, the sound on per- cussion is immediately dull, becoming gradu- ally flat as the quantity of the liquid increases. The flatness is much more decided at the lower than at the upper portion of the chest, and becomes gradually less in ascending to- wards the summit; for the liquid of course gra- vitates towards the most depending portions. Still, the serous effusion is not the only cause of the flatness; it depends, in part, upon the thick deposits of lymph at the inferior portion of the lungs, and does not disappear entirely when the position of the patient is changed, although a change in the level of the liquid is always attended by a change in the degree of flatness. If the effusion be very large, the flat- ness gradually becomes more complete, and at the same time extends over the side of the chest, until the resonance is either completely lost, or is limited to a small portion of the chest near the spine, where the lung generally con- tains a little air. The increase in the flatness enables us to estimate the extent of the effusion with great accuracy; but the converse of this is not true in its declining stage,—for when the compression of the lung is carried to a great extent, it recovers its elasticity but slowly, and remains either permanently or for a long period in a more solid state than is natural; hence the clear sound returns slowly, and generally never recovers its original sonorousness. A moderate but diffused resonance does not, therefore, prove that the lung has not recovered from the inflammation. The enlargement of the affected side accords with the dulness on percussion, and is always met with when the dull sound is at all decided. If, in the early stages of the pleurisy, you examine the lower and posterior parts of the chest, you will readily detect slight changes in the conformation; and this is then generally limited to an alteration of the natural convexity of the thorax, and is scarcely perceptible in the whole semi-circumference. The quantity of liquid which is sufficient to cause a decided change in the conformation, varies from a pint to several gallons. When it exceeds a gallon, the distension is of course very great. I have, PLEURISY. 47 on one occasion, in which the bulging of the affected side was immense, found no less than five gallons in the right pleura. In these ex- treme cases the healthy lung is compressed towards the ribs, at the same time that the dis- eased one is forced against the spine, and death usually occurs from suffocation. The semi- circumference of the chest may be measured with a tape on a level with the sixth or seventh dorsal vertebra, in order to give you an idea of the changes which take place in the quantity of the liquid; but this method is of little use ex- cept in cases in which the effusion is very large. The position of the heart is another sign which is closely connected with the alter- ation in the conformation. If the pleurisy occur on the left side, the heart is sometimes forced to the right of the sternum; if, as is most frequent, the pleurisy attack the right side, the heart is removed towards the left axilla. The respiration in the early stages of pleurisy is always feeble,—that is, if either the pain is tolerably acute, or the effusion at all considera- ble. But at the beginning,the feebleness depends much more upon the pain than the mechanical pressure of an effusion which is still quite small in quantity. When the dilatation of the vesicles in a part of the chest is attended with pain, that portion of the lung becomes to a great degree motionless, and remains so until the pain diminishes. This rule is so general in its application, that if the serous membranes of the chest be inflamed, in a great extent, and over both lungs, the patient may perish from the dyspnoea which arises from the inactivity of so large a portion of the pulmonary tissue. The feebleness of the respiration continues through- out the disease in those portions of the lungs in which the bronchial tubes are small; where they are much larger, the respiration becomes more or less bronchial, or at least rude. The inten- sity of the rude respiration varies very much, and chiefly according to the condensation of the lung; when this is very great, the bronchial respiration is very intense, sometimes quite as loud as in the most severe cases of pneumonia. The condensation of the substance of the lung is, therefore, a circumstance which favours the bronchial respiration. The density of the ef- fused liquid is another cause of the loudness of the bronchial respiration; if there be a large proportion of lymph, or a thick, viscid liquid in place of the usual thin serum, the conducting power of the substance which intervenes be- tween the tubes and your ear is increased, and the same result is produced as if the lung itself were inflamed. When there is bronchial respiration in pleu- risy, the resonance of the voice becomes bron- chial, and you will observe a true bronchopho- ny. This has, however, a peculiar vibration or quivering in its tone, which never exists to the same degree in pneumonia proper. If the bron- chial respiration is not so loud, the resonance of the voice becomes less bronchial, but its vi- bration is increased, and its resonance is termed egophony. This takes place in those cases in which the effusion is but of moderate density, or little more thick than ordinary serum; and it is heard most distinctly from the anterior por- tion of the axilla to the scapula, and between this bone and the spine. It is therefore most evident when the bronchial tubes are moderately large, and there is a tolerably strong compres- sion upon the vesicles. The depth of tone of egophony is modified by the density of the liquid more than its vibration; if the liquid re- main thin, the egophony will continue; but in proportion as th^,density of the lung and of the effused fluid approaches more nearly to that of pneumonia, the resonance becomes more like bronchophony than egophony. When the ego- phony is perfectly pure, it is less loud, and often less easily recognised than in those cases in which the body of sound is decidedly in- creased by the hardness of the lung. In certain cases of pleurisy there is little re- sonance and no vibration of the voice; this must depend upon the obstructions which pre- vent the passage of the air through the tubes, and of course destroy the resonance. It is dif- ficult to state what these obstructions are; in some cases they may depend upon the pressure of the liquid upon the tubes, in such a manner as to interrupt the column of air, or upon acci- dental collections of liquid in them. If the lung remain soft and uncompressed, it will also give rise to an egophony which is but moderately loud; the circumstances, therefore, which fa- vour its development, are moderate pressure and a little increase in the density of the tissue of the lung. If the voice be shrill and clear, it is of course much more decided. The friction sound is another sign of pleurisy, which is much more irregular than the resonance 48 DISEASES OF of the voice. It occurs under two different cir- cumstances,atthebeginningand towards the ter- mination of the disease,—that is, at those times in which the effused matter consists almost ex- clusively of lymph, and not of serum ; for if there be a large and thin effusion, the friction of the two surfaces of the pleura, which is the essential cause of this sound, will be pre- vented. When this sound occurs early in the disease, it of course takes place in the variety of pleurisy which may be termed dry, whether it continue in that stage or not; the friction is then very slight, and is inappreciable by many persons; it is more like the slight noise pro- duced by rubbing together two pieces of tissue paper than any thing else. When it occurs at the close of the disease, after the absorption of the liquid, it is much louder, and then offers the peculiar character of the true friction sound. This is sometimes quite permanent, lasting se- veral days, or even much longer. These irregular sounds are not of value for the pro- per diagnosis of pleurisy; they are only of ac- cessary importance, and should be recollected by you, because every thing should be known which may become of use under any circum- stances. The signs of the lungs, properly speaking, are of great negative importance in the diagno- sis of pleurisy. In fact, it is at times impos- sible to distinguish the cases in which the lung is unaffected, in any other way. If, therefore, you find no signs of pulmonary disease, such as are indicated by the rhonchi and respiration, you may regard the case as one of simple pleu- risy. But, in order to form this opinion, you must take into your calculation both the gene- ral and local signs of pulmonary disease; and even then it will stand good only for the time, for you may be afterwards obliged to modify your opinion. Still, in simple pleurisy, you should recollect that there are no signs of dis- ease of the lungs, other than those which arise from their consolidation by the pressure of the liquid. In practice, the complicated cases are probably quite as frequent as those which are more simple. In the recovery from pleurisy, restoration to health takes place but slowly, and the lung does not recover its natural respiration for a considerable time; the sound remains feeble, and the percussion dull: after a very long pe- riod, sometimes a year or more, the restoration THE LUNGS._______________________ to the natural fulness and softness of the respi- ration may take place; but this is not to be an- ticipated in the great majority of cases, and we must therefore be satisfied with a slow and gradual improvement. Besides the physical signs, there are other symptoms of pleurisy, which are, to a certain extent, quite conclusive. These are generally most decided in the commencing stages of the disease, and they may subside almost entirely, and be almost forgotten by the patient. The diagnosis of the disease is therefore easiest, by the general symptoms, at its very commence- ment, when the physical signs are most ob- scure. We are also obliged to rely chiefly upon the rational symptoms in those cases in which the adhesions between the two surfaces of the pleurae are strong, and of course no effu- sion can take place; this is always the case in pleurisy which has succeeded to a former severe attack of the same disease. Of these local, but at the same time func- tional signs, the most prominent is the pain. This is so acute in many cases of pleurisy, that the ideas of pain and pleurisy are very firmly associated in the minds of most persons, and they are apt to believe that all cases of pleurisy must be attended with pain: this is an error; for the pain may either be totally ab sent, or so obscure as scarcely to attract atten- tion ; it is then limited to a mere soreness along the portion of the chest most affected. When there is severe pain, it is almost always felt near the nipple; it is acute and lancinating, similar to that caused by the prick of some sharp instrument; hence it is in many lan- guages called a stitch in the side. It is in- creased by motion, cough, or even respira- tion. When the inflammation is very sudden and extensive, the pain may be agonizing, and for a time effectually check the respiration. A large quantity of effused liquid rather dimi- nishes than increases the pain; and when it becomes very large, as in very chronic cases, the pain is often limited to a mere soreness, which is often seated in the loins, instead of the thorax. This seems to depend upon the great weight of the thick purulent liquid. In diaphragmatic pleurisy, especially when caused by rheumatic or gouty disease, the pain is dif- ficult to localize, and is generally wandering about the lower part of the thorax, causing more distress than other varieties of the dis- PLEURISY. 49 ease. You perceive, therefore, that the pain is an important symptom of the disease when it exists, but that it is never lasting in the slow and moderately severe cases of pleurisy, and may be either entirely absent or badly charac- terized throughout the disease. The cough is another local symptom: this is generally present in the milder cases of the disease, and is always short and almost insig- nificant. If the inflammation be very acute, the cough is almost entirely suppressed; and even in moderately severe cases, it is in a great degree checked by the aversion of the patient to make the strong respiratory movement ne- cessary to produce a full cough. It is not at- tended with expectoration in the simple inflam- mation of the pleura, for there is of course no secretion to be thrown off externally, unless the substance of the lung or the bronchial tubes are involved in the disease. Hence many of the remarks which you will find in some of the older writers upon this subject, are in reality applicable to pneumonia, and not to pleurisy. The more chronic the disease becomes, the less disposition is usually felt to cough, and in cases of extensive empyema, there is often no cough. The mode in which the respiration is per- formed is sometimes of importance; in the be- ginning of the disease, when the pain is severe, the patient breathes chiefly with the healthy lung: this arises from the pain which is caused by the act of respiration, as well as coughing. When the disease is more advanced, the me- chanical pressure upon the affected lung will prevent its expansion. Hence the patient throughout the disease breathes chiefly by the healthy side. The decubitus in pleurisy is sometimes of importance. When there is pain, you may state, in general terms, that the patient does not lie upon the affected side, which is ex- tremely sensitive to pressure. Even late in the disease, he will prefer the sound side, or the back; but when the effusion is so great that the weight of the liquid would press upon the mediastinum, and thus prevent the expan- sion of the healthy lung, he will naturally pre- fer lying upon the diseased side, and will thus relieve the lung which remains in a state fit for the performance of its proper functions. The rational as well as physical signs which 1 have just described, are those which belong to pleurisy considered chiefly as a local affec- tion. There are many other symptoms which appertain to it in common with other inflam- mations of the serous tissues. These phleg- masia; present a number of characters similar to those of other inflammatory affections, and some that are nearly peculiar to themselves. In general, the serous tissues, like other mem- branes, modify the ordinary characters of in- flammation, rather than offer others which are strictly novel. At the commencement there is usually a chill, which varies in intensity from a slight sensation of coldness to a complete chill. This is generally felt at the same time with the pain,—that is, the pain in the chest excites the chill; it may return at several different times throughout the disease; but it then rarely offers the same intensity as on the first day. The chill is followed, of course, by heat, and by sweating, which occurs at irregular times, and is never very copious. During the disease the fever is generally persistent, and is charac- terized by a quick, tense, but rather small pulse. This is often called the pulse of in- flammation of the serous tissues; although not regularly present in all cases of these diseases, it is found in a large proportion of them. The sweats in pleurisy are sometimes extremely abundant, especially in the varieties of the dis- ease that are complicated with a tuberculous development; but even in simple inflammation of the pleura they are sometimes extremely copious, and form a harassing and alarming symptom. In empyema, the nature of the fever approaches the hectic type, and almost always assumes it when the operation of para- centesis has been performed, and a free commu- nication is made between the external air and the purulent collection. In the latent form of pleurisy the fever may be quite moderate, rather a slow febricula than a perfect fever, and this is one of the causes which render this form of the disease extremely obscure. The secondary irritation and inflammation of other viscera, which are so frequent in the in- flammations of the mucous membranes and the parenchymatous organs, are very slight in pleurisy and serous inflammations in general. The. disturbance of the alimentary canal is strictly proportioned to the intensity of the fe- ver, and not to the gravity of the inflammation, which pursues a course almost unconnected 50 DISEASES OF THE LUNGS. with the other viscera. The strength and the cerebral functions are usually just so far affect- ed, as naturally results from the severity of the pain and degree of the fever; they are, in them- selves, very little disturbed by the inflamed pleura. Hence pleurisy is a remarkably simple disease, if it be the primary affection; it fre- quently occurs as a complication, but has little power to give rise to disorder of other tissues. This is explicable enough when you reflect upon the simple structure and few nervous re- lations of the serous tissues. There is, how- ever, one exception, the tuberculous diseases, whose development is sometimes singularly favoured by pleurisy. The diagnosis of pleurisy is readily enough made in most instances: a well characterized case is always certainly known, and can be confounded with no other affection. That is, when the distension of the chest, the dulness on percussion, and feeble or bronchial respira- tion, coincide with dyspnoea, pain, and fever. If you restrict your diagnosis to the functional signs, you will, of course, be somewhat puz- zled in many cases: with the aid of the physi- cal signs, all decided cases can be mistaken for nothing else. In the slighter cases, where there is little or no physical change, this is not always the case: pleurisy may be confounded with pleurodynia, or simple rheumatic pain in I the intercostal muscles and the adjacent fibrous tissues. The fever is a very uncertain test; but it has a collateral value, for it is more apt to accompany true pleurisy than simple pleuro- dynia. The nature of the pain is a better one; for, in pleurisy, this is, to a certain degree, limited, and almost always is found about the anterior margin of the axilla; but in pleurody- nia it shifts about, and is often found on both sides at once; very frequently it disappears for a time, but soon returns, displaying in this re- spect the peculiar changeable character of rheu- matic disease. When severe, fixed pain occurs during the course of inflammatory rheumatism, you need not trouble yourselves about the diag- nosis,—for in such cases there is almost always something more than a mere rheumatic pain, and the pleura is positively, though perhaps slightly, inflamed. As a general rule, there- fore, if in your suspected pleurisy the pain is at all constant, you may regard it as a true inflammation. The mobility of the pain is there- fore the only good proof of pleurodynia. There is no difficulty in distinguishing between sim- ple pleurisy and pneumonia, or other diseases of the parenchyma of the lungs, with pleuritic complications; for the signs of true pulmonary disease are of course wanting in the one case, but present in the other. The inflammation of the pericardium frequently occurs in connection with pleurisy of the left side, when it is some- times extremely difficult to recognise it; for the signs of one disease, to a great extent, obscure those of the other. If the pleurisy attack the right side, the distinctive characters of the two diseases are quite evident. In simple pleurisy your prognosis is almost always favourable if you see the patient rather early in the disease; if the effusion is very large, or if the disease be chronic, it is then quite doubtful: the mortality is totally different under these circumstances. In the secondary pleurisy, or in that variety which is accompa- nied by tuberculous disease, the prognosis is of course much less favourable. When it pre- cedes tubercles, it usually ends in recovery, but may afterwards give rise to them. The treatment of ordinary pleurisy,—that is, of the disease as distinguished from those cases in which pneumonia plays the most im- portant part, is based upon well established grounds. It is strictly antiphlogistic,—and, as in other inflammations of the serous membranes near the surface of the body, is most effec- tual when you use local depletion in combina- tion with or in addition to general blood-letting. The latter remedy, however, is always produc- tive of great relief in the cases which begin with strong inflammatory symptoms,—that is, much pain and dyspnoea; there is, then, no substitute for it. After you have taken a mo- derate quantity of blood, however, and have re- lieved the pressing symptoms, the indications are then rather to continue the treatment by lo- cal depletion and by diaphoretics than re- peated general bleeding. Cupping or leeching to the painful parts, repeated if necessary, two or three times, is then the best remedy. The effects of local bleeding are much more prompt in serous than in mucous inflammations, or in diseases of the parenchyma of organs. They may be repeatedly applied in either acute or chronic cases; but you will gain most from them if you choose the moment when the pain is most acute; it will then often yield very quickly, and the disease improve after free local bleediner. PLEURISY. 51 There are several other local remedies which are effectual in relieving the pain and inflamma- tion besides cupping and leeching; these are warm poultices of hops, sprinkled with a tea- spoonful or two of laudanum, and kept warm by placing over them a bottle or tin vessel filled with hot water, which should lie on the bed by the side of the patient. The narcotic acts with consi- derable energy upon the part, and its action is favoured by the warmth and moisture. In slight pleuritic pains, as well as in the true pleurodynia, sinapisms are eminently useful; but they are of little benefit in severe pleurisy. This is not the case with blisters, which belong to that established class of remedies whose vir- tues have been tested by the experience of many generations; they are used with two ob- jects in view—to relieve the inflammation, and to favour the absorption: hence they are par- ticularly applicable to those cases in which there is much effusion, both in the acute and chronic diseases; while the inflammation is still ad- vancing, the operation of blisters is uncertain, and sometimes seems to be positively injurious; but after the active inflammatory symptoms have been checked, they are productive of de- cided benefit, and are, perhaps, of all remedies, those whose action is most unquestionable, as the acute pain often subsides immediately after vesication, and the absorption of the effused li- quid sometimes takes place very rapidly. The rapidity of absorption is not generally propor- tioned to the quantity of the serous secretion from the blister, although in a few cases a very copious discharge will pour from the vesicated surface, and the pleuritic effusion will disappear in a few hours. In chronic cases of pleurisy, blisters are amongst our most valuable reme- dies ; but they should be small, and very fre- quently repeated. My own plan is not to make them larger than two or three inches square, and to apply them every two or three days, dressing the surfaces with simple cerate; you should, in this way, pass over a considerable part of the affected side by applying these small blisters successively to different parts of it. When the pleurisy has been entirely or nearly removed, the patient often complains of slight returns of the pain from exposure to damp, or to a cold wind. The only way of guarding against these slight returns of the in- flammation is to cover the affected side with a Burgundy pitch plaster, and to direct your pa- tient to clothe himself warmly. These, then, are the directly depletory reme- dies, and such as act as local counter-irritants. The internal remedies suited for the treatment of pleurisy are numerous, and applicable either to different cases of the disease, or different stages of the same affection. They may be di- vided into three principal classes:—1st. The antiphlogistic remedies, which are intended to relieve the inflammation, and check the fever. 2d. The remedies that promote absorption, which, however, are often fitted at the same time to check the inflammation. 3d. The anodyne, which may relieve the pain. Of course, in a strictly inflammatory disease, the first class of remedies, and those which belong both to the first and second classes, are the most important. The tartarized antimony has long been used both in simple pleurisy, and in the disease complicated with pneumonia; it is usually given as a diaphoretic, in the doses of a fourth to the eighth of a grain,—rarely in larger doses. In these doses its nauseating influence is nut slight. In the early stages of pleurisy, free diaphoresis is a powerful therapeutic agent,— but in the more advanced cases, sweating is productive of comparatively little benefit: its good effects are most evident in those stages of the disease in which resolution is practica- ble before there is much effusion into the pleu- ra; that is, it is a means of depletion from the vessels, and exercises comparatively little influence in promoting absorption. In chronic cases of pleurisy the tartar emetic should either be given up altogether, or restricted to very minute or merely alterative doses. The tartar emetic is almost the only remedy which is nearly exclusively antiphlogistic in its action; most other internal remedies are more powerful from a combined action in pro- moting absorption, and checking inflammation. The most important are mercury, nitre, and digitalis; squill and colchicum are also power- ful remedies, and act like most other diuretics of a moderately stimulating character. Of these the most important is mercury. Mer- cury, given in moderate doses, so as not to dis- order the bowels, produces two distinct effects; one is directly antiphlogistic, the other is the influence which it exerts upon secretion and absorption. In the treatment of pleurisy in its active inflammatory stage, the first action of 52 DISEASES OF THE LUNGS. mercury is that which is most beneficial; in the advanced cases of purulent effusions, the inflammatory character of the disease is less marked, and the action of the mercury is chiefly limited to the absorption and elimination of the effused matter from the body. In the more acute cases you may give mercury more rapid- ly, in chronic cases more slowly. Thus, I would advise a quarter of a grain to half a grain of calomel to be given every four hours, if you design it as an antiphlogistic; it will then pro- duce its specific effect in a short time, and the disease will generally decline. The mercurial treatment is of course but a sorry substitute for bloodletting, which it should follow and assist, but not replace. If the mercury be used to- wards the decline, or in the advanced periods of the disease, when your object is more to pro- mote absorption than to remove the inflamma- tion, you should give the calomel in much smaller doses, as an eighth or a sixth of a grain three or four times a day: this operates but slowly, and is much more effectual in increasing the power of other alteratives than larger quan- tities. The mercurials are usually combined with other remedies, which will work, as it were, in the same direction with them. Thus, in the early stages of the disease, Dover's powder, or the simple opium and ipecacuanha, may be given with them: if full diaphoresis is brought about by these means, the disease is more easily subdued. In the advanced stages, dio-i- talis, and nitre, act admirably as diuretics. There are cases in which others of a more sti- mulating kind, as the juniper berries, or spirit of nitre, come in well; but these are chiefly such cases as approach very nearly to hydrothorax: there is then a feeble condition of the economy, and but little active inflammation. The diaphoretics of a vegetable kind are, like many other remedies, adapted for various stages of pleurisy. In the early stages, full diaphoresis acts admirably as an antiphlogistic remedy, while in the advanced stages it may increase absorption, and remove the effused fluid. The latter effect is, however, very un- certain ; for the disease naturally tends to pro- duce sweating, and the perspiration seems an abortive attempt on the part of nature to throw off the disorder,—the curative action being quite disproportioned to the diseased one. Anodyne remedies in the treatment of sim- ple pleurisy, are merely palliative, and are, therefore, rarely given alone. They consist almost entirely of some form of opium, except in those cases in which the patient is unable to take any preparation of this drug: we are then compelled to resort to various substitutes. You must not, however, suppose that opium is in- significant, or of no value, because it is simply a palliative; for in pleurisy, as in other inflam- mations, the relief of pain prevents the increase of the disease,and is indirectly one of the effectual aids towards its cure. The only objections to its employment are to be found in those ^ases in which the cure takes place chiefly by secre- tions which must be thrown off from the body: this is not the case in inflammation of the se- rous tissues, in which the liquid is necessarily retained until it can be removed by absorption and the adhesion of the coagulable lymph. There is, then, no permanent therapeutic con- tra-indication to the use of opiates: if the skin be dry, they should be given in the forrn of Dover's powders, from eight to twelve grains of which may be given in divided doses during the day. If the sweating be copious, mor- phine will, as a general rule, be the best reme- dy, administered chiefly at night, in the ordi- nary doses of an eighth to a quarter of a grain. This is sometimes necessary for a considerable period. When you find the pleurisy nearly well, but the patient still complaining of some dyspnoea, or a little feverishness, and you discover, on examination, that a portion of the liquid re- mains unabsorbed, nothing is so efficacious as a journey, with its necessary consequence, change of air. Although the sea-air is not al- ways adapted to pectoral diseases, it is often of decided advantage in chronic pleurisy, espe- cially if combined with a voyage. But a course of this kind is necessarily attended with no little expense and inconvenience, and is to- tally beyond the reach of many of your patients: you will be obliged to resort more frequently to land journeys, as a less troublesome and some- times as efficient a course. This is generally the surest means of dissipating the remains of the disease, and insuring a restoration to entire health. Of course, the usual hygienic precau- tions as to dress, should be adhered to. There is no disease in which the treatment is more influenced by a knowledge of its symp- VARIETIES OF PLEURISY. 53 toms and pathological relations than pleurisy; for, simple as it is, the success, in chronic cases, depends chiefly upon steadily watching the physical condition of the chest, and perse- vering in your care until the disease is entirely dissipated. VARIETIES OF PLEURISY. Besides its simple form, pleurisy presents many varieties which are for the most part con- nected with various structural alterations of the lungs, or with peculiar symptoms of the dis- ease itself. I have already given a passing no- tice to several of them; but they require some- thing more, as they constitute the most difficult cases of the disease. There are other varieties of the disease which differ from the usual form,but at the same time are not connected with an important change in the substance of the lung; that is, latent and chronic pleurisy. These are sometimes closely con- nected together; thus, latent pleurisy is almost always chronic, but chronic pleurisy is not ne- cessarily latent. I shall first allude to the va- riety of it which follows a primitive acute pleurisy. It is difficult in many cases to say what ren- ders an ordinary acute pleurisy chronic; some- times it is evidently a badly treated case of acute pleurisy, and the inflammation continues, although some of its symptoms may cease. At other times the inflammation has either entirely resisted the ordinary remedies, or it has recur- red after having nearly ceased. Both of these varieties present the same symptoms; the phy- sical signs are similar to those of acute pleu- risy, but there is evidently an increase in quan- tity and weight of the effused liquid; hence the prominence of the chest, the displacement of the viscera of the abdomen and thorax, and the flatness of the chest, are all much more decided than in ordinary pleurisy, while the bronchial respiration, as well as the egophony, gradually ceases. I have already stated that the general signs of acute pleurisy, such as the inflamma- tions, fever, and severe pain, may gradually dis- appear ; but the fever is apt to recur, and changes its type, either resembling hectic very closely, or becoming perfectly identical with it. The fever is one of the most troublesome and alarm- ing symptoms of this variety of pleurisy; for in other respects the patient does not suffer in a manner proportioned to the extent or the dura- tion of the effusion. I once saw a patient who had performed the full duties of a sailor, going aloft, &c, with an enormous pleuritic effusion; when he returned from sea, it amounted to two or three gallons. This is an exceptional case; but it is very frequent to find patients who can perform many laborious occupations without much inconvenience: it is generally the case if the dyspnoea be not severe, and you will find that some patients complain of little difficulty of breathing with an extent of pectoral disease which will give rise to great distress in other individuals. The symptoms which so fre- quently characterize chronic organic diseases, are extremely variable in this variety of pleu- risy : these are emaciation, loss of firmness of muscles, harshness and dryness of the skin, and slight oedema of the legs. Sometimes they are nearly as well marked as in tuberculous disease of the lungs,—in other cases they are very slight; hence they constitute a diagnostic sign of the disease, and if you find them well characterized, you will do right to regard the case as one probably complicated with tuber- cles; if your impression be erroneous, you will soon rectify it, as the symptoms will gradually become more decided in the latter case, and slowly disappear if the pleurisy be followed by recovery. The diagnosis of chronic pleuritic effusion is often quite impossible without the physical signs, for its symptoms are sometimes nearly similar to those of phthisis. When the physi- cal signs of the disease are present, there is no difficulty in ascertaining it; if it be complicated with tuberculous deposit, the case should be regarded as one of great danger, and your diag- nosis is, as we shall afterwards see, much more difficult. I have already alluded to the prognosis in this variety when speaking of ordinary pleurisy; it is always doubtful, if the effusion be very large, for the liquid then consists nearly of pure pus, and of course the irritation caused by it may be sufficient to produce marasmus, and perhaps deprive the patient of the strength ne- cessary for a cure. The disease may occasion- ally, though rarely, prove fatal, from the mere obstruction to breathing. The liability of the disease to give rise to secondary tuberculous deposit, after the absorption of the pus, is also to be taken into your account: this forms a va- | riety of the tuberculous pleurisy, in connection 54 DISEASES OF THE LUNGS. with which I shall presently speak of it. There is another way by which chronic pleurisy may terminate fatally,—that is, by producing metas- tatic abscesses in parenchymatous organs, as the lungs or liver; this result is, however, not common. The treatment of chronic pleurisy differs so little from that of the acute variety, that I have treated of it at some length in connection with the latter disease. The disease is in both cases essentially the same; but, as it has become chronic, it requires chronic remedies: as a ge- neral rule, these should be such as are at the same time antiphlogistic, and favour the ab- sorption of the pus. But in using these reme- dies, you must not commit a common error, and attempt to force nature through a process which is essentially a slow one; thus, if you subject the patient to what is called a vigorous treatment, you rather impede than favour the cure, and the strength may fail in. the attempt. It is on this account that I advise the repeated application of small blisters, warm clothing over a large portion of the body, which is a mild, but powerful means of counter-irritation, and the careful administration of the mercu- rials and other remedies favouring absorption. Sometimes tonics are necessary in very old pleurisy, as in other diseases in which there is an abundant suppuration; for the strength may fail at the critical point when the largest de- mands are made upon it. In these cases the essential remedies are the chalybeate prepara- tions, which you may use from time to time, and occasionally either combine or alternate them with the vegetable tonics; but as the in- fluence of the latter is much stronger in re- storing the state of the digestive functions than in producing a decided alterative effect upon the general system, they are rather secondary remedies. I have already alluded to the good effects of travelling, and even of a sea-voyage in the treatment of chronic pleurisy. There is another cutaneous tonic and alterative which may be properly combined with them,—that is, stimulating baths, especially the sulphur and salt water baths. These are generally taken at natural sources, by resorting to the sulphur springs or sea-bathing. They are much more powerful, and more safe, taken warm, than cold, especially if you use the artificial baths. But sea-bathing, or bathing in cold sulphur water, is sometimes advisable as a mere tonic, when the patient is simply debilitated, and the inflammation has subsided; they are always re- medies which require some caution in their management. In chronic pleurisy it frequently becomes a question whether the operation of paracentesis should be practised. This is, as you well know, one of the most simple opera- tions in surgery, and no one can meet with the least difficulty in performing it,—but, at the same time, it is often very serious in its conse- quences. There is a rule in surgery which is here strictly applicable ; that is, that the expo- sure of a large suppurating cavity to the air, necessarily excites hectic fever, and sometimes favours the development of secondary abscesses. The chances of recovery are not, therefore, on the whole, increased by the operation,—and it is one which you should not perform, unless it be to relieve excessive dyspnoea, which may in itself be severe enough to threaten life. LATENT PLEURISY. This is another variety of the disease: like all latent inflammations, it is not indicated by the usual functional signs. These are in pleu- risy, pain, cough, dyspnoea, and fever, all of which may be either wanting, or so obscure as scarcely to attract notice. When the disease is slight and latent, it passes through its stages without notice, and the patient usually forgets the trifling indisposition under which he may have laboured ; it is in this way that adhesions are so frequently formed in the pleurae of per- sons who have no recollection of the previous inflammation. When the latent pleurisy is more severe, it gives rise to more decided symptoms; but these are very slow in their progress and formation, and increase very gra- dually, producing a disturbance of the general system, attended with slow wasting of strength and slight fever, rather than with any symp- toms which point decidedly to the local inflam- mation. A disease which begins in this way is necessarily an obscure one, and may imper- ceptibly attain a degree of severity which will either render it fatal of itself, or, as is much more frequent, give rise to other disorders, especially of the tuberculous kind. Indeed, many cases of tuberculous pleurisy are in their nature more or less latent; for the peculiarity of latent pleurisy consists merely in the absence of the ordinary local signs; it may or may not be complicated with this morbid deposit. VARIETIES OF PLEURISY. 55 The diagnosis of latent pleurisy is of course more difficult than that of any other variety of the disease. It depends upon the physical signs of the local mischief, and the evidence of general disorder of the economy. When the disease is attended, as it often is, with consi- derable effusion, there can be no difficulty in deciding as to its nature, provided all the phy- sical signs can be detected,—that is, the dull or flat percussion, feeble respiration, and ego- phony : if the friction sound be present, it is of course still more evident. But if the signs be limited to the mere feebleness of respiration and dulness of percussion, you must take care not to confound the disease with an enlargement of the liver, or a chronic consolidation of the lung. As a general rule, however, the physical signs of latent pleurisy are tolerably well marked in all severe cases, when you compare them with those constitutional symptoms which are com- monly caused by the disease. These generally pursue the following order:—a patient pre- viously in good or passable health is taken with a slight chill, which is sometimes so short that he is scarcely conscious of its occurrence; this is followed by a slight fever, increasing a little towards the close of the day, but rarely severe enough to destroy the appetite; this is, however, a little diminished, while the thirst and dryness of the skin are rather increased. There is often a slight hacking cough, but the expectoration is altogether or nearly wanting. The strength of the patient is a little enfeebled, but not enough to prevent him from attending to his ordinary business. These symptoms are so slight that most patients are totally un- able to localize their disease; this is indeed so difficult that I have known several experienced physicians, who were labouring under this af- fection, without being able to make a positive diagnosis in their own case. If you remember, therefore, that latent pleu- risy is rarely important, unless it be discover- able by the physical signs,—for in no other case does the effusion take place to any great extent,—you will rarely meet with much diffi- culty in recognising the disease. The com- mon source of error is in distinguishing be- tween it and pulmonary phthisis, which is sometimes excessively difficult, for the one may often be complicated with the other. This is particularly true of tuberculous pleurisy, in which there is an actual deposit of tubercles, either in the pleurae or the lungs, and yet the ordinary symptoms of pleurisy are present. I do not wish at present to enter more at length into this matter: it is one of those things which are most difficult to describe; the diagnosis de- pends upon a number of circumstances, which, in themselves, are unimportant, and acquire value only from their combination. The prognosis of this form does not differ from that of other varieties of the same dis- ease,—that is, of those which are equally chro- nic ; and except in the cases in which the dis- ease passes into the tuberculous form, it ge- nerally terminates favourably: if it be long neglected, however, the disease is sooner or later transformed into pulmonary phthisis. The treatment of latent pleurisy does not differ in any respect from that of the ordinary chronic forms; and I need not, therefore, re- peat what I have already detailed to you. SECONDARY AND COMPLICATED PLEURISY. Pleurisy is secondary to many other dis- eases : these may be either the affections of the lungs proper, or of the economy in general. When pleurisy occurs during the course of a disease of the lungs, it is most apt to develope itself when the external portions which are nearest to the serous membranes are affected: thus, pneumonia, gangrene, and phthisis, which are the diseases most frequently followed by pleurisy, are often not complicated with it until the disease has advanced from the central parts of the lung, where they generally begin, to the surface; hence the pleuritic stitch or pain may not be felt until a comparatively late period. As a general rule, all affections of the lungs which approach the pleura, will give rise to pleurisy, which is the surest safeguard against perforation of the pleura. These cases of secondary pleurisy are gene- rally classed with the diseases of the paren- chyma with which they are connected; for these are much more important disorders. The treatment is especially directed towards the pleurisy only so far as it is designed to remove pain. In other respects, the same mode of treatment which is proper for the removal of the inflammation of the parenchyma, will usually relieve the disease of the serous mem- brane. The serous inflammation may occa- sionally prove more severe than the parenchy- matous disorder; thus, there may be but little 56 DISEASES OF THE LUNGS. disease of the substance of the lung, and rather a large effusion into the pleura: this variety is then called pleuro-pneumonia, and it becomes very little else than a pleurisy aggravated by the pulmonary disease. The tuberculous pleurisy is a disease of some importance: in certain cases it is consecutive to the tuberculous deposit in the parenchyma of the lungs, and is then strictly secondary; in another class of cases the tuberculous deposit takes place in the pleura, and is followed by the inflammation; and in a third the inflamma- tion occurs in an individual who is previously in good health, or at least free from evident tu- berculous disease of the lungs, which does not occur until the inflammation has taken place. The first two varieties belong exclusively to the subject of pulmonary phthisis; the latter is rather a cause than a consequence of it,—hence it merits some notice in this place. The third class, you observe, I divide into two subdivisions,—in the one of them, the tu- berculous disease of the lungs occurs after the pleurisy has lasted for some time, or the effu- sion has perhaps been partially or entirely ab- sorbed. It is difficult to say why a simple pleurisy should be more frequently followed by tubercles than pneumonia, yet such is the fact; or at least there are many cases of pleurisy in which neither attentive observation nor careful reasoning can lead us to suspect the occurrence of tuberculous disease during the active period of the inflammation, although it is developed in its declining stage or at its close. If I were to hazard a theory, I should say that the singular analogy between the irritative fever from pleu- ritic inflammation with purulent effusion and that resulting from the acute tuberculous dis- ease, shows that there is a singular alliance be- tween the two kinds of morbid action. This explanation, however, even if its correctness were perfectly proved, does not entirely solve the difficulty; but it is certain that the very dif- ferent ways in which tubercles accompany pleurisy, prove that the mere absorption of pus will not account for it in a large proportion of cases, although the transmission of the puru- lent fluid through the system must be more or less deleterious, and, like all enfeebling agents, it will break up the constitution, and favour tuberculous diseases. The second mode in which tubercles seem to arise from pleurisy is probably rather more frequent than that which I have just described; the pleuritic inflammation occurs in healthy individuals, or those who are apparently healthy; and in the serous membrane as well as in the coating of coagulable lymph or false membrane, we find a great number of minute granulations of various size, some barely visi- ble, others of the diameter of half a line or a line, each surrounded by a beautiful net-work of vessels passing to them. The granulations are, as a general rule, most numerous where the vessels are most developed, although this is not invariably the case. In this variety, it would be an abuse of reasoning to conclude that the tuberculous granulations had existed in a latent state, and were followed by the serous inflammation; for they are, for the most part, equal in size, and evidently of extremely recent origin, some of them often appearing in the false membranes, which are necessarily con- secutive to the pleurisy. There is, of course, something besides the pleurisy; for all cases of inflammation do not give rise to tubercles, al- though the exciting causes of the disease, when complicated with them, are the same as of ordi- nary inflammations. This variety of pleurisy has been little noticed by writers; indeed, you will not, I believe, find that its true value as a cause of tuberculous disease of the paren- chyma of the lungs, is any where pointed out. The varieties of tuberculous pleurisy which are consecutive to pulmonary phthisis, belong more properly to the history of the latter dis- ease than to that of pleurisy proper. The other anomalous products which occasionally take place in the lungs are often complicated with pleurisy; and in a few rare cases you will find that the cancerous or melanotic substance is secreted simultaneously with the serous,in- flammation : this disease is similar in many re- spects to tuberculous pleurisy, but possesses little or no practical interest. LECTURE VIII. Having concluded the subject of pleurisy in its various forms, I might now take up that of pneumothorax, as in this affection the same membranes are involved; but inasmuch as bron- chitis is of more frequent occurrence, and, like pleurisy, in very many cases complicates or gives rise to affections of the parenchyma of the lungs, I think it comes in very well in this place, and I shall therefore now proceed to treat of this disease. The term bronchitis is, in common parlance, applied to various affections of the respiratory organs, as laryngitis, several affections of the lungs, &c.; but it should never be used in this way by physicians, as it is vague and unphilosophical: the term should be confined to inflammation of the mucous mem- brane of the bronchial tubes. Bronchitis, like all other inflammations, is divided into acute and chronic. The acute has been subdivided in reference to the greater or less quantity of the secretion, and its epidemic or sporadic nature. The first di- vision is of very little importance; but the second is well founded, as the disease is much more serious when it occurs in an epidemic form. In the epidemic bronchitis, to which the name influenza has been given, the severity of the constitutional symptoms is by no means proportioned to the intensity of the lo- cal lesion,—the latter in many cases being very slight, while the former are sufficient to con- fine the patient to his bed for several days. The constitutional symptoms are pains in the back, &c., high fever, and extreme prostration. We have no opportunities of examining the anatomical lesions in simple acute bronchitis, as the disease is seldom or never fatal. On his account we can only study them in cases i n which it is secondary to other grave dis- eases, and in these cases we often meet with every stage of bronchitis. In this disease the mucous membrane itself is chiefly involved, and not the subjacent tissue, as is the case in serous inflammations. The lesions observed are injection of the mucous membrane, ecchy- moses, thickening, and induration. The last mentioned lesion is inferred from analogy to occur in primary acute bronchitis, as it cannot be demonstrated; but in cases where the affec- tion is secondary to some other disease, we frequently meet with it. These lesions are more marked in the minute than in the large bronchial tubes, although the signs of inflam- mation of the larger tubes may have been very decided before death. In anemic patients, the mucous membrane, instead of presenting increased redness, is found to be pale; the only change which is perceived is the opacity of the membrane, which, in a healthy state, is almost transparent. This appearance is not at all uncommon in persons whose blood is deficient in red globules at the time of the occurrence of the affection. In acute bronchitis ulceration rarely takes place, although it is by no means infrequent in the chronic form of the disease. It is almost entirely confined to those acute forms which have a specific character, such as bronchitis, complicating rubeolaand variola. In these cases the ulcers are at first confined to the follicles, although they sometimes extend themselves,and acquire an irregular outline, involving the sur- rounding membranes. Ulceration affects prin- cipally the trachea and larger tubes, where the follicles are well developed, and rarely extends to the minuter ramifications of the bronchial tree. I shall not dwell upon this lesion at present, as it does not deserve much attention in this place. There is, however, another modification of much more importance, viz. the effusion of lymph and formation of false membrane. This form of inflammation, which has been termed dipthe- ritis, occurs also in severe cases of croup. When bronchitis commences in the small tubes, and extends upwards towards the larynx, it is not unfrequently fatal; but when it follows the opposite course, beginning at the larynx, and extending downwards, it may be arrested, and the disease will almost always terminate favour- 58 DISEASES OF rably. Inflammation of the bronchial mucous membrane is in some cases attended with a serous effusion, which, occurring under the membrane, gives rise to cedema: when this takes place in the upper portion of the larynx, it constitutes oedema of the glottis. Bronchitis tends, in most cases, to get well without the formation of pus. Its progress is as follows: at the com- mencement of the inflammation the membrane is injected and thickened, and its secretion is arrested. An increased secretion then takes place, which is intended by nature to relieve the turgescence of the vessels: if the inflam- mation continues, the secretion then becomes opaque; if it is not arrested at this stage, but still goes on, purulent globules are mixed with the mucus, and in more protracted cases pure pus is secreted. The expectoration, however, is never found to consist of pus alone, because, although certain parts of the membrane secrete pure pus, yet before it is expectorated, it is mixed with mucus from other portions. Bronchitis may occur as a primary disease, or as secondary to some other affection of the lungs. When it occurs as a primary affection, it may either terminate in perfect recovery, or may give rise to the development of some lesion of the parenchyma of the lungs, such as pneu- monia or phthisis. The former is the more common termination, but the latter is not un- frequent. In other cases the bronchitis supervenes on one of these affections. This distinction is of the greatest importance in forming a prognosis; for when the disease is secondary, it is merely a part of the tuberculous disease; when it pre- cedes this affection, it may proceed to a cer- tain length, and the tubercles may then be arrested. We now come to the signs which indicate acute bronchitis. These may be divided into general and local. The general signs are febrile excitement, with its attendant symptoms of en- feebled strength. The local signs are cough, expectoration, soreness of the chest, with the physical changes in the respiratory sound. In treating of the local signs, I shall first consider those connected with obstructions to the pas- sage of air through the tubes. The sonorous rhonchus is generally heard in the first stage of acute bronchitis: it is produced by the thicken- ing of the mucous membrane of the larger por- tions of the tubes, which contracts their calibre, THE LUNGS._____________________ and thus impedes the passage of air through them. I described this rhonchus in a previous lecture, and pointed out its distinctive charac- ters. As it often occurs first at the root of the lungs, where bronchial respiration is loudest in pneumonia, you may, without you are attentive to the distinctive characters which I laid down, mistake it for the latter sound: it is important to bear this in mind. The sonorous rhonchus is heard in the larger tubes; but when the in- flammation extends to the smaller tubes, a sibilant rhonchus is produced, which is caused by the same physical condition as the sonorous, but differs from it on account of the smaller calibre of the tubes in which it occurs. Although these rhonchi are very frequent, yet if you expect to meet with them in all cases of acute bronchitis, you will be egregiously mistaken, because the thickening must reach a certain point before the sound is developed, and therefore if it does not proceed thus far, no rhonchus will be heard. Feebleness of respi- ration is a more constant sign in bronchitis: it results from the air not passing freely through the tubes; but, like the rhonchi themselves, this sign is extremely variable, shifting from one portion of the lung to another, as it is tem- porarily influenced by the efforts of breathing, which force the air into the lungs, and for a time clear the tubes. In this affection, the chest sounds perfectly clear on percussion in the first stage; it, however, becomes somewhat dull in the second, but the alteration is very slight. In the second stage of the disease, secretion takes place into the bronchial tubes, which gives rise to the moist rhonchi, mucous and subcrepitant. The former, like the sonorous rhonchus, is produced in the larger bronchial tubes,—the latter in the smaller. The sub- crepitant rhonchus resembles very much the crepitant, which is peculiar to pneumonia: this renders the diagnosis somewhat difficult, as the cases in which it occurs, simulate pneumo- nia very much. When, however, the bronchi- tis is of considerable extent, it does not resem- ble pneumonia so closely, for the latter disease scarcely ever extends to a large portion of both lungs, as is often the case with bronchitis. After the secretion from the mucous mem- brane occurs, the thickening subsides, and the respiration gradually returns to the normal state, but, for a time, it may be more or less mixed with moist rhonchi,—that is, the mu- BRONC HITIS. 59 cous and subcrepitant. These gradually cease as the resolution of the disease advances. The expectoration in acute bronchitis is very variable: at first, as the cough is dry, there is little or no expectoration; but as the disease advances towards resolution, or passes into a more chronic variety, the expectoration be- comes much more abundant, and consists of sputa which are almost peculiar to this dis- ease. When the disease is still slight, or if it remain stationary, the sputa are generally transparent, and consist merely of thin mucus. As soon as it tends decidedly towards resolu- tion, or if, instead of tending towards resolu- tion, it assumes a sub-acute form, and becomes chronic, the character of the sputa changes,— they become more thick and opaque, and of a whitish colour. If the disease be very intense, a small quantity of purulent matter is some- times mixed with the sputa, and they assume the muco-purulent character. In these cases their form is irregular, and the thicker portion is generally diffused in irregular shreds through the thinner part. As the disease declines, the sputa gradually become less and less abundant. If the inflammation be very violent, the secre- tion from the bronchial tubes becomes almost of the consistence of coagulable lymph, and is firm, and moulded into the form of the bron- chial tubes; these tubes, or polypi, as they are sometimes called, indicate a high degree of in- flammatory action. The local signs of primary acute bronchitis, differ but little from those of other forms of the disease, such as the chronic, &c.,butthe ge- neral signs are somewhat different,—they are generally very well developed in epidemic cases, and are very slight in the sporadic. The patient is first taken with a chill, which is fol- lowed by febrile excitement, thus resembling other inflammations, as well as those of serous membranes and the substance of the lungs, although it is of much less intensity. The patient, then, has slight fever, and sensations of chilliness occuring at different times, rest- lessness, heat in the palms of the hands, &c. The condition of the pulse is in perfect cor- respondence with the moderate fever, rarely exceeding eighty or ninety in the minute. In epidemic bronchitis the condition of the patient may be very different; the pulse is often small, compressible, and frequent; there is great pros- tration and disturbance of the nervous system; and, consequently, the tolerance of loss of blood is much less than in serous inflammations. There are other symptoms depending upon the febrile excitement, such as anorexia, thirst, and headach. There is another set of symptoms which is secondary, and belongs to affections of the other tissues, principally the serous: of these the in- flammation of the pleura is the most common, producing pain, which is increased during the act of inspiration. The pleurisy supervening on or complicating bronchitis, is very slight, and is usually dry; when the pleurisy is con- siderable, it is looked upon as the primary dis- ease, of which the bronchitis is a complication. This accidental pleurisy may prove a cause of death in certain cases; when, for instance, there is hypertrophy of the heart, or when the patient is loaded with fat, it produces this catastrophe by increasing the dyspnoea which usually at- tends bronchitis, when it attacks the same in- dividuals. The danger in these cases arises chiefly from the pain which impedes the respi- ration: in simple bronchitis the pain is slight, and often limited to a mere soreness. Acute bronchitis generally lasts but a few days, and its termination is in most cases fa- vourable. It sometimes, however, runs into the chronic form. This may depend upon the peculiar susceptibility of the patient to inflam- mation of the mucous membrane, or the unfa- vourable hygienic circumstances in which he is placed. In some cases it leads to the de- velopment of tubercles in the lungs; this, most commonly, is owing to a decided tu- berculous diathesis of the individual affected with it. The treatment of bronchitis is simple, and will occupy us but a short time. You will find in books generally a regular course laid down for the treatment of this affection,—the first step of which is, in severe cases, the abstraction of blood. Bleeding is unquestionably a most use- ful remedy; but it should not be prescribed for all patients indiscriminately, for the milder cases get well very rapidly without it. We should only resort to it in severe cases, for there are other means by the use of which we may cause the disease to abort. These consist chiefly of the nauseating and stimulant expec- torants and diaphoretics. In most cases I pre- fer the vegetable diaphoretics, aided by hot pe- diluvia, and generally make use of an infusion 60 DISEASES OF THE LUNGS. of eupatorium and sanguinaria, or eupatorium and seneca, after the following formula: R. Eupator. Perfol.") — Rad. Senegae 5 "" M., et infunde in aq. bull Oj. A tablespoonful or two may be given every hour, or a larger dose less often. Ipecacuanha and tartarized antimony produce a decided effect on the disease. The latter is not always well borne, and ought to be used in large doses only in severe cases, as it may cause much irri- tation of the stomach. I give it usually in very small doses, sometimes in lemonade or neutral mixture, the object not being to excite severe nausea, but to produce a sedative effect. Dr. Physick has the credit of originating a re- medy which was much used at the Almshouse Hospital some years ago. It consists of tartar- ized antimony gr. ij., bitartrate of potassa jij., dissolved in one quart of flaxseed tea, to be taken in divided doses, in the course of twenty-four hours. This remedy is not altogether safe; for if the patient should drink a large quantity of it through mistake, it would probably produce very unpleasant symptoms, as tartarized anti- mony diffused in a large quantity of any fluid is very apt to bring on violent inflammation of the mucous membrane of the alimentary canal, though the quantity taken be not very large. It may be advantageously combined with opium. Some give a dose of opium alone in the commencement of the affection;—I prefer, however, this combination, which produces dia- phoresis, and often affords very speedy relief. You may give a fourth of a grain of tartarized antimony, with one-seventh of a grain of sul- phate of morphia, or you may vary this to suit the case. When the disease does not subside at once, after active treatment, the patients generally ask for something for their cough. In these cases many cough mixtures are used, most of which are beneficial in their effects. They contain a narcotic, nauseating, or stimulating ingredient, and sometimes a combination of these, commonly mixed with mucilage of gum arabic, which fulfils the indication of allaying the irritation about the throat. A remedy in very general use is the Brown mixture, the composition of which you are well acquainted with. Another common mixture is one, of the syrups of seneca and squills, to which opium may be added if necessary; but you should be very cautious about giving opium in mixtures to children, as the accumulated effect of repeated doses may arrest the secretions, and produce other dangerous results. Certain stimulants are frequently given with advantage towards the close of acute cases, and are very useful in the chronic forms of the disease; these are gum ammoniac, balsam of Tolu, balsam of copaiba, &c. The precautions necessary to be observed in convalescence, are the same as in other acute diseases. The general indications, therefore, in the treatment of bronchitis, are, if possible, to bring about a cure of the disease by resolu- tion; this rarely takes place without a secretion of mucus from the membrane. Hence, if you prevent the fever and local inflammation from running sufficiently high to impede secretion, either by bloodletting, or nauseating, or stimu- lating diaphoretics, you produce nearly the same effect. After this object is attained, the local stimulants which tend towards the lungs favour very much the secretion of mucus, which is almost essential for the removal of the disease. There are several circumstances which mo- dify this affection to a considerable degree. The most important of these is age,—the bron- chitis of children and of old men being very different from this disease as it occurs in adults. The bronchitis of children is particularly in- teresting ; it extends usually from the trachea down to the tissue proper of the lungs, involv- ing the whole mucous membrane of the large and small bronchial tubes. Its chief peculiarity is its tendency to pass into lobular pneumonia; indeed, if the bronchitis continue for a consi- derable length of time, this affection is almost certain to supervene. Secretion takes place very early, and consequently the dry rhonchi do not make their appearance, or continue for so short a time that they escape observation: this is another point in which it differs from the affection as it occurs in adults. As the smaller bronchial tubes are usually affected, we almost al way s find the subcrepitant rhonchus, which can be heard at all times, for children do not expec- torate, but throw off the accumulated secretion by an effort of vomiting. The chest usually gives a clear sound on percussion, though it is sometimes rendered dull by the accumulation of mucus in the small tubes, and of blood in the tissue of the lungs. These signs are more marked, and more early developed in the right BRONCHITIS. 61 lung, which is more commonly the seat of pneumonia than the left. Besides the physical signs, we meet with a loose cough, orthopncea, and flushing of the face ; the redness, instead of being circumscribed as in the case of adults, extends over the whole face, and is of a pur- plish colour, which is to be ascribed to the im- perfect aeration of the blood. There is also at times great febrile excitement, with cerebral symptoms. The treatment is also modified by the age. In bronchitis attacking adults, bleeding from the arm is the best means of depletion,—while in children its advantages are very question- able, and it may sometimes be positively inju- rious. Local depletion is decidedly preferable. Children, who have passed the age of two years, may be treated by general bleeding; but, before this age, it should almost never be prac- tised. I have very rarely found it necessary to bleed an infant suffering with disease of the chest; indeed, in these affections I only bleed as an exception. Nauseating expectorants are the remedies which have been found most ge- nerally beneficial in these affections. Among these, ipecacuanha holds the first rank: this is given in the form of a wine, or, what is still better, a syrup. When much mucus is pre- sent in the tubes, it is sometimes useful to give it in doses sufficient to produce vomiting, thus favouring the tendency which already exists: by this act the mucus is thrown off, and it is the only way in which children can rid them- selves of it, as they cannot expectorate. It is generally, however, used in small doses, which act upon the skin and other secretions without producing much nausea. Antimonial wine is also used in the treatment of this affection, but I prefer the wine of ipecacuanha in the greater number of cases. The former is a more pow- erful remedy, and in very severe cases more re- liance can be placed on it; but it is, on the other hand, more liable to induce inflammation of the mucous membrane of the stomach and intestines. Squills is also a remedy in com- mon use in the pectoral affections of children, and is usually kept in families in the form of syrup. In cases which do not yield at once, we have recourse to other remedies as adju- vants, such as mild sinapisms applied to the chest, legs, and ankles. A very good one is readily prepared by wetting a cloth with vine- gar, and sprinkling it with mustard: blisters I do not consider to be so efficacious as the milder stimulants long continued. Another very important point in the management of this affection is, that the child be not suffered to re- main too long on its back, as this position pro- motes the development of lobular pneumonia, in consequence of the mucus gravitati ng to the infe- rior portion and accumulating in the small tubes, which renders aeration imperfect, and thus fa- vours, if it does not produce, the congestion of the lung which ends in pneumonia. The child should not be allowed to lie on its back for a longer period than two hours. This direction may appear to be trivial, but it is of much import- ance, for I have known death to occur from a neglect of this precaution. As regards the quantity of blood, one or two ounces may be taken from a child under two years of age; as a general rule, an ounce for a year will answer very well. In judging of its immediate effect, you must be guided by the paleness of the patient, and not by the pulse. Sometimes a very small loss of blood produces a very decided effect upon children; therefore they should not be leeched or bled except under your immediate inspec- tion, for cases of death, from leech-bites, have often occurred among them. Cups aie better than leeches, after the child has passed the age cf seven years. BRONCHITIS OF OLD MEN. The bronchitis from which those advanced in age so frequently suffer, is an affection pre- senting much variety of form. In the first place, it varies as regards the affected portion of the bronchial tubes. It sometimes attacks the smaller tubes, and then it simulates pneu- monia. Indeed, it is often called peripneumo- nia notha. The patient suffers excessively from dyspnoea, which is much worse when he already labours under emphysema, or any other disease of the respiratory organs,which of itself occasions a difficulty of breathing. The treat- ment of this affection varies according to the condition of the individual attacked by it, and the form of the disease which it assumes. If the patient be robust, and you are called early, you will find it advantageous to resort to pretty free depletion from the arm. Great cau- tion, however, is necessary in the use of this remedy after the disease has advanced to a cer- tain point. When secretion has taken place, and the patient is reduced in flesh and strength, 62 DISEASES OF THE LUNGS. the bleeding often causes dyspnoea by prevent- ing free expectoration. Vegetable emetics, in small doses, and expectorants, especially those of a stimulating nature, are the most valuable remedies in these cases; and in this disease you will again find that the senega is one of the best expectorants of its class. If the patient be weak and debilitated, some carbonate of ammonia must be added to it; but the bal- sam of copaiba does not answer so well in this variety. If I were to select the diseases in which carbonate of ammonia is decidedly useful, I should place the bronchitis of old men and feeble subjects at the head of the list The ammonia keeps up the strength of the patient, and promotes the natural process of cure; that is, evacuation from the bronchial mucous membrane. It therefore acts directly upon the affected part; blisters and sinapisms exercise a much more indirect influence upon it, and do good rather as revulsives in removing the inflammation, and as stimulants to the nervous system, than as direct curative agents. In some cases of bronchitis there is a viscid secretion, with deposit of lymph, which causes great dyspnoea on account of the formation of a membrane in the tubes; sometimes this mem- brane has a tubular form, and these tubes have been ridiculously termed bronchial polypi. This formation I have observed more frequently in old persons than in children. It causes dyspnoea by protecting the mucous membrane of the tubes from the contact of the air, and by obstructing the passage into the air-cells. The lymph is detected by its presence in the ex- pectoration, as well as by the orthopncea. Eme- tics and expectorants, as those of a nauseant or stimulant kind, are appropriate to this dis- ease, according as inflammation is present or not; but mercurials, which are the most efficient of all known medicines in preventing the forma- tion of lymph, are sometimes required, if the affection be highly inflammatory. Although acute bronchitis is in many cases an idiopathic affection, it also occurs frequently as a complication of other diseases. Almost no acute disease attended with fever is entirely exempt from it; and, as a general rule, the degree of fever is proportioned to the frequency and severity of the secondary bron- chitis. It is thus an almost invariable atten- dant upon measles, typhoid fever, and in fact many of the exanthematous diseases. The se- condary inflammation is most frequent at the same season of the year as the primary bronchi- tis; that is, in the early spring, and in the winter months, when febrile diseases are peculiarly liable to this complication. There are also many chronic diseases which singularly favour the development of acute bronchitis; these are diseases of the heart and of the lungs. I have already alluded to the connection of this dis- ease with tubercles: this is the variety most difficult of recognition, but scarcely more fre- quent than the acute bronchitis which occurs during the course of the chronic variety, or in emphysema. In these cases the distress and difficulty of respiration are much greater than in the simple form of the disease. The treatment of this variety of the disease is similar to that of the acute idiopathic bron- chitis, and consists in the use of depletion, stimulants, expectorants, and diaphoretics. After the secretion from the mucous membrane has set in, local depletion may be used accord- ing to the necessity of the case. Cups are more beneficial than leeches, as they produce greater irritation with a smaller abstraction of blood; they are generally applied between the scapulae. Stimulants applied externally often produce a good effect; sinapisms and other re- medies of this kind are usually placed upon the anterior portion of the thorax. They act as counter-irritants. CHRONIC BRONCHITIS. I have still to speak of the chronic and spe- cific varieties of bronchitis, and shall commence with the chronic. Chronic inflammation of the serous and mucous membranes may originate in two ways: 1st, it may be chronic from its commencement; 2dly, it may follow acute inflammation, which frequently passes into the chronic form. The latter is the more common in the case of bron- chitis. Chronic bronchitis presents several varieties: the common chronic mucous catarrh; chronic ca- tarrh, with a thin, glairy secretion; and the dry catarrh, with thickening of the bronchial mu- cous membrane. There is another form de- scribed by some authors, viz. the pituitary ; but this is very rarely met with so strongly characterized as to be distinguished from the second variety, or chronic catarrh with a glairy secretion, and therefore it may be considered as a mere modification of it. BRONCHITIS. 63 The first variety, or the common mucous ca- tarrh, is the most common. It is characterized by a secretion of white mucus, sometimes puri- form, generally in irregular shreds, and but rare- ly moulded to the form of the tubes. It consists of mucus rendered albuminous or purulent in the progress of the inflammation. The febrile ex- citement in this affection is various, being sometimes very decided, but in a majority of cases comparatively mild. 11 is usually greater at night than during the day. The appetite, and other constitutional symptoms, vary very much. The diagnosis is based upon the presence of cer- tain physical and functional symptoms, and the absence of other physical signs which are found in analogous affections of the chest. The po- sitive signs are, in the first place, the rhonchi; these are of the moist variety, and vary very much, the subcrepitant being heard at one time, and the coarse mucous rhonchus at an- other. The respiration is sometimes loud and rough, at others feeble; the latter state is much more common. These are the positive signs. Our diagnosis is rendered certain by the ab- sence of signs which other diseases of the chest always present. Thus, it is distinguished from phthisis by the absence of flatness at the sum- mit of the lungs, (which we almost always find in this affection,) and of the bronchial or ca- vernous respiration. Although these signs are absent in the commencement of the affection, we not unfrequently find them supervene after it has continued a certain time, as chronic bron- chitis is often a precursor of phthisis. This change in the condition of the lungs is shown by constitutional as well as local signs. An increase of febrile excitement takes place, and the patient becomes more emaciated. Ema- ciation sometimes occurs without the super- vention of phthisis, from the alimentary canal being involved, and from the febrile excite- ment; but this is of rare occurrence, and we scarcely ever meet in our practice with cases in which the diagnosis is rendered obscure on this account. After the tuberculous disease has taken place, it is exceedingly rare that the patient recovers. Sometimes the change that is about to take place seems to be indicated by the constitutional signs before the develop- ment of tubercles has occurred, by the febrile excitement, by the other symptoms being de- cidedly increased, and by a change in the com- plexion and countenance. This is a time when a correct diagnosis is of very great im- portance, as a proper plan of treatment may retard or prevent the development of a disease which is almost always fatal. Treatment.—The treatment of this form of chronic bronchitis is somewhat similar to that pursued in the acute. General blood-letting is not often indicated; but the abstraction of small quantities of blood, by means of cups, often re- peated, produces very good results; the cups are usually applied in the axilla, between the scapulae and under the clavicles. If the disease at any time assumes a more acute form, gene- ral bleeding comes in very well. Leeches are sometimes used, but cups are preferable on se- veral accounts; they produce a greater degree of irritation, without so great a loss of blood, and are cheaper and more convenient. Coun- ter-irritants to the chest are very good adju- vants. These are numerous, and various in the degree of irritation they produce. I prefer the milder ones, such as Burgundy pitch, croton oil, &c, which being applied over a large sur- face produce, I think, a much better effect than blisters and tartarized antimony, which must be limited to a comparatively small portion of the chest. Liniments of a stimulating charac- ter have been much recommended; these con- sist of ammoniacal and terebinthinate mixtures. The noted empiric St. John Long was in the habit of treating thoracic diseases solely by ap- plications of this character. Flannel worn next to the skin, and woolen stockings to the feet, are essential as adjuvants. As internal remedies the stimulant expecto- rants should be used, except in those cases in which the disease approaches the acute form, when the antiphlogistic and sedative medicines are much more effectual. These are ipecacu- anha, tartarized antimony, &c. Of these I prefer the ipecacuanha, as it is much milder in its action, and more easily borne than tartar emetic, which, after it has been employed for a few days, is apt to affect the mucous membrane of the stomach and intestines. In the more chro- nic cases the balsamic expectorants are employ- ed with great advantage. Of these the balsam of copaiba is the most efficient, but it is a very dis- agreeable remedy, and cannot be taken by per- sons who are at all dyspeptic. Your success in the employment of this remedy w»th patients of thi3 class depends very much upon your 64 DISEASES OF mode of administering it. The following for- mula is a very good one: R. Balsam Copaibae ^j. vel 31J. Tinct. Cardamom. Comp. srj. Gum. Acac. q. s. Aq. Menth. 3Y$S- M. You should commence with half a drachm of the balsam in 24 hours, which quantity is to be gradually increased up to one or two drachms in the same period. If it produces much purging after administering it for some days, its use must be stopped, as this is an evidence that it has made an impression on the system. This remedy is only to be resorted to when others have proved ineffectual, as it is exceedingly disagreeable to the patient. There are other remedies of a milder nature, which can be taken with more facility; they are generally given in the form of syrups or lozenges. Most persons prefer the former, as they have been accustomed to the use of cough mixtures, which are gene- rally in the form of syrup. Syrup of seneka is one of the best in the very chronic cases; syrup of ipecacuanha is also frequently used, and many prefer a combination of the two, which answers a very good purpose. I often use a combina- tion of seneka and Prunus Virginiana, or seneka and sanguinaria, but more frequently the former. The following formula is one which I generally prescribe: R. Senegae. ")__- Prun. Virgin. 5 aa 5SS' Aq. Bullient. Oj. M. Macera per horas xij., dein cola et adde saccha- rum album, q. s. This quantity may be taken in two days, and in the management of the disease is a most effectual remedy. Gum ammoniac is a remedy much used by some physicians, and in its action nearly re- sembles the balsam of copaiba. Assafoetida is also an excellent expectorant, but its taste is objectionable to many adults; it may be given in the form of lac assafoetida;. For children it is peculiarly adapted. Opium, as a remedy in bronchitis, has many advocates, and it is certainly very beneficial in some cases; but I am very cautious as regards its employment in those affections for the relief of which a secretion is necessary. I only use it as a means of procuring sleep when the cough THE LUNGS. ________ is troublesome at night, especially when there is much irritation about the trachea and larynx. If you prefer the form of lozenges, one of the best prescriptions will be that of the bal- sam of Tolu, which may be made into lozenges, each containing a grain of ipecacuanha, to which a small portion of morphine may be added if necessary. The next point in the treatment is the hygienic condition under which the patient should be placed. And here the question occurs, should the patient be confined to the house or not1? I would not, as a general rule, enjoin this upon him; but where there is a cer- tain degree of acuteness in the symptoms, I think it necessary. In other cases he would lose much by keeping within doors in mild and pleasant weather, although duringthecool,damp weather which is common in the spring, he should by no means expose himself. You should therefore direct your patient to take gen- tle exercise in the open air in good weather, unless he should find it to disagree with him. A sea voyage to a warmer climate will often remove a bronchitis of long-standing; but it is often very inconvenient for the patient, and in many cases it is not in his power to try it. In proportion as the disease becomes more and more chronic, the patient may increase the amount of exercise, and endeavour to stimulate the muscles and exterior, and thus produce a general but mild revulsion from the interior organs. This treatment is not only of great service in removing the bronchitis, but it is the best means of obviating the danger of pulmonary phthisis. The rules as to clothing and warmth are obvious enough: the great secret of the treatment consists in diffusing the action and nutrition throughout the muscular and tegu- mentary tissues, and thus giving to the bron- chial mucous membrane an opportunity of re- gaining its normal condition. The medicinal treatment is more complex; but if you separate it from the hygienic management, you will find it less efficacious than the latter. The second variety of chronic bronchitis re- sembles the pituitary catarrh of Laennec. It is distinguished from the preceding by several peculiarities. It does not usually follow the acute affection, but commences with its pecu- liar characteristics. It generally occurs at ir- regular periods; but in many individuals it takes place at regular seasons; in this climate usually BRONCHITIS. 65 at the close of the summer, about the month of August. It is quite frequent too in Great Britain. The local signs of this affection consist of the various rhonchi, both dry and moist, the latter being found usually at the lower part of the chest, the former in the upper portion; there is, however, a predominance of the moist rhon- chi over the dry, and of the sibilant and subcrepi- tant over the coarser varieties, as the smaller tubes are more affected than the larger. Some- times all the rhonchi are heard at once, and produce a singular confusion of-sounds, to which Laennec has applied the term cantus omnium avium. In some cases the air-cells are dilated, which renders the respiration feeble, and gives rise to much dyspnoea, resembling asthma, and indeed it may be set down as one of the varieties of this disease. The dyspnoea complicating the affection, however, more fre- quently arises from thickening of the tubes pre- venting the passage of the air into the vesicles. These attacks of dyspnoea are sometimes per- manent, sometimes transitory. The fever at- tending this variety of bronchitis is very slight, and there is very little emaciation. When this disorder assumes a periodi- cal character, and occurs at a particular period, it lasts several weeks, and in ge- neral cannot be cut short by treatment. The duration of this variety of the disease is less than that which occurs at irregular in- tervals, and it resembles in many respects the more ordinary forms of acute catarrh, but is much more intractable. Treatment.—Bleeding in a majority of cases is not well borne; but when the symptoms are acute, it may be prescribed with advantage. The remedies to be used are those which are calcu- lated to relieve the dyspnoea. These are prin- cipally the nauseating expectorants, of which I think lobelia to be decidedly the best, so given as to produce slight nausea; it thus favours se- cretion and expectoration. Balsam of copaiba is also a very good remedy; but the same ob- jections apply here as in the other forms of bronchitis. Venetian turpentine has been very much used, and is an excellent remedy. In the periodical form of the affection, after the paroxysm has commenced, no treatment has yet succeeded in cutting it short. There is, however, one point which demands our at- tention, viz. the prevention of the occurrence of the paroxysm. In one case for which I pre scribed cold affusions and the exhibition of quinine, previously to the attack, the disease appeared much later than usual, was milder in its character, and its duration was much less. Dry Catarrh.—The third variety is perhaps as frequent as either of the others, and is by a strange contradiction in terms called dry catarrh, because there is little or no expectoration, dif- fering in this respect from the other varieties. The prominent lesion in this form of bronchitis is a thickening of the mucous membrane. This, though rendered evident by the ocal signs, is not always found after death: in this respect it is analogous to other congestions of mem- branes. It is attended with very little febrile excitement; and the functions of the alimentary canal are but slightly, if at all impaired. The cough is short and dry, thus differing from the cough which attends the other varieties, the latter being loose. The chest is sonorous throughout, and in some cases preternaturally so, on account of the emphysema, which is a frequent attendant. The respiration is gene- rally feeble, and sometimes a rough rustling sound is heard, arising from the friction of the air-cells against the pleura. The dry rhonchi are usually heard, though not in all cases, as the thickening must proceed to a certain point in order to produce them; they, of course, vary according to the particular part of the bronchial tube which is affected. But, it generally oc- curs that the sibilant rhonchus is chiefly confined to the anterior part of the chest, and the sono- rous rhonchus to the neighbourhood of the larger tubes. Besides emphysema, there is another complication which is frequently met with, and which, like it, is produced by the vio- lent efforts made in coughing,—I allude to hypertrophy and dilatation of the heart. These three affections frequently coincide; and the heart disease, the dry catarrh, and emphysema, form a triple lesion. The duration of this va- riety of chronic bronchitis is greater than that of the other two. It continues to an indefinite period,—the patient often labouring under it for several years, unless some acute affection of the lungs should supervene, which is then rendered more grave by the previous existence of the dry catarrh. When, for instance, pneumonia at- tacks a person who is affected with dry catarrh, the dyspnoea which, under ordinary circum- stances, attends the acute affection, is rendered more severe by the existence of the chronic: 66 DISEASES OF THE LUNGS. this, of course, renders our prognosis much more unfavourable than it is when the disease is not complicated with an acute inflammation, or when the dyspnoea is not severe. Treatment.—Very little advantage results, I think, from the employment of medicines in this variety of chronic bronchitis. It is, how- ever, of importance to attend to the hygienic condition of the patient. His clothing should be warm, and his chest and extremities pro- tected by flannel; and he should not expose himself in damp and inclement weather, while he should take exercise when the weather is dry and pleasant. The patient, however, some- times insists upon having medicine, and it is as well to gratify him in this respect. The balsams and turpentines have been much used; also alkalies, which are highly recommended by Laennec. I have not spoken of the use of mercurials in the treatment of chronic bronchitis. They have been used from time to time; but the results have not been such as, in my mind, to warrant their employment. There is an affection which resembles very much the dry catarrh, that is, the cough which occurs in some cases of dyspepsia; it is usually dry, and sometimes attended with rhonchi, al- though in general they are not heard. The diagnosis here depends upon our knowledge of the previous affection of the stomach. In other cases, however, a bronchitis, previously exist- ing, is aggravated by the occurrence of an affection of the stomach: here the priority of symptoms must be your guide. We can ge- nerally succeed in arresting this cough by the use of tonics, alkalies, and other remedies adapted to the state of the stomach. Chronic bronchitis may arise from a variety of causes, as a fever, an acute attack of disease of the lungs, &c. It is frequently found co-exist- ing with tuberculous phthisis, which may either have preceded or followed it; and it may follow any other disease of the lungs, or it may be the cause of such affection. Indeed, we seldom meet with a disease of the parenchyma of the lungs unaccompanied by bronchitis, which we might naturally suppose would be the case, since the bronchial tubes constitute so large a portion of the respiratory organs. The disease receives the name of bronchitis when the affection is confined to the tubes; when the parenchyma is attacked, the bronchitis is looked upon as a mere complication of the more serious affections, and the designation of the disease accords with the principal lesion. This rule should be adhered to, otherwise you will confound together many different affections, and may include phthisis, laryngitis, and pneumonia, under the common designation of bronchitis. PECULIAR VARIETIES. Besides the modifications of bronchitis which depend upon the duration of the disease, and the age or other peculiarities of the individual, there are other varieties which are specific in their character, and depend upon a peculiar condition of the system, produced by a consti- tutional disorder. Of these varieties one of the most frequent is pertussis, or whooping cough. This is an affection of the nervous system ac- companied by bronchitis, in which sometimes the one, sometimes the other predominates; the affection of the nervous system being in some cases very severe, with but little cough, whereas the cough is frequently very bad, with compa- ratively slight nervous symptoms. We almost always meet with this disease in children, though adults are occasionally attacked by it. It is a self-limited disease, and therefore can- not be cut short by treatment, although its com- plications may be removed or palliated. Though the inflammation of the bronchial tubes is merely the local part of the disease, yet it is in one sense the most important, for patients ge- nerally die of the bronchitis and its immediate effects. The secretion from the mucous mem- brane is much greater than in ordinary varieties of bronchitis; and in children it tends con- stantly to accumulate in the inferior parts of the tubes : they are in this way gradually en- larged until permanent dilatation results. The thickening and congestion of the mucous mem- brane do not differ from the same alterations in ordinary bronchitis. When a fatal termination occurs, it generally arises from the feebleness of the patient, and a consequent inability to expectorate, or as is the case with children, to discharge the secretions by vomiting. The parenchyma of the lungs may become con- gested and inflamed, producing a pneumonia which may prove fatal. The principal sign of this disease is the pecu- liar whooping character of the inspiration: this is caused by the forcible expulsion of air from the chest, in fits of coughing, and sometimes occurs BRONCHITIS. 67 ' in other forms of bronchitis, which, however, do not often possess the paroxysmal character of pertussis. In addition to the cough we meet with the rhonchi, both dry and moist, and very often with a gurgling caused by the collection of fluid in the dilated bronchi. The cough usually lasts for several weeks; it then declines gradually, and the rhonchi disappear. It is gradual in its attack, being at first slight, and then becoming violent. It comes on in parox- ysms, of which, in mild cases, there are usually five or six during the day, the patientbeing free from cough in the interval. In severe cases the number of paroxysms is much greater. They sometimes occur as often as once an hour, and occasionally there is only an interval of a few minutes. In such cases the patient generally dies of exhaustion. The secretion in the bron- chial tubes consists of thick, glairy mucus; when it has continued for a long time, it some- times contains a small portion of pus, inter- mixed with blood. Sometimes blood is effused, and a partial haemoptysis occurs. The secre- tion is usually thrown off by vomiting, espe- cially in young children, who cannot expecto- torate. The appearance of the face in this dis- ease is peculiar, being of a bluish colour, ac- companied by puffing of the eyelids. This is the effect of the violent efforts made in cough- ing, and the congestion consequent upon them. It is in some degree a measure of the severity of the affection. When fever occurs it indicates the ex- istence of inflammation of the lungs, and when high, is a symptom of much gravity. When the development of tubercles takes place towards the close of the disease, the fever con- tinues with a quick, irritable pulse. It is usually the miliary form of tubercles which occurs under these circumstances, and is almost always fatal. The diagnosis is pretty clear after the second week: the paroxysmal character of the cough, with its whooping inspiration,its complete inter- mission, and the recurrence of the paroxysm during any disturbance of the mind, are suffi- cient to characterize it. The prognosis is generally favourable in the simple forms of the disease, but becomes less so in proportion to the severity of the compli- cations. Treatment.—As the disease cannot, as a ge- neral rule, be arrested, we should palliate its symptoms, and assist nature in the means which she has pointed out for its relief, we should therefore promote the secretion in the tubes, and favour its removal. Therefore we should employ mild emetics, which tend to bring about both these ends. They should be given once or twice a day for a week or two, In this affection there is always a disposition to vomit; and as this action, brought on by artificial means, is milder than when it occurs spontaneously, emetics afford very great Telief. After this treatment has been continued for the time above specified, we should make use of remedies whose action is slower but analogous to that of emetics, for this is the means pointed out by nature for the cure of the disease; and it is a maxim in therapeutics, that when a secre- tion is intended by nature to remove any dis- eased state of the economy, we should favour or moderate it, and not arrest it. Ipecacuanha, in the usual expectorant doses, may be used for this purpose, and answers very well,—but one of the best remedies in this affection is assa- foetida, as it favours expectoration, and also controls the disorder of the nervous system, which constitutes so large a part of the disease. It may be given to children of eight or ten years, in doses of two or three grains, several times daily. However, it cannot always be given internally, as it is so repulsive to the senses; applied externally, in the form of a plaster, it acts very well, producing an impres- sion on the nervous system, and moderating the paroxysms. Ammoniac, galbanum, &c, are used in the same manner. Revulsives to the chest are useful, but not always necessary; when required, I prefer sinapisms to blisters or moxas. There is another remedy which is much more powerful than these,—that is, the extract of belladonna; I know of no practitioner who uses it more boldly, or with better effect, than Dr. H.Corson, who resides not far from this city. I regret that I have not his formula at present. Still, you cannot be too cautious in the administration of this medicine, which is cer- tainly always attended with some risk. The success which attends its administration in whooping cough, is stated to be greater than that of any other remedy. The clothing should be warm, flannel to the chest, &c. The complications are various affections of 68 DISEASES OF THE LUNGS. the lungs, which are, when very acute, to be treated by general and local blood-letting, and other remedies required in the affections occur- ring idiopathically. Phthisis occurs as a se- quela of this disease, and does not require me- dication ; it is best treated by a change of air, which is advantageous in the declining stages of all severe cases of pertussis. As pertussis rarely occurs with adults, we are apt to make an incorrect diagnosis when it does thus occur: this should be borne in mind, as we might confound it with a variety of bron- chitis resembling pertussis, which is exceed- ingly difficult to get rid of. Ordinary bronchi- tis may be complicated with the nervous spasm; but the disease should not be confounded with pertussis, unless the spasms are disproportioned to the bronchial affection. This constitutes the peculiarity of the disease, and gives to it that mysterious difference between it and other va- rieties of bronchial inflammation. BRONCHITIS DEPENDENT UPON A CONSTITUTIONAL TAINT. There are certain cases of bronchitis which depend on a particular diathesis, or a peculiar condition of the system induced by a specific affection: to this class belong the syphilitic and scrofulous bronchitis. But you will sometimes find that the syphilitic variety is singularly similar to phthisis in the emaciation and other constitutional symptoms; so much so that the deterioration of the health is such as to end in phthisis. The scrofulous bronchitis is attended with a very abundant secretion of a thick, glairy mucus, and is in most cases complicated with an inflammation of the upper portion of the respiratory tubes, so that the nasal cavities are sometimes more affected than the bronchi; it must be treated with remedies calculated to correct the morbid state of the system, such as mercury, iodine, sarsaparilla, for the syphilitic variety; iodine, iodide of iron, and other cha- lybeates, may be used in scrofulous disease, besides resorting to local remedies. General Remarks.—Although bronchitis, as a disease, presents many varied characters, yet there are certain features which are common to every form of it. In all, the turgescence of the bronchial mucous membrane with blood gives rise to the chief difficulties in the respiration, and, when this congestion extends to the smaller tubes, the dyspnoea becomes excessive, and may be a source of immediate danger. This simple congestion of the membrane occurs in the early period of acute cases, and in the dry catarrh it becomes a chronic condition, and lasts for an indefinite period. The most easy and frequent termination of the congestion is by di- rect secretion from the bronchial tubes; that is, by the formation of a mucous and muco- purulent discharge ; but in many cases the ge- neral circulation may be restored, and the con- gestion removed, by the free discharge from the capillaries of the skin, or some other tissue. If this relief does not follow, the tendency of all cases of dry bronchitis is to congest the heart, and to distend the vesicles of the lung ; hence emphysema of the lungs, and dilatation the heart, frequently depends upon this cause. The other varieties of bronchitis, whether acute or chronic, are those in which secretion takes place; if this secretion be of a natural, healthy kind, the inflammation ceases; thus the thin albuminous secretions are replaced by a more consistent mucous or muco-purulent ex- pectoration, which again gradually passes into a more transparent mucous discharge, which gradually ceases. But, although this is the course of the disease when it terminates favourably, in many cases the secretion of mu- cous and muco-purulent matter will continue, while the inflammation does not abate. These are the chronic cases of mucous catarrh. In this variety the discharge is analogous to what takes place in chronic dysentery, when the in- flammation is not relieved by the secretion. The difference appears to arise from a modifi- cation in the mucous tissue, by which the ves- sels remain permanently enlarged, and recover with difficulty, unless a stimulant is adminis- tered which should excite this new action. Hence we use what are called the stimulating expectorants so largely in these forms of bron- chitis ; these remedies supply the excitement necessary to the relief of the disease by a new and more healthful secretion. The inhalation of the vapour of water, of tar, ether, &c, act much in the same way, but are more direct sti- mulants of the membrane. The depleting re- medies, which are often necessary in severe bronchitis, act, of course, very differently from the stimulating expectorants; they merely equalize the circulation of the bronchial ves- sels, and thus lead towards health by removing the vascular excitement which keeps up the BRONCHITIS. 69 disease. The results of this mode of treatment will, of course, be essentially the same with those derived from the stimulating expecto- rants, but the modus operandi is totally differ- ent. The revulsive means are more analogous to the directly antiphlogistic remedies, and pro- duce very nearly the same effects. Bronchitis is therefore a multiform disease and varies both in symptoms and treatment with almost every modification of the body ; it may be highly inflammatory, and require the most vigorous depletory means, or it may de- generate into a mere chronic oozing of mucus from the vessels. The object of the physician is to vary his treatment according to these dif- ferent conditions, and, at one time, to resort to vigorous antiphlogistic measures, and, at ano- ther, to a course of treatment which is totally different. I have laid much stress upon the latter practice, because it is suited to a greater number of cases, but I am not the less convinc- ed that in the cases which are decidedly inflam- matory, the most effectual relief is produced by the depletory practice; it may afterwards be followed by any other remedies that the case may seem to require. 9 LECTURE IX. Bronchial Tubes. Dilatation of the There are two lesions of the bronchi, arising from long-continued bronchitis, which differ very widely, however, in their physical condi- tion, viz. dilatation, and contraction of the bron- chial tubes. The former of these lesions is by far the more important, and also the more frequent; and it prevails in proportion to the number of cases of long-continued chronic bron- chitis, with abundant secretions. Acute bron- chitis will occasionally produce the same dila- tation, provided the mucus be copious, and be expectorated with difficulty after violent ef- forts of coughing; hence it is not infrequent in pertussis, which is about the only dis- ease of children that gives rise to this le- sion. As dilatation of the bronchial tubes is a mere lesion, which is produced by diseased action, but is in itself of little importance, it must ne- cessarily require less attention than the diseases of the lungs, properly so called: nevertheless, it may be readily confounded with these affec- tions,—and even if it were not liable to this chance of error, there would still remain sufficient reason for studying the symptoms of it. Lesions of this kind should never be confounded with the diseases which give rise to them; but they offer interesting points of relation, and require therefore some attention, in order to recognise them, and to discover the best means of obviating the mischievous effect which necessarily arises from their existence. Dilatation of the bronchi assumes several different forms: the most frequent is an uniform enlargement of several bronchi of a lobe which, after branching off from the principal trunks, re- main nearly of their original size, or even enlarge as they approach the surface of the lung. This variety results very frequently from whooping cough, and the spasmodic bronchitis which re- sembles it most nearly. The mucous mem- brane, at the same time, is thickened, and loses its transparency. The other varieties, which are less common, are merely partial dilatations in the course of a bronchial tube. There may be only one single enlargement, or several successive dilatations of a large bronchus, which afterwards recovers nearly its natural size. The enlarged portions are thus distinct cavities, and physically speak- ing, present nearly the same peculiarities as the cavities which arise from the softening of tuberculous matter. There is therefore neces- sarily cavernous respiration and pectoriloquy, and the condensed pulmonary tissue which surrounds the enlargement may cause a decided dulness on percussion. The condensation of the tissue apparently arises from chronic in- flammation, which causes a deposit of new matter in the pulmonary substance. The pre- cise nature of this substance is not ascertained; but it is probably albuminous, like similar de- posits in other parts of the body. In the va- riety in which the bronchial tubes are generally dilated, there is rarely cavernous respiration; for the air, in diffusing itself through the lung, does not, of course, present the sharp, clear reverberation, which is essential to the forma- tion of cavernous respiration. Hence there is very little difference between the respiration in this variety of dilatation, and that heard in the second stage of pneumonia, when the hepatiza- tion occurs around the larger tubes. But in dilatation of the bronchi, the bronchial rhonchi, as the mucous and subcrepitant, are much more frequent than in pneumonia; and the perma- nency of the signs in the former alteration, and their rapid changes in the latter, will prevent all danger of confounding the two lesions together. The diagnosis between dilatation of the tubes and phthisis is much more difficult, as it depends not upon the physical signs, which differ but little in the two cases, but upon the progress of the general symptoms. If the symptoms be those of chronic catarrh, that is, are attended with severe cough, and but slight emaciation, the disease is probably chro- nic bronchitis; but if the fever and emaciation be much more decided, the probabilities are of course greatly in favour of phthisis. Practi- EMPHYSEMA OF THE LUNGS. 71 cally speaking, the chances of error are very slight; for those cases of chronic cough, in which the dilatation of the tubes is sufficiently great to simulate a tuberculous cavity, are al- most always connected with very general bron- chitis, in which the signs of a general thicken- ing and inflammation of the mucous membrane are very evident, and totally unlike those of a tuberculous disease. There is, however, an- other variety, in which it is impossible to dis- criminate accurately between these two affec- tions, for the tuberculous disease then coincides with the dilatation of the tubes. In this'case the dilated tubes either pass through the masses of tubercle which are deposited at the summit of the lungs, or they terminate as soon as they reach these masses. If the tubercles have ad- vanced to the period of softening, the cavities which are thus produced often communicate directly with the enlarged bronchi, and form, as it were, a continuous tube. When the dila- tation is connected with a cavity, it is often preceded by a deposit of tuberculous matter in the bronchus, which is in this way gradually enlarged, and remains dilated after the soften- ing of its contents. There is, of course, no peculiar treatment for the dilatation of the bronchi; it is strictly a le- sion, not a disease, and being placed beyond the reach of the mechanical means of treat- ment which are adapted to remove an external alteration, it necessarily must remain with the patient. The object of the physician is to re- move, as far as possible, the protracted bron- chitis which generally produces the dilatation. The lesion then ceases to give rise to much mischief, and even a partial cure may take place. EMPHYSEMA OF THE LUNGS. This is an alteration which is closely analo- gous with dilatation of the tubes. In fact, it is the same disease attacking a different part of the structure,—that is, the terminating vesicles of the lungs. In their normal state these ca- vities are very minute, but may still be disco- vered by a good eye; but when diseased their size may increase much beyond their natural dimensions, and they then very frequently attain the bigness of a small pea, and in some cases are even much larger. The vesicles, as they enlarge, at the same time become thickened in their parietes, and press upon those adjoin- ing, of which some are atrophied, and others appear to form a direct connection with the dis- tended ones. It is in this way that the very large sacs, of the size of a pigeon's, or even a hen's egg, seem to originate, not from a single vesicle, but from the j unction of a number of dis- tinct ones, which have gradually broken into each other. The tissue of the lung which is the seat of the emphysema, becomes pale, and crackles under the pressure of the fingers like a piece of dried lung,—the walls of the vesicles losing their elasticity, and becoming much more rigid. The size of the dilated part of the lung is ne- cessarily increased; hence it presses upon the intercostal spaces, and can no longer be con- fined in its usual limits, As a necessary con- sequence of this increase, the walls of the chest are enlarged to an extent corresponding with the distended part of the lungs, and form a decided protuberance. The quantity of blood contained in an em- physematous lung is rather less than natural in those portions of it which are the especial seat of the disease,—that is, the anterior margin of it,—but the posterior parts contain as much blood as usual, and sometimes become con- gested on account of the dyspnoea, which is a necessary attendant upon all severe cases of the disease. The congestion frequently passes into pneumonia, and cases which prove fatal, for the most part terminate in this way. The mucous membrane of the bronchial tubes is rarely perfectly healthy in emphysema, if it be of severe character. There are two forms of bronchitis which commonly complicate emphy- sema,—the chronic, and the acute. The former is a regular, and almost necessary complication; the latter is often absent during nearly the whole course of the disease, but it is more apt to occur in patients labouring under this disor- der than in those who are in the enjoyment of perfect health,—and when it takes place as a complication, the distress of the patient is vastly greater than in cases of simple bronchial inflammation. The chronic bronchitis which so commonly attends emphysema, is~ nearly always of the dry variety, or as it is of- ten termed, the dry catarrh. In this case the membrane is permanently thickened to such a degree as to impede the passage of the air, and constantly react upon the disease itself. The bronchitis is then doubly connected with the 72 DISEASES OF THE LUNGS. emphysema, and may be regarded both as cause and effect; either of the disorders may occur first, and will be almost necessarily fol- lowed by the other. Chronic dry catarrh pro- duces of itself sufficient dyspnoea to distend the air-cells, and favour the development of em- physema; while if the anatomical condition exists, either as the result of original structure, or some peculiar cause, the slightest obstruc- tion to the freedom of the respiratory function may cause a severe attack of dyspnoea, and thickening of the bronchial membrane is then almost a necessary result. Signs.—The physical signs of emphysema are extremely well-marked in severe cases; but, of course, there are many instances in which the alteration deviates so little from the normal standard as to render the signs of doubt- ful value. When there is much distension, the physical signs are all present, and may be re- ferred to the three following heads:—1. Dis- tension of the portion of the chest. 2. Clear- ness of sound on percussion. 3. Feebleness of respiratory murmur. These are the only regular or constant signs, but there are occa- sionally anumber of others perceived. They are sibilant rhonchus,from the frequent complication of dry catarrh, in which it is heard along the anterior margin of the lungs: and subcrepitant, or mucous rhonchus, at the posterior part of the lungs, when they are much congested, or the bronchial tubes are attacked with acute inflam- mation. There is another sign which is occa- sionally met with,—the dry subcrepitant rhon- chus, which is nothing but the slight rustling sound produced by the bubbles of air either forcing themselves into the cellular tissue and forming little bags which rub against the pleura, or the dilated vesicles themselves, which are sometimes sufficiently rigid to give rise to some friction. 1. Dilatation of the Chest___This is necessa- rily most evident in those portions of the thorax where the dilatation of the vesicles is greatest; that is, at the anterior margin of the lungs. The anterior plane of the thorax is rounded, and gradually assumes a convex shape, the most prominent portion of it being near the margin of the sternum; the form of the dilated portion is generally oval, the long diameter of the oval corresponding to the axis of the body; but as the extent of the altered portion of the lung is very variable, the form of the chest dif- fers extremely. The dilatation is more evident in the intercostal spaces than at the level of the ribs, which are but slightly thrown out from the general plane of the body. There is at times a general distension of the chest; the shoulders are then elevated, and rounded, and the thorax approaches very nearly to the cylin- drical form. This extreme distension takes place only in those who have been long subject to emphysema, especially those who have in- herited a predisposition to the disease. In speaking of the dilatation of the chest in em- physema, you must remember that it is mode- rate, and never attains the degree which we find in large pleuritic effusion, or in pneumo- thorax. 2. Resonance on percussion.—The anatomical condition of the lungs in emphysema neces- sarily admits more air into the lung,—in fact, the tissue is permanently distended with air,— and if percussion be made over the part, the sound is of course clearer than in a lung which is perfectly in the normal condition. This clearness is extremely great in thin persons who are affected with emphysema; if the pa- tient be corpulent, and sufficiently advanced in life for the elasticity of the chest to be diminish- ed, a moderate degree of emphysema does not render the percussion very sonorous. The clear- ness of sound is of course greatest at the spot where the dilatation is most perceptible; and when the chest is generally dilated, the percus- sion retains its character of great clearness throughout. The resonance in a few patients is sufficiently great to resemble that produced by pneumothorax, but it never has the tympa- nitic sound produced by the latter lesion. 3. Thefeebleness of the respiratory murmur is the third peculiarity of emphysema. The dila- tation of the cells prevents a free circulation of air; they even remain permanently dilated when removed from the dead body. This im- mobility probably arises from the thickening of the walls of the vesicles, which always follows their permanent enlargement. The respiratory sound is not only enfeebled; but if the emphy- sema be extensive, it is apt to assume a pecu- liar rustling tone, which is probably in part produced by the vesicles themselves, and in part by their friction against the parietes of the chest. The functional symptoms of emphysema are less characteristic than the physical signs, but EMPHYSEMA OF THE LUNGS. 73 are always sufficiently marked to increase the certainty of the diagnosis,—sometimes to indi- cate of themselves the character of the disease. One of them is much more constant than any other,—that is, the dyspnoea. The other symp- toms depend in a great degree upon the compli- cation of chronic or acute bronchitis, which so often attends the disease; hence they vary ac- cording to the intensity of this affection. They are cough, expectoration of thick, pearly sputa, which are small in quantity, or of a large amount of thin, glairy, and transparent mat- ter, which occurs in the paroxysms of the dysp- noea, or during the complications of acute ca- tarrh. There is no fever, or disturbance of other organs than the lungs or heart, which is neces- sarily connected with dyspnoea; when other affections occur, they may be set down as com- plications which may acquire additional seve- rity from the pre-existence of the emphysema, but do not arise necessarily from it. The dyspnoea is in part permanent, and in part comes on in paroxysms. The permanent dyspnoea is developed by any exercise which hurries the act of respiration, such as ascending a flight of stairs or a high hill, or indulging in any unwonted exercise. The subject of the disease then complains that he cannot take as much or as long-protracted exercise as other people; and this inability, if it be not accounted for by decided organic disease of the heart or lungs, is one of the best diagnostic characters of the disease. It is very regularly propor- tioned to the extent and severity of the emphy- sema, and in slight cases may escape notice. The dyspnoea which occurs in paroxysms is not frequent until the disease has become com- plicated with bronchitis, or as is still more fre- quent, with a disease of the heart. In the lat- ter, a disturbance of the circulation is frequently produced by slight causes, and then the parox- ysms of difficulty of respiration become ex- tremely severe and intense, until the patient is partially relieved by a free expectoration of glairy mucus from the bronchial membrane, or until he remains for a considerable time in a condition of perfect repose. If the patient be extremely corpulent, the frequency of the pa- roxysms is of course proportionally increased, and they become more and more severe as the disease continues longer, for the dilatation in the majority of cases tends to increase,—and each successive attack, by distending the vesi- cles, may act as a new exciting cause of a fur- ther enlargement of them. The diagnosis of severe cases of emphysema is readily enough made, for the physical signs are then pathognomic of the affection; but in slighter cases they are not always clearly enough developed to render the diagnosis quite certain. This is the case when there is little or no dilatation of the chest, but merely an increased resonance on percussion, and a di- minished loudness of respiration. We are then obliged to resort to the diagnosis by way of exclu- sion ; and if we find that no other disease which. can account for the permanent dyspnoea exists, we should ascribe it to emphysema. When em- physema is complicated with another disease of the lungs, or with one of the heart which in itself is capable of producing a corresponding dyspnoea, it is difficult to ascertain the precise influence of the two affections. If the dysp- noea be excessive, emphysema alone is rarely capable of producing it; but if it be more mo- derate, the probable share of each affection is extremely difficult to ascertain. The prognosis in this disease is favourable, so far as the chances of death are concerned,— for it is scarcely possible for a patient to die merely of emphysema. But, on the other hand, a complete recovery is scarcely possible, unless in very recent cases of the disease, when the distension of the air-cells has succeeded an acute disorder. In this case the disease tends gradually to recovery, although the restoration is rarely perfect; for the constant dilatation to which the vesicles are subjected prevents them from resuming their natural size. The treatment of emphysema is in a great degree nugatory, so far as the removal of the lesion itself is concerned; but the paroxysms of dyspnoea may be checked, and the attacks of acute bronchitis relieved. The remedies most useful in checking the dyspnoea are sinapisms applied between the shoulders to the dorsal spinal vertebrae, and the use of lobelia in doses sufficient to excite slight nausea. If the tinc- ture, which is the preferable form, be used, the dose should be twenty or thirty drops every two or three hours: some patients, however,will bear or even require a much larger dose, but for the greater number that just specified is sufficient. Opiates are also useful in some varieties of em- physema ; they should be repeated often enough to quiet the cough; and in emphysema, as in 74 DISEASES OF THE LUNGS. common bronchitis, their effect is much en- hanced by combining them with a nauseant. From a quarter to half a grain of opium will in general be found sufficient, if combined with the same or half the quantity of tartarized anti- mony. If ipecacuanha be used, of course the dose should be larger. The remedies which are most serviceable for ordinary bronchi- tis, are in general equally applicable to that variety which complicates emphysema; it does not, therefore, require any specific direction for the treatment. It is to these cases that the physician is chiefly called; for in the large ma- jority of cases the emphysema itself is not a sufficiently severe disease to attract much no- tice from the patient. ASTHMA. The term asthma is extremely vague, and is still used in a very loose sense. It is com- monly applied to any condition of the respira- tory system in which there is much oppression, especially if the dyspnoea comes on in parox- ysms, and is attended with a wheezing noise during the inspiration or expiration. In many of these cases there is sufficient evidence of or- ganic disease in the lungs or heart to account for the difficulty of breathing; hence the term asthma is thus applied merely to a symptom, and does not designate a specific disease. In other cases there is no evidence of any organic alteration; and the asthma then becomes a pe- culiar disease, characterized by regular symp- toms, but without definite lesions; it is there- fore to be classed amongst those diseases to which the common designation, nervous, is ap- plied. The term is a vague one; but if we re- strict it to functional disorders which present a sufficient regularity of symptoms to identify them, there is little practical objection to it. In the present state of the science, therefore, we are compelled to admit a nervous asthma, and a periodical dyspnoea without organic lesion. The diseases of the lungs which are attended with paroxysms of difficulty of breathing, are a variety of bronchitis, emphysema, certain rare cases of miliary tubercles, and the presence of large tumours upon the trachea or the larger bronchial tubes. The variety of bronchitis I have already treated of under its appropriate head; it is one of the most painful and haras- sing to the patient, but at the same time is the most curable variety of asthmatic diseases, for it often yields to the continued use of ipecacu- anha, and other remedies of the kind, with ap- propriate counter-irritants. The probabilities of cure are of course much enhanced by a voy- age to a milder climate. Emphysema may be palliated, if not cured; but miliary tubercles is generally the most intractable, and often the most rapidly fatal variety of phthisis. The tu- mours which give rise to periodic dyspnoea at first, will cause a permanent difficulty of breath- ing if they increase much in size; they are some- times scirrhous growths, but more frequently aneurism of the arch of the aorta in adults, and scrofulous enlargement of the bronchial glands in children. The dyspnoea is at first not per- manent in these cases, because the obstruction to the passage of the air is not sufficient to cause great difficulty of the respiration without some congestion of the bronchial mucous mem- brane ; this is more and more apt to recur as the disease continues to advance, and the case may readily be mistaken for one of nervous asthma. After striking those cases of false asthma from the list, we next come to the diseases of the heart which simulate the same disorder. These are quite numerous; indeed, any serious disorder of the heart, which impedes the circu- lation, may congest the lungs, and, as a neces- sary consequence, great dyspnoea will result. The oppression will be very nearly in propor- tion to the difficulty of the circulation through the heart, and must of course be greatest in those cases in which the valves are most ob- structed. These diseases constitute some of the most severe cases of those classed under the general head of asthma. There remains, then, a nervous asthma, which cannot be classed under these heads. This disease, like most other chronic affections, is in a great degree hereditary, and often passes through several members of a family; all, or a large number of the children of one family, are often subject to attacks of it upon exposure to slight exciting causes. These causes are ex- tremely various; but they are in general such as act particularly upon the nerves of the respi- ration, and produce a slight oppression, even in individuals who are not at all asthmatic; such as the inhalation of deleterious gases, certain perfumes, a heated, and especially a crowded room, changes of temperature, or changes in ASTHMA. 75 the barometrical conditions of the air, will all occasionally produce the same results. The effects of atmospheric changes which are not connected with temperature, and can only be re- cognised by a delicate hygrometer or barome- ter, are very peculiar: a very little difference in the moisture, or in the altitude of a particu- lar spot above the level of the sea, being often sufficient to bring on, or to remove a severe at- tack of asthma. The change from a lower and more crowded to a higher and more airy part of the same town, will often produce the same effect. These attacks of nervous asthma are often periodic, or at least especially apt to recur at particular seasons of the year, which are not always the same, although the summer is in general more apt to favour the development of the disease than colder weather. But there is no disorder which is proverbially so peculiar in its time and mode of attack as asthma,—the most opposite conditions will modify the action of the nerves of respiration. These conditions do not, however, vary much in each indivi- dual; they are generally sufficiently regular, but they are extremely different with different persons who seem to offer the same variety of the disorder. This idiosyncracy is not more remarkable than that which is observed in re- lation to many other functions of the body, especially the digestive, and is of course equally inexplicable. The symptoms of nervous asthma are similar in this respect, that all who are affected with the disease are liable to sudden and violent pa- roxysms of dyspnoea, or to slighter derangement of the respiration; at the same time there are no decided signs of bronchial inflammation. If the respiration be examined, the inspiratory sound is feeble, but there is generally no rhon- chus ; the wheezing which is occasionally heard at a distance from the patient is produced al- most exclusively in the larynx. The rhonchi, and other signs of bronchial irritation, are heard if the attack is accidentally complicated with acute bronchitis. Paroxysms of true asthma terminate by a gra- dual decline, or as in the variety termed asth- matic bronchitis, the attack is not relieved un- til a free secretion of glairy liquid from the bronchial membrane takes place; in either case the disorder is singularly apt to return in a short time upon a renewal of its exciting causes. The diagnosis of the disease is, like the prog- nosis, exceedingly simple. The disorder may always be recognised by the presence of the periodical dyspnoea, and the absence of any de- cided evidence of structural change. The prognosis is, on the whole, highly favourable; for few cases of the kind terminate unfavour- ably, but, like the asthma which arises from emphysema, the disease is exceedingly diffi- cult to remove. At the same time the affection is so peculiar in its nature that it often ceases abruptly, without the slightest assignable cause; and at other times, an apparently insig- nificant impression made upon the nervous sys- tem, either directly on the nervous expansions, or indirectly through the medium of the ima- gination, will often stop a paroxysm, or post- pone one for a long period. The prognosis, therefore, is peculiar; and it is very necessary to be guarded in our promises of cure, or in our anticipations of an unfavourable result when the case is most unpromising. In most patients asthma may be greatly re- lieved by attending to the exciting causes of the disease, and carefully avoiding them when practicable. This is often less difficult than it would appear to be at first sight; for a very slight change of residence from one situation to another in the same city, or district of country, will often suffice. Sometimes a more distant removal becomes necessary, at least at the sea- son of the year when the disorder is most apt to recur, and every patient is not fitted to de- cide as to the proper change of situation. In the same way a change of occupation, or even the avoidance of certain departments of a par- ticular business, will often succeed. If these attempts fail, and the patient is willing to make the sacrifice, a more decided change is advisa- ble ; and, in making it, the warm, moist regions of the sea-side, will generally be found prefer- able to the drier and more hilly country. The hygienic precautions not connected di- rectly with the condition of the air, are less cer- tain in asthma than in most other diseases; and we must here also rely chiefly on the ex- perience of the patient. Those causes which tend to produce bronchitis, favour the develop- ment of asthma, although they do not cause it. Hence the avoidance of cold and unnecessary exposure is essential, unless the experience of the patient should teach him that a cold atmo- sphere agrees better with him than a warmer 76 DISEASES OF THE LUNGS. one. In either case, however, the impression of prolonged cold upon the surface is almost always deleterious, whatever may be its direct influence upon the bronchial mucous membrane. Excesses in diet are also often exciting causes, and the particular perfumes or stimulants of the bronchial membrane which act unfavourably upon the disease, are generally well known to every patient. There are many modes of arresting the pa- roxysms, and for the most part the remedies resemble each other only in their general power of producing a decided action upon the nerves of respiration. Frequently these remedies are the narcotics; at other times a mere counter-irri- tant applied between the shoulders will prove effectual in cutting short the paroxysms. In some cases a galvanic plate applied upon the nucha, and communicating with another placed at the point of the sternum, will instantly check an attack of this disorder; and although the cure is not always permanent, yet in some in- stances the disease does not return. The nau- seants and antiphlogistics, which are often use- ful in emphysema, are sometimes equally effec- tual in arresting the paroxysms. Amongst them the tincture of lobelia is one of the most certain and convenient, but with some stomachs it is oppressive and irritating. The various narcotics which are from time to time resorted to,.for the relief of asthma, may be administered in the usual way, or be inhaled into the lungs, and thus brought directly in contact with the bronchial membrane. Thus stramonium, tobacco, and other remedies of this class, are often smoked with great benefit; andamethod recommended lately by M.Raspail, is sometimes of advantage. This consists in inhaling the vapour of camphor; a few pieces of it are placed in a quill, and the patient may breathe through it. The slow volatilization of the camphor brings it directly in contact with the lungs. These means are, however, all palliative, and there is sometimes no certain relief for, the disease. A careful study of the exciting causes, and attention to some very simple hy- gienic precautions, are the most promising means of treatment. LECTURE X. Pneumonia—Anatomical Characters—Physical Signs—Symptoms—Treatment. In my last lecture I finished the subject of diseases of the mucous membranes lining the bronchial tubes. As I had previously described the inflammation of the investing membrane, it now only remains for me to give an account of the affections of the parenchyma of the lungs. It was necessary to treat of the diseases of the membranes first, because the parenchyma is very rarely, if ever, diseased, without the in- flammation extending to them, for the ten- dency of disease of the lungs is to pro- duce inflammation of the mucous and serous membranes connected with them. What, then, is the parenchyma! To answer this question, it will be necessary to run over the anatomical structure of these viscera. The bronchi con- tinue to divide and subdivide, the ramifi- cations becoming smaller and smaller after each division, and terminating in vesicles arranged in lobules; the vesicles of each of which communicate with one another, but not with those of the adjoining lobules; and each lobule receives a blood vessel, which ramifies within it, and is distributed to the vesicles in the cellular tissue, which invests and unites them together. The pa- renchyma may, then, be said to consist of the air-vesicles, the blood-vessels surrounding them, and the cellular tissue; or the term may be extended further, so as to include the rami- fications of the tubes within the lobules, yet not the tubes which lead to them. The latter defi- nition answers better in a pathological view, inasmuch as the smaller tubes are always involv- ed in diseases of the portion of the parenchyma through which they pass. The term paren- chyma being then understood to include these finer tubes,we will designate the disease as bron- chitis when the inflammation attacks the large bronchial tubes, extending no further than the tubes which lead to the lobules: pneumonia, when it extends to the smaller tubes within the lobules, and the air-cells of the part affected. Pneumonia, which is an inflammation of the | 10 parenchyma of the lungs, may commence in two ways,—either as a bronchitis, the inflam- mation in this case extending to the smaller tubes and air-vesicles; or it may originate in the vesicular structure, and subsequently in- volve the larger tubes, just as dysentery may commence in the form of diarrhoea, and pass into dysenteric inflammation, or originate in the latter form, and present the symptoms of dysen- tery from the first. When the bronchial tubes only are inflamed, as soon as a secretion takes place it is removed from the body, and the in- flammation is partially relieved, and the dis- ease rarely does much harm; but when the lobules are inflamed, the exit is closed, and the fluid accumulates in the lung, thus increasing the congestion, and impeding the respiration, but not relieving the inflammation by a natural depletion. This fluid consists at first of a bloody serum, and is often of a reddish colour. It afterwards passes through the stages of lymph and pus. In haemorrhagia, the blood contained in the cellular tissue is arterial in its character; in apoplexy, it is venous, and in inflammation it partakes in a mea- sure of the nature of both. The lung at this stage of the disease, yields readily to pressure with the finger, and the fluid can be expressed from it. In post-mortem examinations this appearance may be confounded with engorge- ment produced after death, in a dependent portion of the viscus; and there is frequently some difficulty in making the distinction be- tween the two,—but the redness of inflamma- tion is always brighter, and the softening of the tissue is more decided. Still the two con- ditions are not very dissimilar, for the conges- tion, if it occur during life, may readily pass into inflammation. Pneumonia passes through several stages be- tween its commencement, which I have describ- ed,and termination; and its symptoms,in accord- ance with the changes of structure, are divided [ into four stages. The first is characterized by 78 DISEASES OF THE LUNGS. engorgement of the tissue; the second by indu- ration, which has received several names, as hardening, red softening, hepatization. It is called hardening, on account of the increased consistency which is perceived when slightly pressed; softening, on account of the facility with which it is broken, if the pressure be in- creased ; hepatization, from its resemblance to the tissue of the liver. The vesicles of the lung being deprived of air, and engorged with blood, resemble the acini of the liver, their co- lour being thus changed to a brownish red. In the case of children, this resemblance is so clear, that I have known a bystander to mis- take a piece of lung for liVer, although both tissues were before him. A small piece of lung in this stage of the disease will sink in water, although a large mass of it may float on account of some portion of it containing air in its cells; whereas, in the first stage, the whole of the tissue is lighter than water. The bronchial tubes are red, and filled with a fluid containing a large portion of lymph, which in many cases closes the smaller tubes, thus re- ducing the lung to an uniformly solid mass. If the lung be torn, or even if simply cut, it presents an irregular granulated appearance, which arises from the vesicles being separately hardened and enlarged, but still retaining their individual form. They therefore project above the level of the adjoining cellular tissue. In the third stage the lung remains indurated, but assumes a yellowish colour. In this stage the lung contains a considerable quantity of pus, diffused through the cellular tissue, and deposited in the vesicles. The tissue loses its granular appearance, and becomes more smooth and polished, the vesicular structure having been completely obliterated. It yields readily to pressure, and breaks under the finger, afford- ing a puriform liquid, which at first consists of a mixture of pus and blood globules floating in serum, and afterwards of pure pus. By placing the diseased lung under a stream of water, the parenchyma may be completely removed so as to leave nothing but the bronchial tubes. The bronchial mucous membrane is not so red in this as in the second stage, and the tubes con- tain purulent liquid. We may admit a fourth stage, in which the parenchyma is softened down and removed by expectoration, and an abscess remains, resem- bling an abscess in the other tissues of the body; a pus-secreting membrane is formed, and pus is thrown out, which becomes less and less in quantity until cicatrization takes place, and a cure is effected. This stage of the disease is rarely met with; but when it does occur, the patient usually recovers,—which termination you would not expect, as an abscess in the lungs appears to be a lesion of great gra- vity. However, if the patient has strength enough to go through the first three stages of the disease, he will generally survive the fourth, though he may require the aid of artificial stimulants. The symptoms are generally somewhat relieved by the formation of an abscess, as the inflammation is thus cir- cumscribed in its locality. If, however, in- stead of there being a circumscribed abscess, the pus be diffused through the lung, a fatal termination will generally take place. The physical signs of pneumonia, like the lesions, occur in a regular series. The signs in the first stage are obscure, but in the second they become very plain; hence they are looked upon as the pathognomic signs of the disease. In the first stage, the lung is infiltrated with a thin liquid; this produces a sort of rustling respiration, and not unfrequently the respira- tion at the time is rude; that is, the vesicular murmur loses its natural softness and fulness, and the air rushes abruptly into the cells. Subsequently we meet with another sign, which is said to be pathognomic of the first stage. This is the crepitant rhonchus. It is indeed pathognomonic when it does exist, but it is not present in all cases; for when the inflammation is seated near the centre of the lung, the en- gorged vesicles cannot dilate; as this rhonchus is produced by the expansion of the diseased vesicles, of course it cannot be heard. Besides, the healthy tissue, which is to be found between the ear and the diseased lung, gives rise to a healthy vesicular respiration, and prevents the crepitus from being heard after it is formed in the inflamed portion. But when the seat of the inflammation is near the surface, it always oc- curs. There is also slight dulness on percus- sion, which is caused by the secreted liquid partially displacing the air in the tubes. The dulness is of course not considerable, for the air is not completely expelled from the diseased portion. The signs of the second stage are more strictly pathognomonic of the disease. In PNEUMONIA. 79 this stage the tissue of the lung is com- pletely altered, and this alteration is attend- ed with corresponding physical signs. On percussion we find complete flatness, as the cells are filled with fluid, and no air whatever is contained within them. Auscultation gives us, 1st, a bronchial respiration, which is more marked in the second stage of pneumonia than in any other affection of the lungs, as the tis- sue is perfectly consolidated without any ob- literation of the tubes. It is that variety of bronchial respiration, which, on account of its loudness, has been denominated tubal; it is most distinctly heard at the root of the lung, where the tubes are of the greatest calibre. Bronchial resonance of the voice, or broncho- phony, is also heard, and in fact it always co- exists with the bronchial respiration. If the patient breathes rapidly, the crepitant rhonchus is also heard in many cases co-existing with the bronchial respiration; this arises from a portion of the lung remaining in the first stage of inflammation. It is then heard in trains, like the crackling of wet powder, in the tissue which has not been indurated, and which sur- rounds the solidified portion. This state of things is very frequently met with. These signs are present in all cases except when the patient breathes too feebly to impel the air through the tubes, when, of course, they are not heard; but as they are so constantly met with they are usually described as the pathognomonic signs of pneumonia. The patient should al- ways be directed to cough when you suspect that he is in the second stage of pneumonia; and you will then find that the bronchial respi- ration is made much more distinct, and the air is driven so suddenly into the smaller tubes during the following inspiration, that a very characteristic crepitus is produced either in the same spot as the bronchial respiration, or very near it, for the lung can never be completely solidified. The signs of the third stage are not so cha- racteristic of the disease; but, if you have fol- lowed it through the previous stages, you cannot be at fault, nor can you, if the signs of the first and second,orof the three stages be present at the same time. But if you see the patient for the first time in the third stage, you may, by rely- inc on the general symptoms, mistake the dis- ease for an affection of the brain, which it some- times much resembles. The signs are, 1st, those connected with percussion, which is perfectly flat, as the lung remains solid, and very little air is contained in the tubes. The results given by auscultation are obscure, as the cur- rent of air has by this time been diverted from the diseased lung, just as the blood is diverted from a gangrenous limb, and therefore little or no sound is heard. The respiration, when heard, is feebly bronchial; a mucous rhonchus is also present. We have, then, as signs of the third stage, flatness on percussion, feeble bron- chial respiration, and mucous rhonchus. The resonance of the voice is proportional to the respiration, and is of course feeble. These signs are all very obscure, and therefore you must expect to be foiled when called to a patient in this stage of the disease. There may still be heard in very strong inspirations a decided cre- pitous rhonchus; but this is rather owing to a portion of the lung which remains still in the first or second stage, and admits the air in very strong inspirations. The signs of the fourth stage, or that of ab- scess, are the usual signs of formation of a ca- vity, viz. at first a mucous rhonchus becoming more loose and large, until at last a well deve- loped gurgling is heard, produced by the pas- sage of air through the pus contained in the ca- vity. The following table will give you a con- densed view of the physical signs connected with the different stages of the disease : First stage, or engorgement. Rude or harsh respiration; cre- pitant rhon- chus. Percussion clear, or nearly so. Second, or he- patization. Bronchial re- spiration; bron- chophony; cre- pitant rhonchus around it. Percussion flat, or very dull. Third, or puru- lent infiltration. Bronchial re- spiration in large tubes, fee- ble or absent elsewhere; mu- cous and sub- crepitant rhon- chus; broncho- phony imper- fect. Percussion flat. Fourth stage, or abscess. Cavirnous re- spiration, gur- Percussion flat. In practice, several of these stages may co- exist in the same lung; but the signs of each may be recognised without difficulty, and the pro- 80 DISEASES OF portionate extent marked out with tolerable pre- cision. When the disease terminates by recovery, it gradually retraces its steps until it returns to a healthy state. The signs connected with this return to health are called the signs of return, or of recovery: their regularity depends upon the stage which the disease had previously reached. If the disease advance no further than the second stage, it will regularly return to the first. When first the crepitant rhonchus of return is heard, it is looser or more moist than the true crepitant; this gradually sub- sides, and the vesicular respiration re-appears, but remains for a long time much more feeble than it was previously to the attack. The bronchial respiration and dull percussion do not suddenly cease, but remain in some degree for a considerable time after the cessation of most of the symptoms of the disease. This depends upon the consolidation of the lung, and the difficulty with which the tissue returns to its vesicular expansive condition. When, however, the disease has reached the third stage, this series of changes does not oc- cur. The mucous rhonchus is the first sign observed, as a large quantity of fluid is poured into the tubes. The crepitant rhonchus of re- turn is not heard, as no air passes through the smaller tubes. This fluid, which is produced in the bronchi, consists of mucous and purulent matter, resulting from the breaking down of the diseased tissue, and the secretion from the tubes passing through the inflamed mass, which contributes very much to the relief of the disease. This secretion gradually assumes more and more of the mucous character until it becomes perfectly natural. The return from the fourth stage is marked by the secretion of pus becoming less and less, and at last disappearing with the cicatrization of the parts involved in the abscess, while the secretion becomes entirely mucous in its cha- racter. These stages belong to pneumonia of a per- fectly frank character; they are, however, liable to be modified by various circumstances which are necessarily attendant upon the dis- ease. There are some lesions always found in pneumonia,—that is, inflammation of the pleura, and of the bronchial mucous membrane. The pleurisy is at first dry, and merely pro- duces slight pain and a feeble sound of respi-' THE LUNGS.____________ ration. WThen the pleurisy is slight, the affec- tion is simply called pneumonia; when the pleurisy is severe, and attended with a large effusion, it is called pleuro-pneumonia; and when the pleurisy is considerable, with very slight inflammation of the parenchyma, it is merely termed pleurisy. When the pleuritic effusion is considerable, the signs of one or the other affection predominate according to the relative stage of each disorder; the pneumonia is apt to decline sooner than the pleurisy, which may remain for an indefinite period after the cessation of the inflammation of the substance of the lung. The bronchitis which attends pneumonia may be confined to the tubes which lead to the lobules, or it may extend throughout the bron- chial tree; that which is confined to the inflamed portion of the lung is always present to a great- er or less degree; but the general bronchitis is extremely variable, and generally takes place under two different circumstances. In one the bronchitis occurs as an ordinary catarrh, and the pneumonia occurs afterwards during its progress. In the other the bronchial affection comes on late in the disease, and generally in the third stage of it, when the purulent secretion is copious, and passes into the bronchial tubes. Having given the physical signs of frank pneumonia, we shall now proceed to consider the functional signs of this affection. These are of three kinds—local, secondary, and gene- ral. The local comprise cough, expectoration, frequency and mode of performance of the re- spiration, and the pain produced by the act of breathi ng. By secondary signs we mean the affec- tions of the brain, alimentary canal, the assistant chylopoietic viscera, &c. The general signs are those which are common to all inflammatory af- fections, as the condition of the circulation, &c. Local signs, cough, &c. The cough is usually at first the ordinary cough of acute bronchitis, which is either hoarse, or a loose mucous cough. In this case the bronchitis is the predominant affection; as soon, how- ever, as the parenchyma becomes seriously af- fected, the cough changes its character, as- suming the form which is called pneumonic. The pneumonic cough is short and suppressed, which results partly from the pain felt during the act of coughing, and partly from the im- possibility of inflating the lungs completely; hence the force of the column of air, which is PNEUMONIA. 81 expired during the act of coughing, is not suf- ficient to cause a loud and distinct sound. The The pneumonic cough begins from the first, if the disease attack the parenchyma and pleura before passing through ordinary^ bronchitis. The cough sometimes exhibits this character from the first. In some cases of pneumonia the cough is wanting throughout the course of the disease, which is then said to be latent ,• in such cases the patient is generally aged, or the pneumonia succeeds another affection. As the disease proceeds, secretion takes place, and the cough again becomes loose; when an abscess is formed, it becomes exceedingly loose and rattling. The frequency of respiration is increased in pneumonia, and the degree of increase is a to- lerably exact indication of the extent of the affection. This frequency of respiration arises from the diseased lung being rendered unfit for the performance of its functions, so that a smaller portion of the blood is exposed at once to the action of the air, and a smaller quantity of air is inhaled during an inspiration. There- fore it must be changed more frequently. Be- sides, the inflation of the healthy portion is less complete than natural, because the motion of the lungs is suspended, and the action of the respiratory muscles is less complete. Where only one lung is slightly diseased, the frequen- cy of the respiration is but very little increased. If the disease embraces the whole of one lobe of the lung, it is increased to forty or fifty a minute; and when both lungs are involved, the respiration will be as frequent as fifty or sixty in the minute. Should it be more frequent, the extent of the mischief is very great. It must be evident, then, that this sign is important for the prognosis of the disease. The mode of performing*respiration differs from that observed in the healthy state. The patient breathes ir- regularly ; the respiration is usually high, and is performed chiefly by one side of the chest. At first it is not strictly abdominal; but after pneumonia has continued for a time this cha- racter is developed, and then the ribs remain nearly motionless. The pain is very variable, and is proportioned to the inflammation of the pleura. When the inflammation is situated near the surface of the lunc, the pleura is necessarily much involved, and the pain is consequently acute; but when it is deep-seated, there is, generally speaking, little or no pain. In the old and feeble the pain is scarcely felt, whatever be the portion involved. Therefore, as in many cases it is wanting, and as, when present, it does not in- dicate the extent of the pulmonary inflamma- tion, it is a sign of very little importance. The expectoration, in the commencement of pneumonia, consists of mucus, such as is ob- served in ordinary bronchitis, and differs but little from the healthy secretion. As the dis- ease is developed, it becomes viscid and tran- sparent, and in some cases is of a rusty colour; the viscidity and transparency are the charac- teristic properties of the pneumonic sputa. It is sometimes so viscid that it will not flow from the vessel containing it, although the latter be turned bottom upwards. It is small in quan- tity, generally from one to four ounces in twen- ty-four hours; its becoming more abundant is a sign that the disease is retrograding, some- times it is mixed with yellow sputa from some other portion of the lung or tubes. As the disease passes from the second into the third stage, we observe an admixture of pus, and when it declines the sputa become thinner and more mucous in their character. If an abscess form, the sputa is decidedly purulent, and a large quantity is either suddenly discharged or ex- pectorated in a very short time. This is, to some extent, the case, when the third stage is so far advanced that a considerable portion of the lung is softened into a pulp, even if there be no large cavity. The secondary signs may be divided into those connected with the lungs, and those de- pendent upon other organs. Affections of the lungs.—Bronchitis and pleu- risy almost always attend pneumonia, but their severity varies exceedingly. Tubercles are sometimes formed in the lung during the course or in the decline of pneumonia, which, though it is not probably the sole cause of their forma- tion, in many cases hastens their development. Their formation, of course, increases very much the gravity of the prognosis. Emphysema is sometimes produced during an attack of pneu- monia, principally in children. This lesion is not so important when it is an affection owing to pneumonia, as when it has existed previously to the occurrence of the latter affection, in which case, by increasing the dyspnoea, it ren- ders the prognosis more unfavourable. The heart is very often secondarily affected 82 DISEASES OF THE LUNGS. in this disease, sometimes from the general dif- fusion of the inflammatory action, and some- times from the imperfect performance of the function of respiration, the blood becomes con- gested in the right ventricle, and in some cases a coagulum is formed in consequence of the im- perfect circulation, and of the highly fibrinous state of the blood. But often, in addition to this, we find inflammation of the lining mem- brane of the left ventricle, which is more fre- quently affected in this manner than the right, in consequence of the general law, than the ar- terial system is more subject to inflammation than the venous. This occurs in a large pro- portion of the severe cases of pneumonia. This affection of the heart varies in intensity— some- times the membrane is merely reddened, some- times it is opaque and thickened, partly by the deposition of lymph, and occasionally it is ul- cerated ; the ulceration is generally seated at the valves. The brain is very often affected in pneumo- nia, and when the inflammation of this organ occurs, it is attended by delirium, such as takes place in common arachnitis. The me- dullary cerebral substance is not often the seat of the inflammation, which in almost all cases is confined to the membranes, and to the corti- cal substance. Dr. Louis says that one-sixth of the cases of pneumonia which he saw, were complicated with an affection of the brain; like the inflammations of the heart, it occurs most frequently in the very severe cases of pneumo- nia. If the cerebral symptoms should be se- vere, the primary affection is generally masked by the secondary, which often gives rise to an error in diagnosis, as the signs of arachnitis are very evident while the functional signs of pneumonia are obscured, and, therefore, liable to be overlooked. This complication adds very much to the gravity of the prognosis; and un- less active treatment be resorted to at the com- mencement of the attack, the disease is very apt to prove fatal. The liver is sometimes involved in pneumo- nia, but the frequency of this complication va- ries at different seasons, and in different locali- ties, being much more common on our southern Atlantic coast than it is at the north. This in- flammation of the liver is distinguished by some authors from bilious pneumonia, although it closely resembles it, and as it seems to me, differs only in the bilious pneumonia described by Stoll, being an epidemic disease. Its signs are jaundice, pain in the side and shoulder, and cerebral symptoms, such as stupor and somno- lency, which are dependent upon it. Bilious pneumonia^though in some years common amongst us, is now very rare. It differs from pneumonia, in which the affection of the liver is a mere secondary complication, by the liver being attacked, in bilious pneumonia, simul- taneously with the lung. The right lung is the one which is always most inflamed in pneumonia complicated with the inflammation of the liver, and the extension of the inflammation from the lung to the liver, in the simultaneous attacks of the two organs, shows that there must have been previously a disorder of the liver, which favoured, at least, the extension of the disease, hence the af- fection is so frequent in warm climates and mi- asmatic situations. This complication certainly adds much to the difficulty of diagnosis with- out the physical signs, especially as the cere-" bral symptoms are generally so well marked as to suppress, in a great degree, the cough. Inflammation of the stomach and bowels, of the oesophagus and pharynx, have all been ob- served in pneumonia, and also inflammation of the kidneys; but these complications are not more common in this than in other inflamma- tory diseases. They may be known by their proper local signs, and I shall therefore not de- tain you with a minute account of them. General signs—Capillary circulation.—A sign which may be called general, although confined to very narrow limits, is the appearance of the face, for this depends upon the capillary circu- lation. In acute cases we meet with a circum- scribed flush of a circular form, and which is sometimes confined to one cheek, sometimes found in both. When one cheek only is af- fected in this manner, it is more frequently, though not invariably, that which corresponds with the diseased lung. In some cases the whole face is flushed, the colour varying from a light to a deep red; sometimes it is of a blu- ish colour. The whole countenance is generally changed. These various tints depend upon the greater or less obstruction of the circulation of the blood through the heart and lungs, they are darker when the difficulty of the circulation is greater, and often become bluish about the lips and nostrils, while the rest of the face is pale, if a coagulum should form in the heart. Dila- PNEUMONIA. 83 tation of the nostrils in each inspiration, is an- other symptom; this depends upon the dysp- noea, and its extent is in proportion to the lat- ter. General circulation.—The disease makes its appearance in the following manner: The pa- tient is first seized with a chill; this lasts hal f an hour or more, and sometimes two or three hours, and when it goes off is succeeded by a fever, which continues during the whole twenty- four hours, but usually increases at night, and is rarely attended with extreme heat of skin. The pulse is full, hard, and developed at the commencement of the disease; in the latter stages it is frequently feeble. It is very generally from one hundred to one hun- dred and twenty, and rarely becomes more fre- quent, except in the terminating stage of the disease. It is in most cases a good measure of the intensity of the inflammation, and a correct indication of the propriety of blood-letting; but the pulse is sometimes contracted, and at the same time the inflammation is violent; if bleed- ing be practised it rises and becomes softer. A careful bleeding, if the general symptoms be inflammatory, is the best guide in this matter. The alteration of the strength is another sign which is connected with inflammatory diseases, in general, the degree of diminution depending upon the importance of the part affected, and the extent to which the inflammation proceeds. Thus, a patient with pleurisy, will continue to walk about until the effusion causes so much dyspnoea that he is compelled to keep his bed; whereas a slight pneumonia, with scarcely any local signs, will enfeeble him so much that he will be unable to sit up. Although the physical signs are the most im- portant in the diagnosis, as they indicate the extent as well as the nature of the affection; yet there are certain rational signs, which, taken together, may be considered as pathogno- monic, namely, the expectoration, flush, and dyspnoea: these are, however, often obscure at the commencement of the attack. The physi- cal signs are often only required to ascertain the extent of the disease, as its character is ren- dered sufficiently apparent from the rational signs of sthenic pneumonia. Prognosis.—The prognosis is very variable in all diseases of this kind, as it often depends upon circumstances unconnected with the dis- order itself. In ordinary frank pneumonia the prognosis is favourable where other things are not unfavourable; that is, where it attacks a person previously in good health, and the treatment is commenced early, for this mo- difies the disease very much, when begun at an early period; but after it has continued a few days, the prognosis is very little affected by it. When it is complicated with an affec- tion of the brain or liver, the prognosis is more unfavourable. Duration.—A mild case of frank pneumonia without treatment usually lasts from 10 to 20 days, but if it has reached the third stage, it will last much longer. If it has continued a few days before the commencement of the treatment, it rarely ends before the tenth day. If you treat it from the first, you may frequently produce a par- tial jugulation of the disease, and shorten some- what its duration. The observations made at Paris coincide in this respect with the expe- rience of Dr. Jackson, of Boston, and the re- sults obtained in this city. When the disorder terminates fatally, death usually occurs early in the third stage, or just in the passage from the second to the third stage. This stage is reached in different periods, sometimes in three or four days, but generally about the beginning of the second week. Treatment.—The treatment of frank pneu- monia is that of ordinary inflammation modified by the peculiarities of the organ affected. Hence bleeding 4s the most efficient remedy, and should be practised freely at the beginning of the disorder. The method which has of late years been revived by Dr. Bouillaud, consists in repeated bleedings, which are prescribed again and again for several days. This method is reduced to a regular formula, and in the hos- pital practice there are not so many obstacles to this system as in private; but it must be ob- vious to every one that no one method of treat- ment, or at least no regular formula, is applica- ble to all cases, and I do not, therefore, advise a uniform method of blood-letting. The best directions must be gathered from a knowledge of the disorder, and from the present symptoms of the patient. Thus, in the commencement, a very large bleeding, pushed to the verge of syncope, is certainly best in a plethoric indi- vidual, or a moderately strong person, previ- ously in good health, if the pneumonia is of a highly inflammatory kind—that is, if the evi- dence of vascular excitement be decided; for it 84 DIEASES OF THE LUNGS. is in these cases that the inflammation tends necessarily to diffuse itself, as it were, over a laro-e surface, and to attack several organs, especially the serous tissues of the circulating system. A large bleeding is of course the surest means of checking this tendency, and is the most comforting remedy for the patient, as it at once diminishes the headach and the op- pression which are amongst the most disagree- able symptoms. A general bleeding produces much more effect than a local one, which is almost nugatory in its action upon the highly inflammatory cases of pneumonia, although very powerful in the later stages, or in the slighter forms of the disorder. The venesec- tion may be repeated on several successive days, or in the after-part of the days in which the first bleeding was practised, if it seem ne- cessary from the excitement of the pulse and the vascular action. That is, if the pulse should rise again, and especially if it should become more developed after the first bleeding. It is, as you may readily suppose, impossible to lay down positive and unvarying directions for conditions of things which are in their na- ture changeable. But by reflecting on the con- dition of the lung, which at first is merely that of engorgement or commencing hepatization, and on the stimulant properties of the inflam- matory blood, it is easy to see that several bleedings may become necessary, although in the majority of cases one single bleeding will suffice, especially if the sedative effects of it be kept up by other remedies, particularly the antimonials. The appearance of the blood drawn, is, of course, highly inflammatory,—that is, much buffed, with a very firm crassamentum; this is a tolerably correct, but not a sure guide for the repetition of venesection. The blood will generally remain buffed, even in that period of the disease when bleeding is no longer of benefit. A physician is frequently called to a patient late in the disorder, when the inflammation has either not been treated by bleeding, or the dis- ease continues very severe. It is very difficult in these cases to decide as to the propriety of general bleeding; my own impression is, that bleeding is in these cases apt to produce a double influence, which is partly of mischief, and partly of benefit. The inflammation, which is generally commencing in certain parts of the lung, or at least is much less advanced than in others, may be, to some degree, checked by the blood-letting; but those portions of the tissue in which the blood is completely stag- nant, and, as it were, incorporated with it, are restored with more difficulty if blood be drawn from the general system. This is still more strongly the case, if the pneumonia has passed into the third or suppurative stage. The effect of blood-letting upon the general circulation is also in these cases often productive of evil, for the coagula which begin to form in the heart may become a greater obstacle to the circula- tion if the strength of the patient be lessened. The latter effect is difficult to demonstrate; but it has struck me in a number of cases that it was founded on good grounds, and I there- fore state it for what it may be worth. The action of local depletory means in acute sthenic pneumonia is much more limited than that of general bleeding ; the beneficial effects of these remedies is almost confined to the latter stages of the disorder, when a portion of the lung remains in the first or second stage of the inflammation, but the greater part of it has passed into the third stage. The local bleed- ing, then, seems to get rid of the remaining in- flammation with less exhaustion of strength. When we meet with patients who have been neglected during the greater part of an attack of pneumonia, we are often obliged to limit our depletory measures to cups or leeches. Blisters, or tartar emetic ointment, are not necessary as a general rule in acute pneumo- nia; for the disease belongs to those inflamma- tory disorders, for the earlier stages of which blisters are not adapted. They are useful, however, at the beginning of the third stage, when the benefit from them is scarcely equalled by that from any other remedy in the treat- ment of pneumonia. The blisters then act with great power in checking the inflammation, at the same time preventing the collapse which is so frequent at this stage of the disease. The blister should be rather large, and in general the best place for it is under the axilla, or be- tween the scapula and the spine. Tartar eme- tic ointment applied so as to produce a very rapid pustulation, has been recommended un- der similar circumstances; but I do not in ge- neral regard it as possessing any advantages over blisters, while it is for many reasons in- convenient. Sinapisms, or other rubefacients, PNEUMONIA. 85 are often useful within certain limits,—that is, as stimulants to the general strengh, and as remedies which have a powerful influence upon the dyspnoea which attends the disorder. Next in importance to general blood-letting as a remedy in pneumonia, is the tartrate of antimony: this medicine may be given in se- veral ways, either as a simple diaphoretic ex- pectorant, or as a direct arterial sedative. In the former case it should be given in doses from a twelfth to a quarter of a grain every two hours; in general a sixth of a grain is borne at first, and afterwards the patient should take a quarter of a grain, either alone, or combined with nitre or calomel. The medicine is, in these doses, quite free from danger, except in a very few individuals of extremely irritable temperament; for there are some patients who cannot bear antimony in any dose, or in any form. In most cases, however, these small doses of a sixth of a grain are attended with a disposition to sweating, and a diminution in the excitement of the circulation, which, on the other hand, always coincides with a dimi- nution of the general inflammatory action, which plays so important a part in the patho- logy of acute pneumonia. Of late years the contra-stimulant, or Italian method of giving antimony in very large doses, has been much resorted to in the treatment of pneumonia. This method has been perfected in France, and rendered much more 6afe. In my own practice I have adopted very nearly the usual formula of the French hospitals; it is as follows: Tart. Antim. gr. vj.; Aq. Mentha;. §vj.; Gum. Acac. gij. M. Of this a table- spoonful may be taken every two hours. It is not always customary to add the gum arabic, but the irritation of the stomach is certainly lessened by it. The antimony, taken in this dose, rarely produces any other effect than purging, which does not invariably follow, If the purging is severe, it is readily checked by adding a few drops of laudanum to each dose. In itself opium is objectionable, but it may be properly used if there is a decided ten- dency to purging. The medicine should be continued in this dose for twenty-four hours, and not increased until the next day, when eight grains may be given instead of six; either in the same or in a larger quantity of vehicle; it is better to avoid giving it in too concentrated a form. If the tolerance has been established the first day,— that is, if the remedy has not produced decided puking or purging, or very debilitating sweats, it may be safely taken during the second day; and if the disease does not abate, the dose for the third day should be the same as that for the second. But, after the third day, there is some danger in continuing the antimony in a high dose, unless the patient is perfectly conscious, and his brain entirely clear; if the remedy is then attended by no uncomfortable sensations, there is little danger in its administration. But if the patient is comatose, or even slightly stupid, very extensive inflammation and other structural lesions may follow the tartarized an- timony without any symptoms to indicate them. If the cerebral functions are unimpaired, the condition of the nervous system is a very faith- ful guide for the administration of the tartarized antimony. The good effects of the medicine are shown by the diminution of the local signs, and of the oppression and fever; this is espe- cially obvious in the local signs of the pulmo- nary inflammation, for the antimony seems to act more quickly upon the parenchyma of the lungs than even general bleeding. When the symptoms have declined, the remedy should be gradually diminished, and not suddenly dis- continued ; about two grains should be taken from the dose, each day, until the whole amount is withdrawn. There is some danger in attempting to give antimony in these doses to certain individuals who possess a peculiar idiosyncrasy with re- gard to the medicine; for there are some per- sons who cannot bear it in any form, or even in small doses, without great nervous distress and extreme prostration : to such persons the remedy should never be given, at least not in any other than in very minute doses. Besides these peculiar cases, the antimony will occa- sionally produce injurious effects from the mere purging or excessive emesis which it oc- sions,—chiefly from the former cause. It is true that the addition of a small quantity of opium, or even the mere persistence in the re- medy, will often suffice to arrest such a ten- dency ; but if the patient should not lose this extreme susceptibility, it becomes necessary to discontinue the antimony. The remedy which is next in power to anti- mony is mercury, although its effects are some- what different. When given in the period of 86 DISEASES OF THE LUNGS. hepatization it acts in two ways,—as a directly antiphlogistic remedy, and as possessing a pe- culiar power in preventing the formation of lymph,—in other words, it is antiplastic. Hence, when given after bleeding, it is directly opposed to the progress of the inflammation, and modifies the products which result from it. Mercury should be given in such doses as to produce a full impression upon the general sys- tem, not amounting to ptyalism, but producing a slight action upon the gums, as an evidence of its constitutional effect. The proper dose is from a quarter to half a grain of calomel every two hours if it be desirable to make a rapid impression; from a third to half a grain three times daily if the mercury be designed to act more slowly. Even less doses produce at times a good effect. The calomel is often combined with ipecacuanha or opium; but the latter remedy should be given with great re- serve in acute inflammatory pneumonia: the ipecacuanha is free from danger, and is gene- rally of service by its power of facilitating the operation. The mercurial impression is generally fol- lowed by a rapid decline of both general and local symptoms. If it should fail, the disease assumes one of two forms,—it either remains in the highly inflammatory condition, or it, passes into the third stage of the disease. In the first case it may become necessary to recur again to depletory measures; in the second, blisters to the chest, with stimulating expecto- rants, and sometimes wine whey, or in persons addicted to the abuse of alcohol, milk punch may become necessary. The expectorants which are of most value when the antiphlogistic treatment has failed, are the eupatorium and senega, or the sangui- naria. These may be given in the form of in- fusion—half an ounce of eupatorium, and two drachms of senega in a pint of boiling water__of which from a table-spoonful to a wine-glassful, according to the susceptibility of the patient, should be taken every two or three hours; or the senega and sanguinaria may be combined in the dose of two or three drachms of senega, and one of sanguinaria, or half a pint of boiling water, and a table-spoonful given every two hours, unless it should excite much nausea. In a few cases the dose may be increased. After the acute symptoms of pneumonia are dissipated, the patient will often continue to cough a little; and on examination it will be found that the bronchial respiration has not en- tirely ceased at the root of the lung. This state of things depends upon the very slow ab- sorption of the substance which is effused into the cellular tissue of the lung. It requires no special treatment, and in a little while will cease; still the patient should avoid exposure, and to aid in this object he may wear a Bur- gundy pitch-plaster, or some similar covering over the part affected. LOCAL PNEUMONIA. Besides the highly inflammatory cases of pneumonia, there is a variety of the disorder which is simple and inflammatory, but local, attacking only a small portion of the lung, and therefore not producing the general inflamma- tory action of the severer cases. The local signs of pneumonia are present in these cases, such as bronchial respiration and crepitant rhonchus; but the fever is moderate, or may not exist at all, and the prostration is but slight. These cases cannot be distinguished from ordinary catarrh, except by the local signs and the expectoration, which is generally, but not invariably, characteristic. The duration of these cases rarely exceeds a fortnight, but in general it does not extend beyond ten or twelve days. The patient is not often confined to his bed, and in some cases he feels so little inconvenience that he will in- sist upon going out and following his usual employments. The prognosis is always fa- vourable, unless some unexpected aggravation of the disease should take place. The treatment in this form of local pneumo- nia is extremely simple. The disease tends so universally to recovery that there is little diffi- culty in its management, and the large majo- rity of cases would get well under any treat- ment. It is, however, quite possible to has- ten its course. For this purpose the best re- medies are, at the very commencement, a mo- derate bleeding, or after the first few days one or two applications of cups to the affected part. These remedies will relieve the lung, and facilitate the cure, which is brought about by exciting secretion from the inflamed sur- face. If the secretion takes place readily, or if the inflammation is very slight, blood-letting in every form is not necessary; but if the pulse be at all excited, the symptoms are more PNEUMONIA. 87 or less relieved by it, and no inconvenience at least will resull. Bleeding, however, is never followed by the same decided benefit as in the cases of highly inflammatory pneumonia. The secretions from the lungs are promoted by the same treatment which is applicable to the declining stages of the last mentioned va- riety,—that is, the infusion or syrup of senega or ipecacuanha, or infusion of eupatorium or sanguinaria, or combinations of these with the senega. Small doses of the antimonials are also productive of prompt relief when the pa- tient is feverish, hut I do not regard the anti- monials as so generally useful or safe as the vegetable expectorants. Towards the decline of local pneumonia the case requires some attention to distinguish between those cases which are really simple, and those in which there is a complication of pulmonary tubercles: in the latter case the disorder may pass into phthisis; in fact, it is then only one mode of attack of the latter disease. ASTHENIC PNEUMONIA. Inflammation of the lungs does not ne- cessarily assume the sthenic form; it may be connected with symptoms of depression, either from the beginning, or at an after-period of the disease. In the third stage this naturally occurs to a certain extent; that is, when the suppuration^ has extended to a considerable portion of the lung, the patient sinks into a pros- trate or asthenic condition, very different from the false or apparent prostration which may arise at first from the dyspnoea produced by the ex- tension of the inflammation to a large surface. But the secondary asthenia is not altogether similar in its symptoms to that which occurs much earlier in the disorder, and in its progress differs altogether from it. The causes which render pneumonia asthe- nic at the earlier stages of the disorder may be referred to three classes : advanced age, pre- viously enfeebled health, and certain epidemic causes, which are not known. Neglect, and exposure to continued cold, favour the trans- formation of ordinary pneumonia into this va- riety, and have some influence over it at the beginning. The local signs and the expectoration of as- thenic pneumonia do not differ from those of the inflammatory variety, except that as it passes more quickly into the suppurative stage there is but little viscid expectoration; it very soon takes on the characters of the third stage, and in some cases the viscid inflammatory sputa are totally absent. There are, however, many exceptions to this rule, and the sputa are sometimes perfectly well characterized. The general symptoms are more unlike those of ordinary pneumonia : instead of the forcible pulse, and the active excitement of the capil- laries, there is a feeble pulse, a diminished ac- tion in the smaller vessels, and a rapid sinking of the strength. In the worst cases the pros- tration is as great as in the typhoid varieties of fever, and the pneumonia is then frequently termed pneumonia typhoides. The epidemics of asthenic pneumonia are often of this charac- ter, and the disease is then extremely fatal. Gangrene of the lung frequently supervenes in the third stage of this variety of pneumonia; and in all cases there is a close connection be- tween the two affections, so that it is often ex- tremely difficult to draw the dividing line be- tween them, unless the gangrenous sputa should make the case clear. The treatment of asthenic pneumonia is a matter of much difficulty; general bleeding is almost never borne with advantage, and in most cases it is directly contra-indicated by the exhaustion of the patient; cupping or leeching is very often of benefit, and in all cases it is easy to try the effects of a small local abstrac- tion of blood, and to abstain from it if its effects should be injurious; in general, this kind of depletion, if borne well, is in such cases of de- cided benefit. If either the local abstraction of blood should not be tolerated, or the disease should continue, blisters must be applied; they are much more certain in their action than in ordinary pneumonia, and may be used much earlier. The blister often requires to be re- applied if the part should heal very soon, or a new one may be placed over an adjacent part of the thorax. Other contra-irritants, such as sinapisms, are of more benefit as general sti- mulants to the nervous system, than as revul- sives against the pneumonia. The internal remedies demand more atten- tion, because the proportion of their employ- ment is difficult to find out. Antimony should, as a general rule, be proscribed; but there are some cases in which the inflammatory action is acute enough to justify a recourse to this re- medy,—that is, in small doses; in large quan- 88 DISEASES OF THE LUNGS. tities, it is always of danger. The times for its administration must be carefully chosen. It should never be given if there is much sweat- ing, or a small and feeble pulse. The combi- nation of opium, calomel, and ipecacuanha, is much more frequently prescribed, and, as a ge- neral rule, it answers well. The dose may be varied in this form of the disease, just as it is in the advanced stages of ordinary pneumonia; and the opium should be given in minute pro- portions, not exceeding one grain, or at most a grain and a half in twenty-four hours. In a considerable number of cases I exclude the opium altogether,—that is, if there should be much oppression and difficulty of expectora- tion. The stimulating expectorants, and in some cases even wine, or Stronger stimulants, are useful, and even necessary, in this disorder. The senega and eupatorium may be given at first nearly in the same doses, as in the third stage of ordinary pneumonia; but they are, in some cases, tolerated for a very short period before it becomes necessary to substitute for them the milder alcoholic preparations, with some nutritious food,—that is, either wine whey, or, in a few extreme cases, milk punch. In the form of pneumonia which occurs in persons of intemperate habits, and is nearly al- ways asthenic, alcoholic stimulants are often indispensable; this is especially the case if the inflammation should be complicated with delirium tremens. If stimulants be omit- ted in this class of individuals, the morta- lity of the disease will be very great; but if they be combined with local depletion and blis- tering, the local inflammation will be relieved, while the nervous asthenia, which is so apt to occur in these persons, may be prevented. Carbonate of ammonia is another remedy which is often of extreme importance in this disorder; it is peculiarly adapted to those cases in which the secretion into the tubes is consi- derable, and the patient expectorates with diffi- culty. It may often be confbined with small doses of ether, or Hoffman's anodyne. The usual dose is five grains of carbonate of ammo- nia, and from twenty to fifty drops of the ethe- real preparation, every two or three hours; when the depression is very great, the medicine may for a short time be given even in larger doses. Asthenic pneumonia sometimes prevails as an epidemic, and is attended with so much prostration of strength and alteration of the blood, that it has received the name of ty- phoid pneumonia, or even of typhus fever. These cases require more decided stimulation than those of the same variety in which the inflammatory symptoms predominate over the general feebleness, and will often scarcely bear even the local abstraction of blood. Blisters, with stimulating expectorants, especially am- monia, and sometimes wine, or other alcoholic preparations, become necessary. LOBULAR PNEUMONIA, OR PNEUMONIA OF YOUNG CHILDREN. These terms are used as nearly synony- mous, although lobular pneumonia is not strictly confined to children. It is, however, much more frequent in them than in adults. It differs from the ordinary pneumonia both in its progress and pathological conditions. In- stead of the disease occurring in one lung, and in a limited portion of the tissue, it is scattered over a large extent, but it attacks isolated lo- bules, leaving for a time the intermediate tis- sue in a healthy state; these inflamed lobules become more and more numerous, until the whole parenchyma is gradually consolidated. It is this progress of the disease which gives to it the term lobular pneumonia; the lobules af- fected are chiefly at the posterior part of the lung, for the gravitation of the blood towards this portion favours the development of the dis- ease. The appearance of the tissue is different from that of ordinary pneumonia ; it is much darker, harder, smoother, and imperfectly granulated ; it rarely presents the characters of the third stage, passing with difficulty to purulent secre- tion. The pleura covering the hardened tissue is sometimes, but not always inflamed, and if but few lobules are attacked, there is little or no accompanying pleurisy. The disease is rarely confined to a single lung; both are al- most always attacked, but the right lung at an earlier period and to a greater degree than the left. The bronchial tubes are much more fre- quently inflamed than the pleura ; they contain the usual viscid mucus of the bronchitis of children. The affection of the bronchial tubes is often the first step in the series of diseased actions constituting lobular pneumonia, and the indu- ration of the lungs follows at various periods of time after the commencement of the bronchitis. LOBULAR PNEUMONIA, OR PNEUMONIA OF CHILDREN. _________89 The induration then appears first at the poste- rior portion of the lungs, and surrounds the smaller and more'numerous tubes; it thence ad- vances gradually towards the anterior part. In other cases the induration of the lung takes place very rapidly, after the impression of cold or some other cause of pulmonary congestion. The difference in the mode of attack naturally establishes two varieties of lobular pneumonia; one is acute and primary, the other more chro- nic, or at least less acute, and secondary to bronchitis, or to some general disorder of the economy. In either case the symptoms of the disease are nearly the same. The physical signs are at first merely those of the ordinary bronchitis of children; that is, a sub-crepitant or mucous rhonchus, the percussion remaining at first clear, but gradually becoming dull as the dis- ease advances. The dulness is not confined to one side of the chest, as in ordinary pneumo- nia, but is nearly equal on both sides, hence it is difficult to draw the line of distinction be- tween the sound and that yielded by a healthy lung. The only way of doing this is to fix in the mind a correct idea of the average sound yielded by the healthy chest in children of the age of the patient, and then to institute the com- parison. The dulness does not, in the majori- ty of cases, pass into complete flatness, for there is rarely a perfect consolidation of the parenchyma. The respiration is also in most cases not completely bronchial, for the same reason that the percussion does not often be- come perfectly flat; but it approaches this cha- racter more and more nearly as the disease ad- vances, and sometimes offers it to a very de- cided degree. Previously to this point, how- ever, it assumes several intermediate changes, becoming gradually harsh and incomplete. The other signs of this affection do not differ from those of ordinary bronchitis of children; there is in both cases cough, but no expectora- tion, and the dyspnoea gradually increases as the disease advances from point to point of the lung. There is fever, which is sometimes intense; and the disturbance of the circulation extends to the capillaries, which are much con- gested, especially those of the face, where the redness is in the early stages of the disease ex- tremely marked, forming circumscribed patches on each cheek. This peculiar colour, with the dilatation of the nostrils caused by the dysp-' ncea, forms one of the best indications of the disease. The accidental symptoms are those con- nected with the abdomen and brain; these are, from their nature, very variable. There is al- most always more or less disturbance of the digestive functions; sometimes vomiting, and either diarrhoea or constipation. The very ir- regularity of these symptoms proves their little importance for the diagnosis, and that they are only of value in the prognosis of the disorder. The cerebral symptoms are more constant; the obstruction to the circulation necessarily pro- duces congestion of the brain, which is shown by decided stupor, which, in bad cases, passes into coma, or even active delirium. Now, if these cerebral symptoms become extremely se- vere, they may, to a great extent, conceal the pectoral signs; for cerebral disorder produces, as an inevitable consequence, a more or less complete obliteration of the symptoms of other organs, or at least it causes a decided diminu- tion of them. The diagnosis of this disease is obvious enough from the symptoms which I have de- scribed, excepting in one Tespect. As it arises insensibly during the course of bronchitis, there is no precise dividing line between the two disorders; in practice this is of but little mo- ment, for when the diseases approach nearly, they require a treatment which differs but little. There is also a difficulty with one other dis- ease—that of tubercles in the lung; these begin nearly in the same way as lobular pneumonia, and the local, as well as the strictly physical signs, are very similar. At first they cannot be distinguished; but, after a short period, the softening of the tuberculous matter will render the distinction very clear. The prognosis in this variety of pneumonia is, as a general rule, favourable in its early stages; and, indeed, in all cases where it occurs as an acute disease; but is not from the commencement sufficiently severe to cause extreme dyspnoea. In those cases which are strictly secondary, and succeed to chronic, exhausting diseases, the enfeebled state of the patient's health renders the proba- bility of recovery much less. Under all cir- cumstances the disease is attended with more danger than ordinary acute pneumonia, which is very rarely fatal in children more advanced in age, in whom it often occurs. The treatment of lobular pneumonia varies 90 DISEASES OF THE LUNGS. according to the manner in which the disorder commences. If it begin as an acute disease, with much oppression, and other evidence of active excitement from the beginning, it may require active treatment,—that is, venesection in a few cases, and very frequently leeching to the chest; these remedies are not, however, in most cases imperatively necessary, but they relieve the patient more rapidly and certainly than any other. Blood-letting, in any form, is to be avoided, if possible, in cases of children; and it is only in those stages of inflammation in which the natural secretory efforts of the system seem to be insufficient for its relief, that it should be resorted to. The external re- vulsive remedies are, to a certain extent, useful in this form of pneumonia, but are less so than in the same disease as it occurs in adults; hence blisters, and other depletory revulsives, although they do relieve, are rarely of benefit until the advanced stages of the pneumonia, and even then are uncertain. Revulsives that act upon a larger surface, and at the same time are slightly stimulating, are much better, such as large mustard poultices. These should be applied not only to the thorax, but also to the lower extremities, especially to the soles of the feet and ankles. A convenient way of making them is to soak thick pieces of bread in vine- gar, and to sprinkle them with mustard. In the declining stage, or in the milder forms of the disorder, a simple onion or garlic poultice is an excellent application. The natural cure of lobular pneumonia is, like that of bronchitis, by secretion from the bronchial membrane; hence, in mild cases of the disease, nothing more is required than the prevention of injurious influences and the use of a few simple remedies, which may favour the natural tendency to bronchial secretion. These are the wine of ipecacuanha, graduated so as to keep just within the point of exciting nausea, either given alone or with a slightly stimulating expectorant; of these, one of the best and most simple is the domestic syrup of onions, or the lac assafcetidae. If the mucus be- comes very abundant in the bronchial tubes, it will often much relieve the patient to increase the ipecacuanha to a dose sufficient to produce vomiting; there is, however, little difficulty on that score,—for the tendency to vomitino- is in these cases so great, that very small doses of ipecacuanha will excite it, or it may occur spontaneously. Vomiting is of course to be avoided if the congestion of the lung should extend over a large portion of the parenchyma. Tartar emetic may be substituted for ipeca- cuanha if there is much fever; but it is not, as a general rule, equal to this remedy, nor is it as safe. Still, there is no important objection to it, provided it be given in small doses to produce a secretory, rather than a contra-stimu- lant effect. The other expectorants to which I have alluded under the head of bronchitis, are often advisable in lobular pneumonia; but the rules for their employment present nothing re- markable. There is a hygienic precaution, which is es- sential both in acute and chronic lobular pneu- monia : the child should never be allowed to remain long upon its back, nor, if the disease be severe, should it be permitted to sleep more than half an hour at a time. If this be neg- lected, the congestion of the lungs is greatly favoured, and the disease may prove unex- pectedly fatal. The child should be gently car- ried about, or allowed to sit up in bed, or be simply inclined a little towards one side or the other. It is evident, therefore, that lobular pneumo- nia differs chiefly from the ordinary disease in its seat, and in its frequently assuming more of the congestive than inflammatory form. But there are many exceptions to this, in which the circulation is excited, and decided depletory means are indicated. PNEUMONIA OF THE AGED, AND LATENT PNEU- MONIA. In old age, as in early childhood, pneumo- nia assumes certain peculiar characters, but in the former case it approaches more nearly to certain stages of ordinary pneumonia. The only important difference is the great tendency of the disease to become latent, that is, to lose the ordinary functional signs of the acute in- flammation, and to offer little but the feebleness and prostration which occur in most severe dis eases, with little cough and little or no expecto- ration. Hence, the disease is often scarcely suspected, and in a number of cases it is not re- cognised unless the obscurity of the general symptoms and the dusky purple tint of the face should lead the physician to explore the chest. When the disease is not strictly latent, it is never so well marked by the ordinary pectoral symptoms as in more vigorous individuals, and LOBULAR PNEUMONIA, OR passes rapidly through the first and second stages to suppuration. This peculiarity leaves little room, or at least but a short space of time for antiphlogistic treatment, and obliges us to resort, at a comparatively early period, to the more stimulating remedies which are appropri- ated to the third stage. At the commencement, however, the antiphlogistic^treatment is direct- ly indicated, and may sometimes be pushed with nearly the same vigour as in younger per- sons ; but the period for this is short, and some- times from the first, hardly discernible. SECONDARY AND INTERCURRENT PNEUMONIA. Pneumonia is naturally enough of common occurrence as a sequel to many diseases of the lungs, especially bronchitis and consumption. In the former case the original disease is in a great degree absorbed by the- more severe but secondary affection; but in the latter the inflammation will go through its stages, and leaves the tubercles nearly as they were at first. This is, however, not always the case ; even if the tubercles are not advanced, their progress is occasionally hastened by the pneu- monia, and after an attack of this kind, we often find that gurgling or crackling is heard when PNEUMONIA OF CHILDREN. 91 there was merely a slight bronchial respiration previously to the pneumonia. In more advanc- ed cases the pneumonia is not unfrequently the immediate cause of death by invading the por- tions of the lungs which remained free from tu- bercles, and were therefore essential for respi- ration. The inflammation may also form an ex- citing cause of new tubercles in a portion of the lung of a consumptive, or may give rise to them in one previously free from them, but of a tuberculous predisposition. In this case the gray granulations are found thickly disse- minated through the part most inflamed, and are evidently of recent origin. If there be not, how- ever, a strong tendency to this disease, pneu- monia has less influence in developing tuber- cles than pleurisy, notwithstanding there seems to be a more natural connection between the former disease and phthisis. There is nothing peculiar in the management of these complicated cases, except that they bear a less decided antiphlogistic treatment than pure pneumonia, and mercurials must be used more sparingly. The rules for their ma- nagement are essentially the same as those which 1 have already laid down. LECTURE XI. Gangrene. I have now gone through pneumonia in all its forms, and shall proceed to the consideration of an affection, which, though not very fre- quently met with, still requires a notice in this place: I refer to gangrene of the lungs. This, like gangrene in other parts of the body, may occur either as a primary or secondary affec- tion. When primary, it is probably owing to an alteration in the condition of the blood, which, being rendered unfit for nutrition, can no longer support the vitality of the parts. It occurs as a secondary affection in cases of asthenic pneumonia. The anatomical charac- ters of the gangrene are nearly the same in both forms, although, when it is in its secon- dary form, the tissue is at first hard and congest- ed, and is seated in the midst of an inflamed pa- renchyma, while, in the primary form, it is mere- ly infiltrated with a thin, serous liquid, which is evidently in a state of incipient gangrene, and gives rise to the fcetor of the breath met with even in the first stage of the affection. In the second stage, the tissue begins to break down, and gangrenous matter is expecto- rated ; next, the bronchial tubes slough off, and nothing is left in a sound state but the vessels: these resist the destructive process for a long time; and on examination after death they are usually seen traversing the cavity; however, after a while, they, too, are destroyed, and their destruction sometimes gives rise to a hae- morrhage which destroys the patient, although generally the blood has ceased to circulate through them before they slough, and little or no haemorrhage ensues. The sputa and breath in this stage of the disease are pathognomonic; they are both exceedingly foetid, and the dis- ease can, on this account, be easily distin- guished from any other. There are two va- rieties of the gangrenous sputa: one consists of a dark thin liquid, which somewhat resem- bles tobacco juice, or liquorice, occasionally containing small pieces of black, gangrenous lung; the other consists of a grayish-yellow pasty fluid, which is probably a mixture of pus and gangrenous liquid; the latter occurs most frequently in cases following pneumonia; both, however, are extremely foetid, though the odour differs slightly. In some cases of phthisis the sputa resemble the second variety, and it is probable that in these cases the tuberculous portion of the lung becomes gangrenous. The third stage begins with the formation of a cavity, which continues to increase for some time, and may go so far as to involve a lobe, or even nearly the whole of one lung. After the formation of the cavity, the sputa are nearly the same, consisting of a thin, foetid liquid, frequently stained with blood, which flows from the sphacelated vessels. When the case terminates fatally, the sputa increase in quan- tity, and the patient gradually sinks until he is completely exhausted, and death ensues. But when the disease terminates favourably, the following changes take place: the gangrenous portion of the lung is first circumscribed by a membrane which separates it from the sur- rounding healthy tissue. As the gangrenous portion sloughs away, this membrane is left as a lining to the cavity, and secretes pus; there- fore, we find the latter fluid at first mixed with the gangrenous sputa, and supplanting it en- tirely when the whole of the diseased portion has been removed. As the inflammation subsides, the membrane assumes the character of a mu- cous membrane, and at last becomes similar to that lining smaller tubes and air-vesicles, which resembles very closely the serous mem- branes in the delicacy of its texture. If the cavity ceases to communicate with the bron- chi, the lining membrane being no longer exposed to the stimulus of the air, loses its mucous character entirely, and we find a cyst lined with a membrane, which is almost se- rous, and nearly similar to that found in the brain and elsewhere after cicatrization; this may continue during the remainder of the ex- istence of the individual, or be gradually ob- GANGRENE. 93 literated by the formation of cellular tissue. After the entire cure of the gangrene, the tis- sue involved is more or less dense, and contains less than the natural proportion of air. The local signs of this disease are the cough, expectoration, and fcetor of breath. The cough at first resembles that of ordinary catarrh, but as the disease advances, it becomes looser and pa- roxysmal in its character, which is produced by the accumulation of fluid in the,bronchial tubes requiring a violent effort to throw it off, which ceases as soon as this is accomplished, and the paroxysm does not recur until the ac- cumulation of fluid again renders this effort ne- cessary. These fits of coughing are often ex- tremely distressing to the patient. The physical signs are, in the first stage, feeble respiration and a moist rhonchus, gene- rally either the mucous or sub-crepitant; the percussion is either natural or a little dull. They are not, therefore, characteristic. As the disease advances, we find the usual signs of a cavity, viz.: cavernous respiration, a loose gurgling and cavernous resonance of the voice, or pectoriloquy; the last, however, is not so clear as in phthisis, unless the cavity should be large, and near the surface of the lung, for the quantity of liquid in the cavity, and the softness of its parietes, deaden the resonance. When cicatrization takes place, we find merely feebleness of respiration, which gradually diminishes, but does not entirely dis- appear. If the liquid is discharged from the cavity in its early stages, the cavernous respi- ration and resonance of the voice are rendered much clearer. The general signs are the following: there is usually considerable fever during the pro- gress of the disease, with a small, frequent, ir- ritable pulse; sometimes the pulse is exceed- ingly feeble. The fever is only important as it is connected with the prognosis, which is very unfavourable when the fever is high, and the gangrene is progressing; but if the disease do not advance, the fever is unimportant. There is an almost complete loss of appetite, produced by the nauseating character of the gangrenous liquid which is swallowed by the patient, who often has diarrhoea from the same cause. The skin is pale, and usually lead-co- loured in the advanced stage, which is ob- served in almost all cases of gangrene, what- 12 ever part of the body may be affected. Very often there is extreme dyspnoea. Prognosis.—As an average result, about one-half of those attacked will die. In hospi- tals the mortality is rather greater, amounting to three-fifths, while in private practice it is probably about two-fifths. Diagnosis.—The only pathognomic charac- ters of gangrene, are the foetid breath, and ex- pectoration of the patient. When these occur as an acute disorder, or supervene suddenly upon a chronic one, they are quite characteristic of the disease. If they occur slowly, and con- tinue tor a long period, they may depend upon a vitiated secretion of the bronchial membrane, caused by chronic bronchitis; but this either never occurs in acute inflammations of the lungs, or is so rare as not to be taken into the account. Numerous as are the cases of gan- grene which I have met with in hospital prac- tice, I do not recollect a case in which the foetid sputa arose from simple acute bronchitis. The other signs of the disease are common to it and some other affections of the lungs; but the rapidity of the softening, and the formation of a large cavity in a short period, occur so seldom except from gangrene, that these signs are very good indications of the disease. Causes.—About these it will be proper to say a word or two before going farther. The proximate, and at times mainly predisposing cause of this affection, is an altered condition of the blood; it becomes thin, and probably is vitiated in some unknown manner, which frequently coincides with a local inflammation. The ultimate causes are intemperance, indul- gence in food of an innutritious nature. An attack of some acute disease, most frequently pneumonia, is the immediate exciting cause in rather more than half the cases: in others, the disease is general, and arises from the fluids alone. In both cases gangrene of the lungs at times follows that of other parts of the body. Treatment.—This is not in most cases anti- phlogistic, but supporting in its character, to- nics and stimulants being required. When you detect the occurrence of gangrene, you must use all the means that you possess to support the strength of the patient, who is in a short time very much prostrated; fc>r this pur- pose you must administer stimulants and to- nics, with the free use of porter, wine, and nu- tritious food. This is the best and almost 94 DISEASES OF THE LUNGS. only mode of treatment. There is a remedy, I however, which I have used in addition, and,' I think, with some benefit, viz. chlorine; I give from ten to twenty drops of the solution of the chloride of soda every three or four hours; if, however, there is disposition to diarrhoea in the patient, he will bear very little of it. In addition to the internal use of chlo- rine, I place near the patient's bed, vessels con- taining chloride of lime, which adds much to the comfort of the patient and his attendants. Opium is necessary in some cases of gangrene of the lungs, to check the violent paroxysms which return so frequently as to fatigue the pa- tient extremely; but it should be given sparing- ly, for it has the disadvantage of checking the secretions of the lungs; hence, it should be ad- ministered in the smallest possible quantity, and even then may be combined with senega and ipecacuanha, unless the nausea should be excessive. The indications for the treatment of gan- grene are, therefore, extremely simple; a gene- rous, supporting diet and treatment, with blis- ters, and, in a few cases, cupping to the chest, to check the intercurrent and accompanying in- flammation, constitutes our main reliance, but the chances of success are greatly increased by the accessary remedies, some of which I have mentioned. The absolute antiphlogistic treat- ment is decidedly bad, and of the remedies iwhich are classed under this head, none is more positively mischievous than mercury and I its various preparations. LECTUI Tuberculous Tuberculous phthisis, or consumption of the lungs, is the most formidable disease of the thorax; that is, a much greater number of individuals fall victims to it than to any other affection. It is natural, therefore, that we should study the disease with attention, and should strive to acquire the means of detecting it in that early stage when treatment is often of de- cided benefit. In the later stages, unfortunate- ly, we do not possess the means of arresting the progress of the disease; we may, it is true, to a certain extent, modify the symp- toms, and thus alleviate the sufferings of the patient, but we can only in a few cases contribute to positive recovery. Even in these few instances we do not possess the same controlling influence as in many other diseases, but must limit ourselves to acting strictly as the handmaid of nature, and aiding the process of cure which she institutes. It is very probable that our power of control will be greater when the intimate pathology of the dis- ease is more thoroughly understood, and the circumstances which favour the formation of tuberculous matter are completely known. Consumption of the lungs is frequently re- garded merely as a local disorder, but although the chief lesions are seated in the pulmonary organs, the essential characters of the disease depend much more upon its diffusion through the whole body than upon the local mischief, which is often comparatively slight. The cause of the fatal termination is sometimes to be found in the local lesions, and the secondary exhaus- tion and irritation caused by them, and at other times in the general disorder which attends both the earlier and latter stages of pulmonary con- sumption. Hence consumption is to a great extent a complex disorder, and must be regarded in two distinct points of view ; which must be kept steadily in mind, not only in the diagnosis but the treatment of the disease. On the one hand there is a local mischief which is often accom- RE XII. s Phthisis. panied with inflammatory symptoms, and on the other there is a vice or diseased action going on in the whole economy, which is brought especially into play in the lungs, but is rarely confined to these organs. This diseased con- dition of the whole body has received different names ; by some it is called the tuberculous diathesis or cachexia, and by others the scrofu- lous constitution; but when the latent mischief is brought into action, it then receives a name from the organ, which is most decidedly at- tacked, and the original predisposition is al- most lost sight of. Hence the tuberculous dia- thesis, that is, the general disorder, may be de- veloped to a very intense degree, and yet the local mischief may be slight, and tubercles may be scattered over a large number of organs. In these cases it is difficult to say whether the disease should be called pulmonary phthisis or not, for the disease of the lungs scarcely pre- ponderates over that of the rest of the body, and the seat of the disorder is to be looked for in the fluids rather than in the solid tissues ; at most, the affection of the lungs is important in such cases as a sign of the general disorder, not as a disease in itself, and the only means we possess of modifying the progress of the disease, consist in such remedies as are essen- tially general in their nature. In other cases the pulmonary affection either begins as the earliest point of the disorder, or it occurs very early in the disease, and the func- tional disturbance of the lungs becomes so con- siderable that it necessarily attracts a large share of attention. This is the case in a large proportion of tuberculous diseases, especially amongst adults, in whom the lungs are not on- ly the part which in most cases is earliest at- tacked, but it is that which is most deeply affect- ed,and becomes the seat of the most extensive le- sion. Just in proportion to the early appearance of these lesions,and to their inflammatory charac- ter, does the disease participate more in the cha- racters of a local and less in those of a general dis- 96 DISEASES OF THE LUNGS. order; still, the latter part of the affection must in no case be lost sight of. Even in those cases wrhich are most inflammatory, and which differ least from pneumonia, there is something more than a common inflammation, for a secretion of tuberculous matter is added to the ordinary pro- ducts of inflammation, and this secretion im- plies a peculiarity of constitution, either con- genital or acquired, in the patient. If this pe- culiarity did not exist, it would be an ordinary local disease, which it evidently is not, either as regards its symptoms or lesions. The essential character then of pulmonary consumption is, that tuberculous matter should be deposited in the lungs, and the disease may begin with the local mischief, or this may take place as an evident sequel to a constitutional disorder. But in both these varieties, the con- stitutional mischief is present, and the evidence of this consists mainly in the formation of the tuberculous matter. It is very clear, however, that tubercles do not constitute the disease, and we must avoid falling into an error into which the exclusive study of pathological anatomy might lead us. The disease is essentially a morbid condition which either precedes for a long time the formation of tubercle, or it is more acute in its character, and is then accompa- nied or quickly followed by this product; the local diseases which often precede tuberculous formations being, as we have often seen, mere- ly an exciting cause. It is now agreed to restrict the term consump- tion of the lungs to the cases in which there are tubercles, although it was at one time used as synonymous with all chronic diseases of the lungs, attended with emaciation, which of course included chronic bronchitis and pleurisy. Tubercle is the same in all its essential cha- racters, in whatever part of the body it may be formed. It consists of a white opaque or yel- lowish body which increases to a moderate size, rarely more than that of a large almond, and ge- nerally much smaller, when it begins to soften and is finally converted into a very thick pasty yellowish liquid, of a dull yellow colour, and and heavy but not foetid smell. As soon as this softening takes place, the delicate cellular membrane which always encloses tubercle like other morbid products of an analogous kind, begins to assume the characters of a pus-se- creting membrane, and becomes thicker; ulce- ration finally takes place of some portion of it, and the matter finds its way towards the exte- rior of the body, generally by means of a mu- cous tube. At first tubercles appear under se- veral different forms, either that of a yellow opaque granulation, or of a grayish semi-trans- parent one; in either case they are rounded, probably from the pressure of the adjoiningtis- sue. In other cases the tissue affected is infil- trated with a grayish semi-transparent liquid, which does not at first reveal its peculiar struc- ture ; little by little this disappears, and is gra- dually absorbed as the quantity of the new sub- stance increases. This infiltrated tuberculous matter is not always of a grayish semi-trans- parent colour; in some cases it is yellow and opaque from the very commencement, but in the greater number it passes through the changes of colour just described; these are ac- companied with a corresponding change in the intimate structure of tubercle; it becomes more granular, more fragile, and less perfectly anima- lized. But in both cases the essential consti- tuents of tubercle are the same, consisting chiefly of albumen, with a small proportion of the salts of lime. There is, therefore, nothing peculiar in the chemical composition of tuber- cle, its characters depend upon its tendency to increase and finally to soften, and on the dis- eased condition of the whole economy which is necessary to its production. The gradual changes which occur in its structure give rise to peculiar symptoms which are secondary to the disease properly so called. Hence in the study of tuberculous diseases in general, but especially in that of the lung, we have two sets of symptoms, one being primitive, and the other secondary, and not directly so much connected with the disease as with its effects. The pa- tient may perish from either cause. Although in its regular progress, tuberculous matter ends in softening, and in the formation of a pus-secreting cavity, this is not a necessa- ry or invariable consequence. In many cases the tubercle ceases to increase after it has at- tained a certain size, and becomes harder and drier; the earthy matter increases in quantity, and a calcareous mass is left in place of the tu- bercle, surrounded by a membrane; in such cases the secondary symptoms are either want- ing, or are very slight. In a smaller propor- tion of cases, the tubercles do not even ad- vance so far, but are actually absorbed; this TUBERCULOUS PHTHISIS. 97 fact is difficult to prove, because tubercles are not in their earliest stage susceptible of physi- cal demonstration, but there is every reason to admit it, for patients who have laboured under the decided symptoms of commencing I phthisis, have on the one hand recovered, and on the other passed into the more advanced stages of the disease. W7e have, however, more direct proof of the curability of tubercle. That is the evidence derived from pathological examination, and of this there is no more strik- ing illustration than the case of a late lamented physician of this city. It is well known that he regarded himself as labouring under pulmo- nary consumption at an early period of life; he recovered vigorous health, lived to the age of sixty, and finally died of a disease of the kid- neys. In his case there was undoubted evi- dence, not merely of the previous existence of phthisis, but of its absolute cure. At the sum- mit of each lung were cicatrices and deposits of calcareous matter, proving that some portion of the tuberculous matter had passed to the state of softening, and that another portion had be- come dry and indurated. We learn from pa- thology that the more advanced tubercles are almost never met with, unless some gray gra- nulations or incipient tubercles are found at the same time scattered amongst or around the larger tubercles; hence the inference is very conclusive, that the granulations had disap- peared in those cases in which, although there are evident indications of the larger tubercles in the cicatrices and in the calcareous matter, no trace exists of the granulations. Their cure probably takes place by absorption. Phthisis is therefore strictly a curable disease, notwithstanding that in the majority of cases it terminates fatally, at an earlier or later period. This arises not so much from the effects of the first crop of tubercles as from the successive deposit of new ones in different parts of the lung, or rather from the accompanying fever and irrita- tion. Hence a patient rarely dies -of one at- tack of phthisis, except it be of a very acute form. ANATOMICAL CHARACTERS. These have been already described to a cer- tain extent. As they essentially consist in the deposit and formation of tubercles, little need be added. The most frequent variety of tuber- cle in the lungs is that which commences by o-ray granulation, and gradually passes into a more developed stage; but the infiltrated tuber- cle is also extremely common, although rarely found alone, that is, without the gray granula- tions. Both of these varieties begin at the summit of the lungs in the majority of cases, and are found with nearly equal frequency on the two sides. In other cases the tubercles are formed in a different way,—that is, at the mid- dle or lower portion of the organ, and they then begin more frequently as the formed tu- bercle, without being preceded by the gray granulation; this is particularly the case where the general health of the patient is much vi- tiated, and the fluids of the body are much al- tered. In the latter case the tuberculous mat- ter is softer, and less perfectly eliminated; but it passes more rapidly through its course, and is, therefore, dependent upon a more severe form of the disease. The exact seat of pulmonary tubercle is dif- ficult to point out. In fact, it is not always the same. In some cases, especially the last mentioned variety, the tuberculous matter is evidently found in the mucous membrane of the bronchial tubes and small vesicles; but the gray granulations follow the usual rule upon this subject, and are formed in the cellular tis- sue of the lungs, as in that of the pia mater or the spleen, and are nourished by distinct ves- sels distributed to each granulation. These granulations, as they enlarge, press upon the neighbouring vesicles, and gradually cause their atrophy, and finally give rise to absorp- tion of the pulmonary tissue. The cysts are formed in the lungs, or in other organs, by the newly developed cellular tissue around the tubercle; this gradually thickens as the soften- ing advances, and, as I have already stated, it is then lined by a regular pus-secreting mem- brane. The process of cicatrization is nearly the same as in other cases of cavities in the lungs; as soon as the specific tuberculous matter is completely discharged, there remains merely an ordinary cyst, which either becomes conti- nuous with the mucous membrane of the bron- chi, or is filled up by the deposition of cellular tissue. The condition of the surrounding tissues is very various. If the case occur as a purely constitutional disorder without previous local inflammation, the tissue remains pervious to the air, and nearly healthy; but if inflammation 98 DISEASES OF THE LUNGS. either precedes the formation of tubercle, or follows its development, the tissue is indurated, and of many shades of colour from a light gray to a decidedly reddish tinge. At other times the tubercular matter is infiltrated through the pulmonary tissue, and gives rise to an appear- ance similar to that of inflammation. When the inflammation is of that kind which disposes to the formation of tubercle,—that is, when it occurs in an individual labouring under a highly developed tuberculous diathesis, the granula- tions are scattered abundantly through the most inflamed portion of the tissue, which, in these cases, is often nearly similar to the local con- gestions, or lobular apoplexy, which occur in connection with metastatic abscess of the lung. As this variety of phthisis is not so frequent as those in which the inflammation is compara- tively slight or doubtful, the appearance is by no means a very usual one; on the contrary, in most cases, the lung is vesicular, and respira- tion is carried on in the immediate vicinity of the tuberculous matter. Besides the lungs, the appendages of these organs are a common seat of the tuberculous deposit; particularly in those cases in which the disease is more general or diffused in its character. These are the serous tissues and the lymphatic glands at the root of the lungs, or as they are called, bronchial glands. In chil- dren they are more frequently the seat of tubercle than the lungs themselves, and even in adults are a common seat of this deposit though to a less extent. But the pleurae are more important as a seat of tubercle; they are often deposited on the adherent surface of the membrane as in other cases, and are very fre- quently formed in the thickness of the false membranes thrown out in the pleurae. This subject belongs, however, more properly to the accompanying inflammations of phthisis. Tu- bercles are, of course, not confined to the tho- racic organs; on the contrary, I have shown, in the preliminary remarks, that the disease is eminently constitutional, and that, like all ca- chectic disorders, the development of the pecu- liar product in the organ primarily affected, fa- vours its formation in other parts; and, there- fore, many organs suffer from the same cause. Of these complications, the most frequent, and per- haps mostimportant,is the formation of tubercles in the follicles of the intestinal canal. At least, this is the most important consequence of ad- vanced tuberculous disease of the lung, for al- though there are other diseases of the same kind in which the mischief is more considerable, they are not simple sequelae of phthisis; but are earlier manifestations of tuberculous dis- ease, the lungs generally remaining healthy until the other organs are attacked, or present- ing but a few scattered tubercles, which deve- lope themselves slowly. For a more full ac- count of the relative frequency of tubercles, I must refer to Andral's pathological anatomy. It is, however, imperfect, because it is founded upon observations made by physicians who were studying chiefly a single variety of tuberculous disease, or at least did not extend their obser- vations to a sufficiently large number of sub- jects, or to a sufficient variety of age and con- dition. PULMONARY PHTHISIS—MODE OF ATTACK. Pulmonary phthisis, like other forms of tuberculous diseases, occurs either as an acute or chronic affection. A certain number of symptoms are common to both varieties; but others are peculiar to each, or at least are so much modified that it is difficult at times to re- cognise the identity of the two affections. The acute disease is attended by much febrile ex- citement, and by the general characters of an inflammatory affection. Indeed, it is either connected with an ordinary inflammation, or the secretion of the tuberculous substance itself is but little different from that process by which the common products of inflammation are formed. In the chronic disorder the alteration is not of an inflammatory, or even of an active, secretory kind,—it is a slow change in the condition of the capillary vessels of the body. Both the acute and chronic varieties may be attended with a local inflammatory action in the lungs, or may be almost entirely free from it. In the latter case the lungs are merely in- volved as a part of the general disorder which shows itself in these organs, from their struc- ture being favourable to the tuberculous depo- sit. When the disease is complicated with lo- cal inflammation, this may precede, accompany, or follow the tuberculous secretion. In the acute variety the inflammation generally attacks the serous membranes, and in the chronic the mu- cous, although this is not always the case, for the inflammation of any tissue of the lung may be closely connected with the abnormal formation. PULMONARY PHTHISIS. 99 There has been much confusion of ideas on this subject from the great variety in the connection which often exists between inflammation and tubercle; this is very similar to the connection be- tween the local disease and the general diathesis; in fact, the complicating local disease is almost invariably of an inflammatory character, so that the question is at last almost narrowed down to this—is inflammation the cause of tubercles in the lungs, and we may say in the other or- gans, though this is not immediately connected with our subject? If you seek a reply to the naked question, you will be compelled to an- swer negatively,—but if you modify it so as to apply it to those varying conditions which are j continually occurring in the human body, you will answer that it is one of the causes. That is, it will develope the disease very frequently in persons who present a strong tuberculous diathesis, and occasionally in those who do not. In the latter case especially, and to a certain extent in the former, it acts in two ways,—as a direct disturber of the lungs, and as a depress- ing agent upon the whole system. When in- flammation occurs in this way before tubercles are positively developed, it may act during its continuance, and the tuberculous affection then coincides with the inflammatory action, or this may occur after the latter has terminated. It then acts chiefly as a disordering agent upon the general system, with a slight local deter- mination to the part. In the former case, the local action of the cause is the predominant one. The inflammation of different tissues does not, as I have stated, exert an equal agency upon the development of tubercle. To under- stand this, we must analyze them separately. 1. First of the serous membranes. Pleurisy is perhaps the most active of all these inflam- mations. Like the others, it attacks individuals in good health, or labouring simply under a scrofulous diathesis, and tubercles are deve- loped during its course, or soon afterwards, or it coincides with the rapid formation of tuber- cles, which are then usually formed at the same time in the pleura, the false membranes, and the lungs proper, or it may occur as a mere secondary inflammation after the tubercles are formed, or are even tolerably advanced; in the latter case the pleurisy is a healthy, or at least a preservative inflammation, designed to pre- vent perforation of the pleura. All these varie- ties may be properly classed under the head of tuberculous pleurisy. The first variety is the most difficult to dis- tinguish, because the disease does not at first differ from ordinary pleurisy, and the important complication may be overlooked. The signs of the pleurisy are either gradually mingled with those of the tuberculous disease, or at least disappear when the symptoms of phthisis show themselves. In this case the pleuritic effusion is often extremely large, and the dis- ease is then sometimes ascribed to the absorp- tion of the empyema. The pus has undoubtedly an influence upon the formation of tubercles, but in most cases it acts merely as other causes of the disease,—that is, by producing an irri- tating action upon the part, and a general de- pressing influence on the whole body. The se- cond variety is that in which tubercles are form- ed at the same time, and apparently by the same morbid action as the ordinary products of in- flammation. The pleurisy is readily recog- nised; but the tuberculous complication can only be distinguished by careful attention to its symptoms, and even then the diagnosis is but a probable one. In the last variety there is, of course, no difficulty in ascertaining the nature of the pleurisy. 2. Bronchitis and pneumonia occasionally oc- cur amongst the earliest lesions in the acute forms of phthisis. The bronchitis is then of the common mucous kind, and very rarely passes into tuberculous phthisis, except in those cases in which itT is connected with a strong developed scrofulous diathesis. But the bronchial inflammation is extremely fre- quent as an early complication, coinciding with the first formation of tubercles, or follow- ing them. In the latter case it is most marked in the tubes which run through the clusters of tubercles, and it is then nothing but the ordinary secondary bronchitis, which gradually increases as the disease advances, and is most intense when softening has taken place, and the mu- cous membrane is irritated by the continual passage of the softened tubercles. Pneumonia is the least frequent of those local inflamma- tions which act as determining causes of acute tubercles; it is rarely of the frank sthenic kind, but generally occurs in scattered lobules, bear- ing a close analogy to the lobular pneumonia of young children, or the variety of inflammation which attends the formation of metastatic ab- 100 DISEASES OF THE LUNGS. scess; it is, of course, difficult in these cases to decide, if the pneumonia is really antecedent to the tubercles, or occurs under the relation of a mere attendant, or even a secondary result. In chronic cases of phthisis the preceding inflammation is usually of the bronchial variety, a common chronic mucous catarrh passing by insensible shades into pulmonary phthisis,— that is, a time arrives when the secretion of tu- berculous matter takes place, and the bronchi- tis is no longer simple. This is not, however, the only inflammation which proves a deter- mining cause of the more chronic forms of phthisis; pleurisy not unfrequently produces a like result, especially in those cases where the effusion has been large. Pneumonia rarely produces the same result; indeed, this inflam- mation is, on the whole, remarkably indepen- dent of tubercle. Phthisis without heal inflammation at the commencement. There is no doubt that many cases of phthisis, probably the larger number, originate without being preceded, or even at first accompanied by local inflammation; when this occurs, it is strictly secondary. These cases of the disease are sufficiently described in the commencement of this lecture, and in fact do not differ from those of general or con- stitutional tuberculous disease, except in the predominance of the disorder of the lungs. They may therefore be latent for a considerable time, and only attract attention to the lungs when the disease is sufficiently advanced to produce some secondary inflammation. The principal symptoms of the disease are therefore those of the general disorder, with or without the addition of the signs caused by the local mischief; these are not always developed suffi- ciently to attract much notice until the disease is quite decided. The mechanism of the pul- monary disorder, if such an expression can be used, is merely a direct secretion from the vessels, and is sometimes connected with a di- minished, instead of an increased vascular ac- tion in the part, although this is not invariably the case even at first, and is very seldom so after the disease is developed. Symptoms.—Phthisis is, or soon becomes so complicated a disorder, that a constant analysis is necessary in the study of the symptoms. If these are regarded in a crude, general way, they are often extremely indistinct; hence, many writers upon the subject content them- selves with the signs of the disease as fully established when diagnosis is no longer a mat- ter of doubt, or they add to this the general characters which are usually described as de- signating the scrofulous temperament. But as the discoveries of Laennec prepared the way both for a full understanding of the pathologi- cal characters of the advanced disease of the physical signs which attend them during life, physicians have not rested satisfied with this view of the subject, but have ascended, as it were, to the source of the affection, and have laboured to point out the initial steps, or at least the symptoms which occur very early in the disorder. Still you will find in many works on the subject, even of the most recent date, that the physical signs which occur sometimes quite late in the disease, are brought forward as indicative of the earliest stage of the disorder, which in most cases they certainly are not. We are obliged, therefore, to divide the symp- toms into several different sorts, which will lead us naturally to the study of the connected or dependent diseases. 1. First we have a series of symptoms dependent upon the tuber- cular disease, considered as a general disorder. 2. Symptoms connected necessarily with the development of tubercles in the lungs, in- cluding, of course, the physical signs of the disorder, properly so called. 3. Symptoms dependent upon the accessary disease of the lungs and air-passages, including larynx and trachea, which are present to a greater or less degree, in nearly every case of the disease. 4. Symptoms of disorder of the organs, some of which depend upon a deposit of tubercle in the tissue, but for the most part are connected either with a positive inflammation or a mere functional disorder; to a greater or less extent these take place in most instances of phthisis. You do not, of course, expect to meet these symptoms in every case of the disease; many of them may be obscure, and some absent en- tirely ; but we do in reality scarcely ever meet with a case in which they are all badly defined; that is, with a case of true latent phthisis; cases in which the disease is nearly latent, are quite common. 1. General symptoms common to phthisis and other tuberculous diseases. These differ in the acute and chronic varieties, in degree and to a certain extent, in nature. In the acute variety a rapid deposit of tuberculous matter takes PHTHISIS—SYMPTOMS. 101 place, generally throughout a number of organs at the same time; this approaches very nearly to an inflammatory secretion, and it is attended with a general disturbance of the body, which differs little from inflammatory fever, especially the fever which attends a sub-acute inflamma- tion of the pleura or other serous membranes. The pulse is extremely frequent, generally from one hundred to one hundred and thirty in the minute, quick and jerking; these characters are often difficult to define, but are at the same time very well marked. The febrile excite- ment is continued, and does not cease during the twenty-four hours, diminishing a little in the morning, and becoming more intense to- wards the middle of the day; at night there is almost always sweating, which at times is ex- tremely profuse, and as a general rule, is abun- dant. There are rarely chills, generally a mere sensation of chilliness at irregular times, and differing therefore from the chills of well-de- fined hectic, which occur in the latter stages of phthisis. The accessary symptoms, or those connected with the alimentary canal, are strictly such as would be supposed to exist in cases of high fever, such as thirst, anorexia, and consti- pation ; but they are less severe than in most instances of febrile excitement, because the stomach and bowels do not at all participate in the earlier disturbance of the system. The ge- neral appearance and countenance of the pa^ tient change when the fever is developed. The expression is restless,—the lips and countenance pale and flushed at irregular times,—the flush is often circumscribed when the fever is most considerable, but the tint is of a much lighter red than in pneumonia. The flush is not pecu- liar to any one form of tuberculous fever, but occurs without reference to the part affected. The countenance is often indicative of much dyspnoea, with dilatation of the nostrils, if there be a very large and rapid secretion of tubercles. The emaciation is rapid, partly as a direct effect of the tuberculous disorder, and partly from the profuse sweats which rapidly enfeeble the patient. These signs, in themselves, are not positively pathognomonic of acute tuberculous disease, but they scarcely occur in a high degree from any other cause,—not that all cases of acute tuberculization are necessarily attended with them in their highest degree, but you will find that they exist to a greater or less extent in 13 nearly every case of the disorder, and that their value is much increased by the very slight de- velopment or entire absence of other lesions sufficient to account for the fever, especially if conjoined with one other character,—that is, persistence,—for this fever does not rapidly de- cline; on the contrary, it usually lasts for a considerable period, and then resists all treat- ment. Pleurisy of a sub-acute character ap- proaches very nearly in the febrile symptoms to acute phthisis, whether the pleurisy be com- plicated or not with tubercles; in fact, I have little doubt that the pathological condition of the economy which attends the formation of the lymph, and that of acute tuberculous dis- ease, differ but very slightly from one another. This, however, is not sustained by a course of demonstrative reasoning, and therefore is of little interest until it is better developed. It is the reasoning by exclusion which gives to the acute tuberculous fever a great portion of its value. In the more chronic cases of phthisis the ge- neral signs of the disorder are more difficult to distinguish, because their development is slow, and the fever in the early stages is compara- tively unimportant. The signs which are most decided are those indicative of a deteriora- tion of the constitution and of the nutrition. The skin of the patient is generally of a dull tint; or if his complexion be naturally very clear, and the capillary circulation extremely active, the cheeks are from time to time flushed with a circumscribed redness, not very unlike that of acute phthisis, but less decided. At the same period, those peculiarities which are supposed to indicate a scrofulous or tubercu- lous constitution are often more developed,— that is, the blueness of the conjunctiva, and the rounded fusiform appearance of the ends of the fingers, which, although not peculiar to this condition of things, is certainly more common then, than under any other circumstances. The moderately chronic cases are also accompanied with fever, which is often slight, and sometimes limited to a mere sensation of heat or burning at the palms of the hands and feet: the sensi- bility to cold is at the same time often much increased; but there is very rarely a distinct chill, except from inflammatory complica- tion. In short, the ordinary cases of phthisis offer as symptoms, emaciation and slight fever, with 102 DISEASES OF THE LUNGS- an increase of the peculiarities designating either a constitutional diathesis or a tendency to the disease from an original feebleness of constitution. The very chronic cases are more and more obscure as regards the general symp- toms in proportion as the disease is slower in development. The addition of local signs of irritation confirms the vajue of the more chronic constitutional symptoms, as well as of the acute, provided these local symptoms do not disappear very readily. Hectic Fever is a very frequent conse- quence of tubercles after they have attained a certain stage of development,—not that the fe- ver is peculiar to tubercles, but, on the con- trary, it is common to all diseases attended with suppurating cavities communicating with the exterior. It scarcely occurs under other circumstances,—that is, the true hectic; the fever of irritation, on the contrary, is very fre- quent, when no suppuration exists, and is then very analogous to the initiatory fever of ordi- nary tuberculous disease. The true hectic oc- curs in the advanced stages of phthisis, when softening of tuberculous matter has taken place, and a pus-secreting cavity is formed. It is characterized, as is well known, by a strong tendency to a regular paroxysmal type, which sometimes approaches closely to inter- mittent, and by a pulse, which is at least as frequent, but generally more compressible than that of the early irritative fever. We may add to the general symptoms of phthisis the extreme exhaustion and tendency to oedema which occur in the latter stages of the disease. These, of course, are not pecu- liar to it. 2. Symptoms directly dependent upon the de- velopment of tubercles in the lungs. The bron- chial or other inflammations which occur very early in phthisis, are not properly dependent upon this disorder if they precede it, but the true secondary inflammation of the lungs is a necessary consequence of the tuberculous de- posit, and is strictly consecutive to it. The signs of the inflammation are of course scarcely different from those of ordinary bronchitis, and have been sufficiently noticed already,—that is, if we restrict the term bronchitis to those cases in which the inflammation extends over a large surface, and is in itself tolerably severe; but if the slighter cases of bronchial irritation, in whicli a cough occurs very early in connection with tubercles, are to be regarded as instances of bronchitis, the symptoms are very different from those of ordinary catarrh. It is not pos- sible to discriminate between the influence of the slight bronchial inflammation and of tuber- cles in the production of the cough. We therefore class both these causes together, and regard the cough which occurs at the com- mencement of phthisis as the result of either; this is at first very insignificant, and sometimes, though rarely, quite absent. At first it is much more frequent early in the morning than at any other period of the day, although you will find a great irregularity in this respect; it gradually increases in severity, and in the frequency of its return, until at last it becomes severe and more or less paroxysmal. This occurs when cavities of some size have formed, and the li- quid contained in' them tends gradually to ac- cumulate until it gives rise to a violent parox- ysm of cough. In the last stages of the dis- ease the cough becomes feeble and hollow, or cavernous in its character; a circumstance which is familiar to every one who has seen many cases of consumption. The expectoration is of course nearly con- nected with the cough ; at first it is, like the cough, very slight, and often insignificant; but, after a time, it becomes more and more abun- dant, and of the usual bronchitic character, for there is either no purulent matter, or this is so small in quantity as not to attract notice. After the tubercles have begun to soften, pus is neces- sarily found in the sputa, and those are of a yellowish colour, differing often in appearance from ordinary muco-purulent sputa, for the softened tuberculous matter of which they are in great part composed, is extremely viscid and different in appearance from pure pus. If the softening is very rapid, the quantity of the thick pasty substance often amounts to ten or twelve ounces in twenty-four hours. In gene- ral, it is combined with more or less thin mu- cus, which is intermixed with the thick yellow matter. As soon as cavities form, the thicker, more purulent part of the sputa, which is re- tained in the cavities, is moulded into a rounded, irregular form, often with loose, cottony edges; these portions are suspended, if they contain air, or if not, they fall to the bottom of the transparent mucus. This constitutes the num- mular sputa, which are not characteristic of PULMONARY PHTHISIS. 103 phthisis in general, but only of one stage of it. If the cavities become hard, and cease entirely, or in great part, to secrete purulent matter, the expectoration consists merely of thin mucus, as the lining membrane does not materially differ from that of the bronchial tubes. In the advanced stages of phthisis, and occasionally at a rather earlier period when the strength of the patient is much enfeebled, the walls of the cavity may soften down rapidly, and fall into a foetid, thick, grayish liquid; this is nothing else than gangrene of a tissue partly filled with tuberculous matter. The gradual obstruction of the lung with tuberculous matter, and its removal by soften- ing, renders so large a portion of the vesicles unfitted for purposes of respiration, that the dyspnoea is always considerable in the ad- vanced stages of phthisis. In the earlier period, however, this will often occur to a great- er or less extent, so that dyspnoea is very far from being a mere mechanical result of the obstruction, but is in part caused by the vital action going on in the lungs. It is most se- vere in acute phthisis. There is almost no pain from tubercles, property so called; the uneasiness felt from time to time in the chest seems to depend en- tirely upon the accompanying inflammation. The local signs purely belonging to phthisis, with the exception of the cough and expectora- tion, are slight; those belonging to the secon- dary inflammations are very numerous; even the cough and expectoration may be nearly absent, owing to causes which, in many cases, are not understood. We know, however, that the same causes which render other pectoral diseases latent, act here,—that is, the feeble- ness of the patient, and the diseased condition of the brain. Hence in lunatics we find that phthisis is always obscure, and sometimes scarcely betrayed by any local symptoms. Physical signs.— These are amongst the most decided in advanced cases, but very ob- scure in the early periods of the disorder. We do not now refer to the signs of the concomi- tant inflammations, but to those of phthisis, properly so called. At first these are limited to the signs of mere obstruction; the vesicular inspiration is feeble or harsh, and slightly puerile, while the expiration is becoming louder and louder. The character of the respi- ration, therefore, gradually becomes rude, and at last approaches the bronchial, in which it terminates as soon as the vesicular structure is completely replaced by the tuberculous matter. The bronchial respiration is more or less local, according to the quantity of tubercle, and the more or less obstruction of the larger bronchi themselves: if these remain uncompressed, the air of course passes freely through them, and the bronchial respiration may be tolerably loud; if, on the other hand, they are soon closed, the respiratory sounds are all feeble. As soon as softening begins, a slight rhonchus is heard, approaching more nearly to the sub-cre- pitant than any other, this gradually passes into decided crackling, and finally into gur- gling, as the liquid becomes more abundant, and the cavity increases in size. The cavern- ous respiration is generally developed with the gurgling, and sometimes replaces or alternates with it. The signs of percussion are of course limited in phthisis to those of induration of the paren- chyma ; they give us no information as to the progress or approach of softening. As the tu- bercles are generally most developed at the summit of "the lungs, the dulness is early per- ceptible there; hence it may often be first de- tected by percussing above the clavicle, or upon, or immediately beneath it; and however slight the dulness may be, there is little diffi- culty in distinguishing it, if attention be paid to the natural degree of resonance, and to the comparison of the two sides. The intercurrent inflammation may, of course, give rise to vary- ing degrees of dulness, which may rapidly in- crease or diminish. The signs of percussion and auscultation are the most important, but in the course of the dis- ease, attention should be paid to the conforma- tion of the thorax. The parietes of course contract when pleuretic adhesions have taken place; even if there are no adhesions, the con- solidation of the lung produces a partial con- traction of the tissue, which causes a slight sinking of the ribs; the most sensible, how- ever, is caused by the adhesions. These are most perceptible near the clavicles and behind them. The same causes render the ribs com- paratively motionless in this situation, as the air enters imperfectly into the tissue which is thus hardened. It naturally occurs to every one that these signs are rather applicable to the advanced than 104 DISEASES OF THE LUNGS. to the early stages of the disorder ; but there are generally some characters which afford a tole- rably good indication of commencing phthisis, as soon as a slight deposit has formed, or a partial infiltration of the tissue has taken place. These are not so much signs which are refer- rible to any of the fixed classes which I de- scribed at the early period of this course, but mere trivial alterations of the natural respira- tory sounds, which become important from their position and the coincidence of the general symptoms of common phthisis ; without these, the signs are of some value, though a very limit- ed one. Thus the commencement of a rude respi- ration, which is denoted by a trifling increase of expiratory sound, especially if in the left side, and a harsh, rough, inspiratory murmur, which differs from the natural vesicular sound, are both of some value, if they are combined with a slight dulness on an extremely careful percussion; that is, always with the pro- viso, that the general symptoms should be in some degree developed, for I cannot re- peat too often that the general signs are at the commencement of the disease the most important. But if the physical signs are added, a probable opinion may be converted into a cer- tain one, which affords a good measure of the degree of the disorder; if they are absent, the importance of the general signs is diminish- ed, but not destroyed. The physical signs of deposit and softening of tubercle extend gradually over the lungs, in proportion to the progress of the disorder, until a considerable portion may be involved. But the parts last affected do not offer as well mark- ed characters as those first attacked ; hence the respiration in the parts which remain compara- tively healthy, becomes in a great degree sup- plementary and puerile ; and, even when tuber- cles have invaded it, the vesicles still dilate, and their peculiar murmur is loud and harsh, notwithstanding a certain number of them may have become impervious to the air. 3. Symptoms dependant upon the accessary disease of the lungs and air passages, including larynx and trachea.—To a great extent the re- marks relative to these affections have been al- ready anticipated, from their necessary connec- tion with the subjects previously treated of. Thus the secondary inflammation of the bronchi produces few symptoms differing from those of the tuberculous disease of the lungs ; the bron- chitis, however, may occasionally become acute, and thus the rapid increase of the cough and dyspnoea, and the formation of the characteris- tic rhonchi, establish the nature of the intercur- rent affection. The sputa are also often in- creased in quantity, and become more transpa- rent, like those of the earlier stages of ordinary bronchitis. Pneumonia .too gives rise to in- creased dyspnoea, and to more or less crepitus and roughness of respiration, with frequently a viscid transparent expectoration; but the bron- chial respiration is much less loud than in ordi- nary pneumonia, and the increase of dyspnoea is much less considerable than we might apriori suppose it to be. In other words, the chronic dis- ease modifies the symptoms of the acute affec- tion. The secondary pleurisy is almost always of the dry kind. Effusion sometimes, however, takes place during more advanced stages of tu- berculous disease, but this is rather an excep- tion than a rule; the ordinary symptoms of the pleurisy are pains which vary from a mere stitch to a severe, sharp, lancinating pain, preventing the patient from lying on the affected side. The flying or wandering pains which are at times felt in the thorax during the course of phthisis, are probably dependent upon the same pleuritic complication, although this is not perfectly cer- tain. The inflammation of the larynx and trachea has a much more important connexion with phthisis. Chronic laryngitis is often called laryngeal phthisis, which is a sufficient proof that a close connexion or a great similarity was supposed to exist between these diseases. When the affection of the larynx occurs late in phthisis, it is absolutely secondary, and results, in part at least, from the irritation of the sputa passing from the lungs over the larynx and tra- chea, and thus giving rise to inflammation and ulceration; but the form of chronic laryngitis which attracts most attention is that in which the lesion preceded the disease of the lungs, and for a long time appeared totally inde- pendent of it. But after a time, which is very variable as to length, the signs of consolidation of the lungs are apt to supervene, and the case may then terminate in decided phthisis. From our knowledge of this frequent connexion, we must be cautious as to the prognosis of such cases. It is true that if the laryngitis can be arrested at a tolerably early stage, the patient will probably not become consumptive; but PULMONARY PHTHISIS. 105 should it resist our efforts to cure, the disease almost always terminates in a tuberculous af- fection : this is the case both with the common and syphilitic varieties of acute laryngitis. Of course the existence of a highly developed tu- berculous diathesis greatly enhances the danger of the case, and, under these circumstances, the laryngitis is sometimes little else than the com- mencement of the morbid phenomena. The same remarks apply to chronic trachitis, except that it is a more obscure affection, not con- nected with a special function like the larynx. The symptoms are generally merely cough, with an obscure sensation of tickling or sore- ness above and immediately below the upper margin of the sternum; while those of laryngi- tis, in addition to the sensation of irritation, are hoarseness, gradually passing into aphonia. The trachitis is less important in itself than the laryngitis, unless there be some evidence of ge- neral tuberculous disorder, when it is quite as grave. Like the laryngitis, it should be re- moved as soon as possible. The disease known by the name of chronic pharyngitis, or sometimes "clergyman's sore throat," is occasionally connected with phthisis. But the connection is rather an accidental than a fixed one, for the disorder consists essentially in an inflammation of the fauces, including uvula and tonsils. It is certainly rather more apt to occur in individuals who offer the characters of the scrofulous diathesis, than in others; and it has apparently some agency in favouring the development of phthisis in these individuals. It is often complicated with a chronic inflam- mation of the larger bronchial tubes. 4. Symptoms of other organs than those of respi- ration.—The symptoms of the diseases of other organs than those immediately connected with the lungs, are very numerous in the different periods of pulmonary consumption. Indeed, every disease which produces so deep an im- pression on the whole economy must of neces- sity give rise to many functional disorders in the different stages of its progress; and, on the other hand, those local affections will often de- termine the development of phthisis by the operation of the general laws which we have already laid down as to the connection of tu- berculous disease with the enfeebled condition of the body, which is readily brought about by the action of a local affection. When these local symptoms precede phthi- sis, they are not in most cases dependent upon the development of tubercle; when they occur during the course of the disease, they are more frequently the direct symptoms of the growth and progress of this morbid body, but in the majority of instances this is not the case. The proper way of stating the subject is this:—1. In some cases of tuberculous disease the mor- bid product is developed in different organs of the body to a sufficient degree to cause its pro- per symptoms, while the proportion of the tu- berculous matter in the lungs is still so much greater than in other viscera, that the specific de- signation, pulmonary consumption, is retained; in most of these cases the tubercles in the dif- ferent viscera, are developed at a later period than those of the lungs ; in a few, the former precede the latter. 2. The accompanying dis- orders and symptoms of other organs than the lungs, may have no immediate connection with the growth of tubercles; these are extremely numerous, and occur either previously to phthisis, or in its various stages. The symptoms of tuberculous disorder of the organscannotreadilybedistinguished from those of ordinary chronic inflammation; indeed, the two affections are often united, and occur to- gether. This is particularly the case in the serous membranes; that is, the pia mater, pleurae, and peritoneum. The inflammation is in these cases of a slow sub-acute variety, and we recognise the tuberculous complication chiefly from its persistence and slow progress. In the intestines the tuberculous disease of the follicles is essentially intermittent at first, and the symptoms vary incessantly, diarrhoea often occurring for several days, and then being fol- lowed by constipation; after a certain time the diarrhoea may entirely cease, and the follicles, which are the seat of the tuberculous deposition, will cicatrize. There are no other cases of tu- berculous deposit in mucous membranes, in which we can recognise its symptoms. In the serous membranes, it is essentially connected with inflammation; hence the symptoms are in- flammatory, but of the sub-acute kind. All the varieties are closely allied together, and consti- tute the tuberculous disease of serous membranes which may occur before any tubercles are formed in the lungs, but in the majority of cases they occur in adults during the progress of pul- monary phthisis. In other cases of tubercu- lous deposit than those just mentioned, the le- 106 DISEASES OF THE LUNGS. sion is attended with symptoms of functional disorder of the organs attacked, in proportion as it produces a positive destruction of the tis- sue, or as it is accompanied with inflammatory action. We see, therefore, that the tuberculous deposit gives rise to few symptoms, except it is so situated as to disturb the function of an organ. The other lesions, and the attending symp- toms which occur in phthisis, or before tuber- cles are actually formed, are extremely nume- rous, and very various in character. They are sometimes prominent enough to attract atten- tion almost exclusively to them, and these ob- scure the characters of the most important af- fection. Of this nature is dyspepsia, which is a very frequent, though extremely irregular symptom. In some cases it occurs very early in the disorder, and may appear before there is either positive or probable evidence of tubercu- lous formation; there are cases of dyspeptic phthisis, in which the disorder of the stomach appears often to be quite independent of either general or local tuberculous disease; but in other cases the gastric disturbance is evi- dent before the local disorder, and is clearly connected with the loss of appetite; it may give rise to phthisis in one of two ways,—either by the febrile excitement which it produces when the disease assumes an acute form, or by the alteration of the fluids which produces a pecu- liar action of the mucous membrane, and causes a slow softening and destruction of it. The complication of dyspepsia and phthisis consti- tutes one of the worst forms of consumption; as long as the digestive functions are unim- paired, the disease is slow in its progress, and attended with little suffering to the patient; but if the nutritionfails,itbecomesmuch more acute. The intestinal canal is subject to many de- rangements ; the natural effort of the disorder, like most febrile affections, is to produce con- stipation ; but diarrhoea may occur not only from the formation of tubercles, which has been already mentioned, but from the usual causes of inflammation. In most cases, the symptoms do not differ from those of the same diseases when they occur in a less complicated form; but those of the pulmonary affection are singu- larly modified, the cough frequently subsides, and the disease is apparently much better. The inflammation of the bowels then acts like any other revulsive action. Fistula in ano is another affection closely connected with the alimentary canal. Dr. Louis came to the conclusion that this was a rare complication in phthisis, but his conclu- sions are based upon peculiar data: on examin- ing all the phthisical patients who entered the wards of an hospital, he found that fistula in ano was extremely rare. If he had examined, on the other hand, all cases of fistula in ano admitted into a surgical ward, he would have found that a large proportion of them end in phthisis, either during the continuance of the fistula, or after it has been healed by a surgical operation. The affections of the liver are frequent in phthisis, especially in women, particularly the young. The most frequent of them is the fatty degeneration of the liver, which is rare, except in phthisis of women and in drunkards. Why these two conditions should both give rise to the same, or nearly the same alteration, is ex- tremely difficult to explain. The functions of the liver are but moderately impaired, notwith- standing a large portion of its tissue should be converted into fat. There is another disease of the liver which occasionally occurs in phthisis, or rather just before the tubercles are developed, which is more important than the fatty state. That is, cyrrhosis: this disorder is most frequent when phthisis occurs in countries where intermittents are endemic, and there- fore it is often difficult to distinguish the time when tubercles are formed. The only mode is to attend carefully to the local indications of disease of the lungs, especially the physical signs. I am compelled to group together the secon- dary lesions of phthisis, and their symptoms, otherwise this subject would be extended to too great a length. Condensed as this view is, however, some of these secondary altera- tions must be omitted, for the very sufficient reason, that a disease of great duration, per- vading the whole economy, and causing much febrile excitement, necessarily gives rise to nervous and irregular secondary lesions. Hence we often find that the phthisical patient com- plains of severe pains in the bones, or muscles, which appear to have no necessary connection with the disease, but belong to the class of un- explained sympathies. Diagnosis.—The diagnosis of phthisis is not PHTHISIS--PROGNOSIS. 107 attended with any difficulty in advanced, or I even in early cases, provided they are regular, and the symptoms follow their usual order. But in cases in which the local signs are not well developed, or the symptoms connected with other organs predominate over those of the lungs, the subject is much more difficult; and we are then obliged to resort to two modes of diagnosis. One is to group together care- fully the symptoms we observe, and then to compare with these groups those of other dis- eases which might possibly give rise to similar symptoms. Thus, any two or three of those symptoms which I have just described as be- longing to the lungs, with the addition of ema- ciation and the febrile movement so frequent in commencing tubercles, would render it proba- ble that the case was one of commencing phthisis. It is true that a complete diagnosis cannot always be made until the disease has advanced far enough to betray some of its es- sential physical characters, but this is not the case in the majority of patients. There are certain other signs which are of great value in the diagnosis of early phthi- sis. These are either individual symptoms, or peculiar groups of collective signs, which would singly be of little value. The most important of them is, perhaps, haemopty- sis. This symptom receives different degrees of attention; some writers consider it almost pathognomonic of phthisis, while others attach comparatively little importance to it. There is, however, little difficulty in reconciling these conflicting opinions; and if we examine the facts relative to it under several points of view, but little real difference of opinion remains. Haemoptysis occurs in three different relation13 to phthisis: 1st, before tubercles are developed; 2d, when they are still crude, and perhaps few in number; 3d, when cavities are formed. In the first two cases the blood is evidently se- creted from the mucous membrane of the smaller tubes, and probably from the vesicular structure; in the third it comes in most cases from vessels which pass through the bands running across cavities; these may finally give way to ulceration before their caliber is com- pletely obliterated, and a large haemorrhage may suddenly occur. Haemoptysis is of little value as a diagnostic character, unless abundant,—that is, exceed- ing a wine-glassful in twenty-four hours; a dis- charge of blood from the lungs in less quanti- ties may, to a certain extent, indicate a tendency to tuberculous disease of these organs, but is not in itself of much importance. If the hae- morrhage be more abundant, and occurs with- out any obvious cause, it must always be re- garded as a sign of commencing phthisis, or of a peculiar condition of the lung itself, or of its capillaries, which often ends in tuberculous formation. The evidence in favour of this conclusion is extremely strong, and is not re- futed by the fact that a number of patients affected with haemorrhage recover; for the first stages of phthisis are by no means incurable; and the varieties in which haemoptysis occurs are amongst the most favourable. These cases of exemption from phthisis after abundant haemop- tysis are not extremely numerous, as any one may ascertain for himself by simply interro- gating individuals who have arrived at the mid- dle periods of life, and enjoy good health: of these a very small proportion have ever had haemoptysis; and this is true not only with re- ference to healthy individuals, but as compared with the whole number of phthisical patients; amongst the latter the proportion of cases of haemorrhage is very large. The occurrence of tuberculous, or even the long continuance or frequent repetition of sim- ple pleurisy, is another indication of phthisis which will strengthen the more direct symp- toms of the disorder. But we must not imagine that any single symptom is ever sufficient for the diagnosis of a disorder, which, at its com- mencement, is necessarily complex. Nothing but the grouping together of a number of signs, together with indirect evidence afforded by ex- clusion, will afford the basis of a positive diag- nosis. Prognosis.—The prognosis of phthisis is un- fortunately quite clear in the large majority of cases; and when the disease is established, it is regarded as almost necessarily fatal. This prognosis must, however, be taken with some reservation, as the disease is in its nature es- sentially different in different stages, and can- not be said to be unavoidably fatal except when the disorganization of the lungs is much ad- vanced, and the tuberculous degeneration of the whole economy is carried to a very high de- gree. In the earlier stages the disorder may terminate in recovery; and there is no doubt that it not unfrequently gets well, even when 108 DISEASES OF THE LUNGS. the local sign of the disorder, the deposit of tubercles themselves, is actually formed. But these are not the most frequent cases; for be- fore any actual deposit of tubercle can take place, a very extensive alteration of the whole fluids has in all probability occurred, and the deterioration will be found to have reached that point which renders recovery rare, if not im- practicable. Although in many cases of phthisis the pos- sibility of recovery is now generally admitted, this result is by no means probable, except when a number of favourable circumstances concur; for, as the causes of phthisis are for the most part very slow, but at the same time very powerful in their action, the disease can- not in many instances be materially influenced by remedies. It is therefore unfortunately true, that even when we foresee that the disease is approaching, or distinguish the first steps of the tuberculous formation, it cannot always be arrested,—but there are other cases in which the result is happily much more favourable. In order to distinguish these cases, we must bear in mind the circumstances already men- tioned as complicating the progress of phthisis, or influencing its development. Of these the most important are a strong predisposition to phthisis, whether hereditary or acquired, and an exposure to circumstances known to favour the development of the disease. Individuals who present this constitutional tendency are those who offer the well-known signs of the scrofulous constitution known by the peculiar colour of the skin, and have generally the very dark or the light rosy complexion; when the disease is hereditary, the dark complexion is perhaps more frequent than the light, and the skin has then a dusky, earthy tint, or a dirty aspect, which is often almost peculiar to this disease. It is not always the case that those persons are thin and feeble,—some of them are stout and muscular, but feebleness of body in- creases the tendency to the tuberculous deve- lopment, and we may make the same remark with still greater force of the fat, pale, tallow- like complexion of some individuals, especially women, who possess an hereditary tendency to phthisis; the latter class of patients generally offer an enlarged, fatty state of the liver, and the prognosis in this case becomes very unfa- vourable. If exposure to the causes favouring tu- berculous development cannot be prevented', the influence of them must be obvious enough, and will greatly increase the probability of an unfavourable issue. In all cases, therefore, in which any direct evidence of tuberculous deposit is conjoined with hereditary tendency, or other strongly disposing causes, the dis- ease is most intractable; this accounts in a great measure for the more frequently fatal ter- mination of phthisis in the crowded and im- pure wards of an hospital. If there be no lo- cal signs whatever, but merely that constitu- tional deterioration which, unless arrested, is sure to end in phthisis, our prognosis is differ- ent; these indeed are scarcely to be consi- dered as true cases of consumption; they are so only in embryo, and may be often arrested by change of residence, or other means. The mode of development, and the early symptoms of phthisis, have also a considerable influence upon its termination. Some cases are unfavourable from the beginning, not merely from the strongly marked general symptoms, but because the local signs are known by experience to coincide with intractable forms of the disorder. The signs which may be regarded as impressing a favourable charac- ter upon the disease, are haemoptysis, if occur- ring from time to time after exertion, and very moderate, and local inflammation of the lungs before tuberculous matter is deposited in any large quantity. Haemoptysis, if extremely abundant, is not favourable, unless the patient should get perfectly well without irritative fever or further symptoms of tubercles, it then seems to relieve the lungs, and the disease is in general milder, and not unfrequently abates at an early period. But there is another form of haemoptysis which often occurs long before the disease seems to be concentrated -upon the lungs, and is perhaps rather referrible to a peculiar condition of the whole capillary sys- tem, than to any local mischief, this renders the prognosis much less favourable; it is the spitting of blood, which often continues for years, a mouthful or two at a time after coughing or very slight efforts, and is hardly noticed by the patient. It is most frequent in young women, and in those who offer a strong constitutional tendency to phthisis. The local inflammation of the serous mem- branes, or of the serous tissue of the lungs, is a PHTHISIS—TREATMENT. 109 favourable sign, because the action which gives rise to the disease is here apositive,tangible one; and if we succeed in changing it, or modifying its progress before tubercles are formed, the disorder may be arrested much more easily than in the more constitutional cases. If the tuberculous matter be actually formed, but li- mited to small portions of the lung, the prog- nosis may still remain favourable to a certain extent,—that is, the disease will be slow, and in a few cases will terminate happily, notwith- standing a cavity is formed. The least favourable local signs are those observed when the disease begins in a slow, insidious manner, by the trachea or larynx, which does not always call attention to the lungs, and the tuberculous degeneration pro- ceeds in an unsuspected form. Not that chro- nic laryngitis is of itself necessarily fatal, but it certainly promotes the formation of tubercles; and when this point is once reached, the dis- ease generally assumes a severe and unma- nageable character. In these cases, too, the tubercles are often scattered widely through the lungs, and of course are of more mischief than if they are limited to a small space at the summit. The prognosis of phthisis must be taken in a more extended sense than that of its ultimate termination : we have to decide in many cases whether the disease is to terminate speedily or slowly in death or recovery: this investi- gation leads us to the study of the varieties of phthisis in*relation to its character. Duration of Phthisis.—Although consump- tion of the lungs is, in the large majority of cases, a chronic disease, it is from time to time met with in an acute form; that is, it may prove fatal in a period of less than three months. This depends upon the rapid forma- tion of gray granulations, or tuberculous in- filtration in a large portion of the lungs. The disease is then attended with much fever, and the general tuberculous signs, as already men- tioned, are extremely developed. In many instances, death does not take place so much from the pulmonary disorder, as from the co- incident inflammations, or tuberculous deposi- tion in other organs, especially in the serous membranes of the brain. But phthisis may become acute, when it begins in the ordinary chronic form, and the change is then rendered 14 apparent by the rapid increase and severe cha- racter of the fever and sweats. Hence, although we know that the usual course of ordinary phthisis is slow, it is always possible that the type may change, and the termination may be hurried much more rapidly than usual. Our prognosis in acute cases is directly de- pendent upon the diagnosis; for if we once re- cognise the disease as of the acute form, we can confidently state that its course will be probably a short and a fatal one. The dura- tion of the ordinary variety of phthisis has been estimated by Dr. Louis to be about eighteen months; this is, perhaps, sufficiently near the truth,—but a large proportion of cases in hospital practice terminate in less than that period; in private practice the course of the disease is delayed so much by treatment, that the average duration of all cases, except the acute, is probably two years. The dura- tion of consumption is greatly influenced by age: the disease is often acute in the young— rarely so in those more advanced in life; the female sex has a similar influence with child- hood, so that the most frequent cases of acute phthisis are to be met with in young girls, a little after the age of puberty. Treatment.—The treatment of phthisis is by many regarded as never curative, but merely as a means of palliating the most severe or harass- ing symptoms of the disorder. If we apply the term consumption only to those cases in which the disease is far advanced, and the constitu- tional deterioration is extreme, it is very plain that no means of cure exist, and that even pal- liation is in many cases difficult; but if we speak of consumption as of other diseases which tend to a fatal termination only after having passed through their early and more curable stages, it is strictly curable, and, like these disorders, must be treated in different ways, according to the mode of its develop- ment ; for as tubercles are attended with very different symptoms, and originate in various modes, it is very clear that the most opposite methods of treatment may prove efficacious in combatting the affection in its forming stage, But after the tuberculous deposit has fairly commenced, it obeys its own laws of growth, and presents the secondary symptoms, such as hectic fever, emaciation, &c, which are pecu- liar to itself, and then one uniform method of treatment is desirable, or at least seems indi- 110 DISEASES OF THE LUNGS. cated. Besides, although the modes of deve- lopment of tuberculous disease are very nume- rous, there is a form in which the symptoms are regular and uniform ; and even in those va- rieties in which the modes of origin are most unlike, there is a peculiar character impressed upon the various symptoms, which is dependent upon the scrofulous or tuberculous diathesis. This treatment would be specific for the disease, and would be curative if it could cause with certainty the absorption of the secreted product, and favour the cicatrization of cavities, when the loss of substance was not extremely great. If we possessed such a mode of treat- ment, we might then, with great confidence, expect to cure phthisis in nearly every stage. But as no such specific exists, we are obliged to content ourselves with the administration of alteratives, which have but a limited influence on the grow th of tubercles, and of such remedi es as act either upon the causes of the disease, or on the accidental disorders which favour the tuberculous deposit in an indirect way. The alteratives used in phthisis are, for the most part, such as exercise a tonic and invigo- rating influence, at the same time that they pro- duce their proper effect as alteratives. Mer- cury is always injurious as a direct remedy in phthisis; it can never be of service except in those cases in which there is decided inflam- mation, and the tubercles result directly from it; but even in this class of cases, the influence of the remedy is certainly injurious so far as it affects the proper tuberculous disorder, and it must be discontinued as soon as the inflamma- tory symptoms are removed. The effect of mercury in phthisis is now so well known that it has almost become an axiom in medicine to avoid it in the treatment of this disease. Iodine is much more used than any other alterative; and if employed with discretion, it scarcely ever does harm. I have found it beneficial at the commencement of cases in which the fever was but moderate, and the local inflammation but slight, especially when a circumscribed chronic bronchitis has preceded for a long time the actual development of tubercles. Hence it is well suited to those cases which are preceded by chronic inflammation of the trachea and larger tubes, and pass slowly into phthisis, and to the cases which are most closely connected with external scrofula. The patient is then often robust in appearance, and the local dis- ease is slow in forming. Iodine is also useful in the purely constitutional cases, provided it be given cautiously, and the emaciation of the patient has not advanced very far; it should then be combined with vegetable tonics. The preparation to which, from habit, I have re- stricted myself, is Lugol's solution, prepared of the strength directed in the United States Pharmacopoeia,—that is, one scruple of iodine, and two of hydriodate of potassa, to seven drachms of water. Of this I give to an adult from three to six drops two or three times daily; I very seldom exceed six drops three times daily, and often give much less. For the good effects of the medicine may be ob- tained much more certainly in this way than by giving it in larger, but more irritating doses. I have never witnessed any other mischievous effects from the iodine than the disorder of the digestive canal, and a fulness of the head which sometimes results from it, but it is very certain that in some rare cases it acts as other power- ful alteratives occasionally do, and it may en- feeble or disturb the functions of the whole body without removing the morbid action. Hence it is advisable to discontinue its use from time to time, and resort to mild purgatives for a few days, or to abstain totally from all medicine until the tone of the stomach is re- stored ; it then is scarcely possible that an in- jurious result should follow. As the action of iodine is slow, we cannot observe any imme- diate impression produced by it; but when it is acting well, the complexion and strength of the patient improve, and the cough at the same time gradually diminishes. The latter effects may be promoted by appropriate expectorants, which should be given at the same time with the iodine. The appetite and strength almost always increase; and if these fail, or become less, instead of increasing, it is almost a sure indication that the medicine is not acting well. It is often useful to administer laxatives from time to time, even if the medicine be not sus- pended. As iodine evidently acts merely as an alterative, it is beneficial in that condi- tion of the economy which precedes the secre- tion of tubercles, as well as in their more ad- vanced stages, and it may be conjoined with other alteratives, such as the compound decoc- tion of sarsaparilla, or with mild tonics. Without attributing to iodine any specific vir- tue, I am quite convinced that its powers are THTHISIS—TREATMENT. very great in commencing phthisis, and that it j sometimes effectually arrests the progress of the disorder. The remedy seems to me to be least adapted to those cases in which tuberculization is very rapid, or the inflammation of the serous membranes very acute. There is no other alterative of a medicinal kind to which I attach much importance. There is none to which I could refer as pos- sessing enough certainty of action to make it useful in the majority of cases of phthisis: the mineral alteratives are more or less irri- tating and depressing in their effects ; and the vegetable, although they are, in some cases, of service, cannot be relied upon with much cer- tainty. They are evidently most beneficial where there is a constitutional deterioration which is going on very slowly, and rather pre- cedes than actually accompanies the deposit of tubercles,—that is, it is the same disease which has not yet reached its highest point; and although the knowledge we possess of the virtues of this class of medicines is as yet ex- tremely limited, there is great reason to believe that they may possess considerable power in ar- resting the early stages of constitutional phthi- sis. Most of the alteratives now used for this purpose are at the same time tonic, such as the preparations of sarsaparilla and the com- pounds of rhubarb with the bitter tonics, or with soda. In my own practice I resort to these remedies, chiefly to replace the iodine, or to aid its action. When phthisis has fairly commenced, iodine, or any other alterative, is designed to favour the absorption of a product which is actually deposited. But there are many cases in which we know that a tuberculous action is going on; that is, that the process which ends in tubercu- lous secretion is actually at work, but as yet there are no tubercles. It is then im- portant to arrest the formative action, and iodine is often of benefit in these cases. It is true that direct proof of this is extremely diffi- cult, because it is not easy to prove that a disease which is slow and obscure in its mode of formation, is really influenced or not by any remedy. The reasoning must be probable, and not demonstrative; and the truth is ap- proached more or less nearly as the observer possesses the proper abilities for drawing con- clusions of this kind. In these forming cases of tuberculous disease, iodine seems to act like alteratives of a hygienic character, and is certain- ly useful if no directly injurious consequences result from it; but it must be given in small doses, and from time to time should be inter- mitted. If these cases be very acute, the remedy must be omitted; for as a general rule it is quite unsuited to either the forming or the formed cases of acute phthisis or any other inflammatory form of tuberculous disorder. In these acute cases the inflammatory element predominates, and the action of the remedy is too stimulating, as it is in cases of phthisis which begin by lo- cal inflammation. With these reservations as to its use, iodine is one of the most efficient re- medies in early and in forming phthisis. How far its usefulness extends, is not a subject upon which we can speak with entire confi- dence. In advanced cases of phthisis hectic super- venes ; and iodine and all other alteratives are useless, unless they act merely as* tonics. In- deed, iodine has generally appeared to me to be of positive injury as soon as softening had taken place. For even if its influence upon those portions of the lungs in which the dis- ease has not advanced very far is good, it acts injuriously upon the surface of cavi- ties and the softened tubercles. In the early stages of tuberculous disease of the lungs, hygienic alteratives have always claimed the first place; indeed, you may readily believe that no medicinal alterative can well be useful if the hygienic measures which are best adapted for the disease be neglected. These are very well understood ; and, besides the choice of proper localities for a residence, and for a journey or sea-voyage, consist mainly in adopting such precautions, and in pursuing such a course of life as is least fitted to develope the disease. This part of our subject leads us naturally to th e examination of some of the causes of phthisis. When we remember the circumstances under which the disorder occurs, we may divide them them into two classes—those of a general and those of a local character. The general causes are such as exist originally in the individual, or arise from the circumstances in which he is placed; the latter are those which may be to a great extent obviated by art, and the action of the former may thus be checked indirectly, or at least not favoured. The local causes of phthisis are either directly inflammatory, or at least belong to morbid conditions which must be removed by medicinal rather than by hygie- 112 DISEASES OF THE LUNGS. nic measures. If the general causes include an hereditary predisposition to tuberculous dis- ease, it is of course necessary to insist the more strongly upon those that are accidental. You find these causes enumerated in the work of Dr. Clark, and in most others upon the sub- ject, and it is not necessary to enter much into dotail upon this subject; some classification, however, may be adopted, to render the same intelligible. 1. We may place hereditary predisposition in the first instance. This is universally ad- mitted, and the strength of it is increased if the parents were actually labouring under the formed disease at, or a short time previously to the birth of the child. It may descend from either parent; but it would seem that the mother exercises the greatest influence in this respect, especially if she nurses the child herself. In other respects the usual laws of hereditary transmission hold good, and the probabilities of their action are increased if the child present the character of the scrofulous temperament. 2. Depressing causes which debilitate the powers of life, increase the tendency to the morbid action. These, of course, are very nu- merous. Imperfect diet, exclusion from light and fresh air, and mental depression, are amongst the most powerful. Inaction, or a di- minished activity of body, favours the same re- sult. These causes are very obvious in pa- tients admitted into hospitals with other chronic diseases, and afterwards attacked by phthisis. The reverse of these causes is always to be ad- vised, and whenever practicable the greatest at- tention should be paid to them. One of the ad- vantages of a journey certainly arises from its invigorating influence, and the abundant sup- ply of healthful air which is thus obtained for the patient. The depressing causes often arise from the effects of a disease which is cured, but leaves the patient in an enfeebled state: this is often the case with typhoid fever; in other instances it produces a more direct im- pression, and the phthisis supervenes before the fever entirely ceases. 3. Certain occupations are known by direct observation to favour the development of con- sumption; these are such as require a con- strained position, and especially sedentary con- finement in close rooms. Mineral or vegetable dust or powders diffused in the atmosphere con- tribute to the same result. Hence the propriety of changing a pursuit is often a matter of strict necessity. Irregular exposure to cold and heat has a similar tendency, but it is much more ef- fective as a cause of the accidental inflamma- tions that often precede phthisis. Although these are the chief of the general causes of phthisis, the list might be much ex- tended ; they are, however, more or less anala- gous in their character, and more or less di- rectly depressing upon the individual. The alterative effects of a long journey and of change of residence, are well known in phthisis. They both act nearly in the same way : a journey in a pleasant season of the year, or in a climate which renders all seasons agreeable, is often of great benefit in forming phthisis, or in those varieties of the disease in which there is not much febrile excitement or local inflammation ; if these exist, the journey is irritating, instead of invigorating. If the strength of the patient be good, the journey should be made on horseback, or in an open carriage, and be pursued as long as the strength of the patient continues to improve. A sea-voyage is sometimes preferred to a land journey; as a general rule, however, it is less useful; but there are cases in which the strength of the patient is not great, but the dis- ease at the same time is slightly advanced, and the fever moderate, in which a sea-voyage in a mild latitude is of great benefit. It is also of great benefit in those cases in which the phthi- sis is attended with slight, but frequent haemop- tysis during its early stages. A short voyage is of little comparative benefit; it should be long enough to act as a decided alterative; hence, one to the East Indies, or to the Medi- terranean, or South America, answers best. The shorter voyages to Madeira, or the West Indies, are only advisable as necessary to a winter's residence in these climates. The question of a change of residence is al- ways of great interest to a phthisical patient; in fact, there is no one upon which he is more disposed to consult his medical adviser. The general anxiety felt by patients to resort to this mode of relief, is a conclusive proof that there is something in it, for it still continues al- though the lapse of years shows that the advan- tages of such a residence are much overrated. These advantages may be stated very briefly. PHTHISIS—TREATMENT. 113 by a winter's residence in a warm, but equable climate, the tendency to slight congestions or inflammations of various portions of the organs of respiration is obviated, and a cause of irrita- tion is then removed. Secondly, the mildness of the climate allows the invalid to enjoy the advantages of fresh air and exercise without much discomfort or risk. Lastly, the change of climate and of air is of itself of great benefit as an alterative. These advantages are, how- ever, limited; they are not specific in the treatment of consumption; hence many cases are not at all relieved, some are even aggra- vated. If the disease be of the acute form, and especially if it be attended with much fever, the patient is almost always rendered more fe- verish by the journey, and the affection tends to advance more rapidly; or if the disorder be so much advanced that the strength of the pa- tient is rapidly declining, no advantage can be expected. It is in the milder and more chronic cases that the change of air does good, espe- cially if the patient has found by experience that the winter is of injury to the organs of re- spiration, and gives rise to much cough or other signs of laryngeal or tracheal irritation. Of this class of patients very few individuals will be found to die abroad; most of them return with some benefit, especially for the first win- ter ; if the disease be not arrested, however, the benefit of a second winter is very doubtful. When the disorder of the digestive organs is a prominent symptom, the benefit from the voy- age is very considerable, but that from a pro- tracted residence in a warm climate is doubtful. The advantages resulting from a change of climate are not, therefore, such as to induce us to advise patients to leave their homes, and subject themselves to many privations with- out due consideration; and we should steadily oppose it, if the reasons for the voyage are not strong. It is difficult to point out the precise spot which is most suitable for the winter residence of a consumptive patient. Many physicians differ with perfect good faith as to the relative advantages of the different places which they recommend. The island of Cuba, Santa Cruz, the West India islands in general, and Florida, are most in fashion with invalids from the United States. Madeira is much resorted to by those from England, and, to some extent, by Americans; and various parts of the South of France, of Italy, and the shores of the Medi- terranean generally, are preferred by the conti- nental nations. A full account of the various advantages of many different situations will be found in the work of Sir James Clark, to which I may refer you. My own advice is regulated very much by the peculiar circumstances of the patient, his willingness or his desire to un- dertake a distant sea-voyage, his pecuniary means, &c. All of the different localities have some advantages; perhaps, at present, the island of Cuba offers more than any other. But it is not expedient to recommend any one situation to the exclusion of others,—still less is it expedient to advise a change of residence, even for a season, or a change of occupation, except upon strong grounds, and in cases where no harm at least will ensue. The treatment specially intended to prevent the growth of tubercles being very limited in its action, we are obliged to resort to collateral measures, which act rather upon the intercur- rent diseases which favour the development of tubercle, than upon this product itself. These intercurrent diseases are for the most part of an inflammatory character, and, as already men- tioned, precede or accompany the tuberculous deposit. Those which precede it do not re- quire any special treatment; but we must watch their termination, for the greatest danger is to be feared just at their close. Hence, in long- protracted inflammations of the larynx, trachea, or bronchial tubes, and in severe or repeated at- tacks of pleurisy, the treatment should be con- tinued until the disease entirely disappears, and the restoration of the patient to his former health is complete. The intercurrent inflammations of the chest are more difficult to manage, because the tuber- culous matter is actually developed, and the directly antiphlogistic treatment must be less continued. Of these inflammations the most common is that of the bronchial or tracheal mucous membranes; most of the tickling and cough depends upon this, and a large portion of the sputa comes from the same source; hence, the patient is solicitous to quiet the irritation, and the physician is constantly tempted to re- sort to opiates and other palliatives. It is often necessary to give opiates,—that is, if the pa- tient be unable to sleep, the cough must be al- layed ; and if the tickling and irritation be in- cessant during the day, it is necessary to quiet 114 DISEASES OF THE LUNGS. them. Still opiates are essentially disadvan- tageous, and in most cases they should only be resorted to if other means fail, and then in small doses, so as to preserve the stomach in as healthy a condition as possible. Hyoscia- mus is preferable with many patients to opium; that is, if it tranquillize the cough—for it will not do so always; a mixture may be made of an ounce of the syrup of Tolu, the same quan- tity of the syrup of senega, and six grains of hyosciamus, with four ounces of gum arabic mucilage. Half an ounce of wine of ipecacu- anha may be advantageously substituted for the syrup of senega in many cases, especially if there be much fever. This quantity may be taken in the course of three days, a dessert spoonful at a time. In this dose it is well to watch the effects of the hyosciamus, for at the end of one or two weeks it will occasionally produce some symptoms of narcotism. The opiates most used are the salts of morphia and the elixir of paregoric; on the whole, the for- mer are preferable, but the quantity should not exceed a quarter or a third of a grain in the twenty-four hours: with many patients it is best to give a small quantity of morphia at night, without any other substance, but in most instances the cough is soothed by a com- bination of a mucilaginous vehicle and of an ex- pectorant. As expectorants, we may use the syrups of senega, or ipecacuanha, or antimony; the latter is best fitted for those cases in which there is much fever,and in many instances no inconvenience follows,—in others the sto- mach rejects all remedies of this class. There is, in fact, no expectorant used in the treat- ment of bronchitis which may not occasionally be given in phthisis; even the balsam of co- paiva is sometimes of great benefit when there is much chronic bronchitis and but little fever or gastric irritability. In most cases, however, it is much too irritating. Venesection is rarely requisite in pneumonia attending consumption, and is almost never in- dicated in bronchitis. Cupping is, however, of signal benefit in the treatment of both in- flammations. Pneumonia in most cases does not need any other remedy; where an internal medicine is necessary, minute doses of tartar- ized antimony are much to be preferred to large ones, or to mercurials. The treatment of pleurisy is more difficult. The intimate relation of this disease with phthi- sis has already been explained, and it seems a matter of more urgent necessity to remove it completely at as early a period as possible. For this purpose the usual antiphlogistic mea- sures are indicated at the beginning of the dis- ease, with small doses of antimony and opium, or Dover's powder, or one of these remedies combined with digitalis, according to the strength of the patient. After the acute stages have passed off, the surest remedy is the re- peated application of small blisters to the affected part from two to three inches square, so as to keep a continual counter-irritation, by changing the place of their application, and renewing them as often as they heal. Large blisters are better adapted to the acute than the chronic forms of pleurisy. It is often a ques- tion whether mercurials should be given under these circumstances; it is true that they pro- duce an injurious effect upon phthisis proper; but when the inflammation of the serous mem- branes predominates very much over the scro- fulous or tuberculous type peculiar to the dis- ease, mercury may be given with discretion. That is, the circumstances proper for its em- ployment are almost limited to the pleurisy of commencing, not of advanced phthisis; and it does not seem to matter much whether the pleu- risy be of that variety in which the tubercles are developed in the serous membrane, or whether they are formed afterwards in the substance of the lung. If we decide upon giving mercurials, they must be limited to very small doses, and should be given for a short time only, never producing ptyalism. The other intercurrent inflammations must be treated as the same disorders would be if in an uncomplicated state. But gastritis and hae- moptysis, or tracheitis, require a passing no- tice. If the gastritis occur in a healthy indi- vidual in whom phthisis afterwards declares itself, there is nothing special in its manage- ment, but it often occurs in those who have previously offered the signs of a scrofulous dia- thesis, and is then difficult to treat. We must then look to the constitutional character of the disorder, and must place the patient upon ge- neral alteratives, especially the hygienic, as a sea-voyage or a journey, while we resort to the usual treatment for dyspepsia. Laryngitis is often a mere symptom of phthi- PHTHISIS--TREATMENT. 115 sis; and if it occur in its advanced stage, opi- ates will scarcely succeed in palliating the dis- tress which is caused by it; the difficulty of deglutition, and the uneasy feeling at the throat, often constitute one of the most dis- agreeable symptoms of advanced phthisis. But the commencing laryngitis is sometimes arrest- ed readily enough when no tubercles are yet developed. Repeated, but small applications of leeches, followed by frictions with iodine ointment, and the internal use of the solution, are the most important means. A blister be- hind the neck is much less certain; sometimes it is applied in front of the larynx, but little benefit results from it except in the early stages. I have not used nor seen employed the cauterization of the larynx, by injecting a so- lution of nitrate of silver into it from a small syringe more than half full of air, so as to break the little stream into numerous fine drops. Dr. Trousseau gives some favourable accounts of its success; but I am not inclined to think that it is applicable to many cases. The pha- ryngitis which sometimes precedes phthisis, is more easy of cure, and requires local altera- tives with a general tonic treatment. When the disease is nearly removed, cold ablutions of the neck and upper parts of the breast are the best means for preventing its return. There are many symptoms in phthisis which are not connected with proper inflammations, but may reach a sufficient degree of intensity to require special treatment. These are the diarrhoea, hectic fever, and night sweats. Di- arrhoea and dysentery often result from proper inflammation of the bowels, and are then nearly similar to the same disease as it occurs under ordinary circumstances. But diarrhoea assumes two other forms; it may be the proper tubercu- lous diarrhoea, which follows the softening of this substance in the follicles of the intestines, especially the glands of Peyer, or the colli- quative diarrhoea, which occurs late in the dis- ease, and sometimes carries the patient off very rapidly. The former variety of diarrhoea nfay be palliated by small doses of opiates; the lat- ter requires the same treatment, but with less prospect of success; for when colliquative diar- rhoea supervenes in the last stage of phthisis, it is almost always fatal. The astringents may be advantageously combined with opi- ates, especially kino, and given in small quan- tities, if the tongue is not dry and red, and they are not productive of gastric uneasiness. If the diarrhoea be moderate, and the pectoral symptoms have abated upon its occurrence, it is better to abstain from any active medicines, as the discharge is then to a great extent a na- tural drain, and more mischief would follow from its repression than could be compensated for by the temporary relief of the patient. At the beginning of the diarrhoea, small doses, as two or three drachms of the spiced syrup of rhubarb, will often relieve it. The sweats, which are so frequent in phthi- sis, are extremely exhausting to the patient, and occasionally require special remedies. The sweating i s sometimes connected with the irri- tative form of early phthisis, or follows the hectic, which occurs only in the advanced cases. In other cases the sweating is a termination of a febrile paroxysm, and is in itself a mode of relief to the patient; but as it is a cause of great depression, and often prevents sleep, we are often compelled to resort to some efforts to check it. Several external applications have been proposed with this view, such as bathing the skin with a solution of alum, or some other astringent application. They sometimes suc- ceed; but any external application intended to suppress what may be considered as a natural discharge, is fraught with danger; and whether this be sweating or the secretion from a cuta- neous eruption, it should, if possible, be avoided. It is much better to use no external means, other than rendering the clothes as light during the period of fever as they can be made with safety to the patient. Another useful means of moderating the night sweat, is antici- pating it. That is, the patient may take a hot pediluvium early in the evening, while he is still labouring under fever, and then go im- mediately to bed. The sweat will generally follow, and he should rise as soon as it dimi- nishes and change his linen, and, if possible, the sheets of the bed. In this way he is al- most sure of obtaining some hours of refresh- ing sleep. This remedy, however, like all others under similar circumstances, will fail after a time. The internal remedies used for the same purpose are notoriously uncertain. In fact, their administration is almost entirely empirical, and the most opposite medicine will sometimes succeed. That is, a remedy which produces a certain action upon the secretion of the gastric mucous membrane has generally a 116 DISEASES OF THE LUNGS. reciprocal action upon the cutaneous surface, and very different substances applied to the gastric membrane have the power of so modi- fying the condition of the whole body, that sweating is for a time suppressed. The most used of these remedies are the acids and alka- lies, especially the former. The nitric or sul- phuric acids are generally preferred to any other, especially the elixer of vitriol or aroma- tic sulphuric acid; this should be given in dose=! of from ten to twenty drops two or three times daily, either in some sweetened water, or in an infusion of the bark of wild cherry. Sometimes this remedy is disagreeable to the stomach, and produces various ill-defined sen- sations ; it should then be discontinued, and a remedy of an opposite kind resorted to. The alkalies often answer well in such cases, espe- cially lime water, with milk, in various pro- portions, as may be found to suit best with the stomach of the patient. This combination may be taken with some simple biscuit as a suitable article of food, when the stomach digests with difficulty. It should not, however, be used merely as an article of food, but be taken at dif- ferent times throughout the day. Although it may seem singular that alkalies and acids are both of occasional benefit in the treatment of phthisis, yet it is what is often observed in or- dinary cases of dyspepsia, in which the condi- tion of the membrane of the stomach is not ve- ry dissimilar to that in phthisis, and the same causes which render these different remedies of service in the former case, appear to do so in the latter. At least this is the most reasonable explanation. The chills of hectic fever are often extreme- ly severe, and occur with such regularity that the sulphate of quinine has naturally enough been proposed as a remedy. Given in doses of from two to six grains before the expected chill, it will sometimes arrest it; in other cases it fails entirely, and is rather irritating to the patient than the contrary. In most cases the best treatment is to palliate the hectic by sim- ple attention to warmth and other hygienic cir- cumstances at the time of the paroxysm. There are several remedies which at one time enjoyed a reputation in the treatment of consumption, which is by no means merited. The principal of these are digitalis, hydrocia- nic acid, and the acetate of lead. Digitalis was given mainly because the excessive fre- quency of the pulse, which constitutes so pro- minent a symptom in many cases of phthisis, cannot be reduced by blood-letting, while it will sometimes partially yield to digitalis. The powers of this remedy extend no further; and as the good results of it are extremely doubtful, while it is often positively mischievous, it is now almost abandoned. I have from time to time made a trial of its virtues, but without sa- tisfactory results. Much was expected from hydrocyanic acid when it first came into use. It is certainly a good sedative; but as the remedy is necessarily extremely uncertain, and is attended with no little danger when the strength of it happens to be greater than usual, it is, in fact, not much prescribed. I do not, however, object to it, as it unquestionably is a good anodyne. The fer- rocyanate of potassa is occasionally a good re- medy, possessing some sedative powers, and to some extent controlling the night sweats; the dose which I prefer is five grains three or four times daily, gradually increased to twice that amount, should no effect follow. One of the advantages of the wild cherry bark certainly arises from the proportion of prussic acid which it contains; this is sometimes considerable enough to cause some fever, and a disagreeable sensation of feebleness in the head. The acetate of lead I have rarely used in the treatment of phthisis proper, although it is recommended for its power in checking the hectic fever. But in the diarrhoea which often occurs, it is one of the most useful remedies, given in combination with a small dose of opium. The chalybeates are occasionally resorted to in the treatment of phthisis, especially the iodide of iron, which is given in doses of from ten to thirty drops of the solution two or three times daily. Few patients will bear larger doses, which are apt to cause nausea and a dis- agreeable feeling of constriction at the epigas- trium and head. My own impressions are less favourable to this remedy than they for- merly were; it certainly acts well in some cases, but fails entirely as a curative agent, and from its aptness to cause the disagreeable symptoms just referred to, it cannot be given in as large doses, or as frequently as would other- wise be desirable. It differs a little from other chalybeates, and possesses more decidedly al- terative properties. Other forms of the same PHTHISIS—TREATMENT, 117 class of remedies are occasionally resorted to; and, like the preparations of iodine, answer best when the patient is depressed, with little or no febrile excitement, and the constitution is feeble and deteriorated. There are certain mineral waters which have acquired more or less celebrity in the treatment of phthisis: amongst these are some of the springs in the Pyrenees, and the Red Sulphur Springs in Virginia. These are all situated in mountainous districts, which ren- ders the climate injurious to many classes of phthisical patients. In advanced cases, the benefit, if any result, can be but palliative; and the circumstances attending the position of the springs, and the long journey necessary to reach them, should be taken into the account, before advising patients to resort to them. My own experience as to their virtues is limited to a short residence at the Red Sulphur. This is a cold and very agreeable water, containing very little saline substance, and impregnated with a moderate quantity of sulphuretted hy- drogen. The analysis of the spring is found, however, not to be complete enough to render it conclusive. The most benefit was derived by patients who were in need of an alterative, especially of one which was capable of acting upon the digestive canal. Such cases appeared to derive essential benefit from the combined influence of the water and the journey; and in this way, at least, it appears to be serviceable in commencing phthisis, where the irritability of the chest is not great, and there is little or no tendency to acute bronchitis or pleurisy. In the latter cases the climate does not appear to me very favourable, at least not in a wet sum- mer. The treatment, therefore, of phthisis, is al- most entirely indirect, and we hope to check the progress of tubercles by removing acciden- tal complications, or diseases and conditions of body which favour their growth, rather than by acting directly upon the tuberculous secre- tion. Hence it is necessarily uncertain, and often fails when every thing seems to be most 15 promising; for as tubercles themselves are ma- nifested by but few symptoms, the greatest part of the sufferings of the patient is caused by the complications. These are often readily removed, and the patient is apt to fancy that the apparent amelioration is real. But though the fatal cases constitute a large majority of those in which phthisis is tolerably advanced, or has from the first assumed a cha- racter of great severity, yet there is so much left for the physician to do as a faithful coun- sellor in warding off the first approach of the constitutional disorder by appropriate hygienic and medicinal measures, as an active practi- tioner in checking the progress of the varieties in which inflammation of the organs plays a decided part, and, lastly, in allaying the suf- ferings in those cases which are actually in- curable, that the treatment of consumption is far from being as ingrate a task as is often sup- posed. How far the power of therapeutics ex- tends, is difficult to define with accuracy, but the gradual increase, of our knowledge will probably furnish us with means which are of more certain application, and will certainly teach us how far the use of those we now pos- sess may be extended.* * In referring to the exercise of the whole body, as a means of resisting phthisis, particular allusion was not made to the exercise of the lungs themselves. This is often a question of great importance. Should the patient be in the habit of reading or speaking aloud, I have not in general forbidden the exercise, provided it was not carried to the point of fatigue, and there was no active inflammation going on. This was the case with a well known and popular preacher who consulted me some time since, with cavities ac- tually formed, and who still fulfils his laborious du- ties with improved health. This exercise may in some cases be increased by protracted efforts of inspi- ration, but much caution is then necessary to avoid increased irritation. A mode of exercise ot this kind constituted the basis of a plan of treatment which at- tracted some notoriety in London a few years since, but was so strongly tinctured with charlatanism, and its results evidently so much exaggerated, that its actual value was soon ascertained to be extremely limited. LECTURE XIII. Pneumothorax. There is a lesion of the lungs and pleurae which is rather a result of disease than a posi- tive morbid action. This is pneumothorax, or perforation of the lung. It is true that as soon as this accident occurs, pleurisy is set up, and only differs from common inflammation in the mingling of the symptoms of the pleurisy with those of the perforation. The mechanism of perforation is very simple; in almost every case it results from tuberculous disease of the lungs, but any alteration of those organs situat- ed near the pleura, and gradually destroying the parenchyma beneath it, may produce the same result. As soon as the pleura is left unsup- ported by the tissue of the lungs, it becomes of a dull yellow colour, and soon sloughs; a small hole forms in the centre of the dead por- ion, which is enlarged by the passage of air through it during the act of inspiration. The size of this opening varies from that of a pin's head to a third of an inch in diameter; it is ge- nerally of a valvular form, and allows with difficulty the passage of the air from the pleu- ra. As the air enters more easily than it passes out, it of course accumulates in the cavity, and the chest quickly increases in volume, from the quantity of atmospheric air which finds its way into it. The air is an immediate irritant to the se. rons membrane, and gives rise to inflamma- tion, which is followed by the secretion of its usual products, lymph and serum. The latter accumulates at the bottom of the cavity, mixed with a few floccnli of lymph, but the greater part of this substance adheres to the surface of the serous coat in the form of a false mem- brane, which extends to the point of perfora- tion, and then closes it completely, in which case there is no difference between empyema and advanced pneumothorax. The liquid con- tained in the pleura is at first merely serum, but it afterwards is replaced by pus, which is secreted by the false membrane as in chronic pleurisy. As pneumothorax is a physical lesion which produces a rapid change in the condition and functions of the viscera of the chest, its physi- cal signs are very evident, and are often beau- tiful illustrations of the accuracy of physical exploration. The immediate result of the pas- sage of the air into the cavity of the pleura is the collapse of the lung ; the inspiratory mur- mur therefore ceases, or is replaced by amphoric respiration, which is often heard over the whole cavity, and in other cases is limited to the part nearest the perforation; the sign is much clearer and sharper than in those cases in which it is caused by a cavity in the substance of the lung, forthe walls of the chest are more elastic and pro- duce a clearer sound than those of an ordinary ca- vity. The expiration, however, is often unheard, for the opening is in many cases too small to allow the air to pass out with sufficient freedom to give much sound. In this respect the am- phoric respiration resembles that of very large pulmonary cavities. The amphoric respiration often ceases after the pus has increased, and the coating of lymph has formed over the opening, and there is then either no sound, or a slight and bronchial res- piration heard at a distance at the root of the lungs. As a necessary attendant upon the amphoric respiration, we find a corresponding resonance of the voice, which follows the same course, and ceases at the same time. The metallic tinkling is another phenomenon of equal inter- est. It resembles the tinkling of a pin against the sides of a glass or metallic vessel more nearly than any thing else, and was at one time supposed to depend upon the dropping of a small portion of liquid from the top of the pleura upon the surface of the effusion. Dr. Bigelow, of Boston, performed a number of ex- periments upon the dead body, and satisfied himself that the cause of the tinkling depended upon the air forcing its way upwards through the liquid and not in the dropping from above. The tinkling is by no means a constant sign, and is, therefore, much less important than the amphoric respiration and resonance of the I voice. PNEUMOTHORAX. 119 The signs of pneumothorax gradually de- cline as it passes into ordinary empyema, and the necessary flatness of percussion follows, with entire absence of respiratory murmur. The quantity of pus is much greater than in com- mon cases of pleurisy ; it sometimes amounts to several gallons, and causes extreme difficul- ty of the respiration. The rational symptoms of pneumothorax are by no means conclusive, but in most cases they are sufficiently well marked to excite a suspi- cion of the nature of the accident. They are the usual signs of acute pleurisy with extreme and sudden dyspnoea from the rapid entrance of air into the cavity of the pleura. Their uncer- tainty arises from the occasional absence of pain in cases of acute pleurisy, and from the dyspnoea not being always very intense. As a general rule, however, if a patient labouring under symptoms of phthisis be taken with very sudden and acute pain in the chest, and extreme dyspnoea, there is strong reason for suspecting that perforation of the pleura has taken place ; especially if the pain occur during an effort of coughing, or some other sudden shock given to the chest. It is true that all of these symp- toms may depend on acute secondary pleurisy, which sometimes developes itself, or at least shows itself almost instantaneously, and the test is therefore to be sought in the physical signs of the disease, which are alone to be relied upon. The pain is described as similar to that occurring in severe cases of pleurisy, as cutting or lancinating, and at first prevents the patient from lying on the affected side, but after the disease has continued for a time, the patient follows the ordinary rule of chronic pleurisy, and lies on his back or on the affected side, in order to avoid the pressure of a large quantity of liquid upon the mediastinum. The other symptoms are also those of pleurisy ; the fever which follows the perforation is of the acute kind observed in cases of pleurisy, with a ra- pid and rather wiry pulse, followed by abun- dant sweats at night. After the effusion has be- come purulent, the fever approaches more near- ly to the hectic form, and the patient complains much more frequently of chills than he does in the earlier stages of the disease. Although he gradually loses flesh, he does not become nearly as much emaciated as in those cases in which tuberculous disease is passing through its ordinary course; nor is the disturbance of his general health nearly as great, provided he escape the first dangers of the accident. The other functions of the body are more or less dis- ordered, but in very different degrees, and are scarcely similar in two patients. This variety depends upon the different susceptibility of in- dividuals, which necessarily renders all the ac- cidental or secondary symptoms of a local in- flammation extremely uncertain and variable nor can they be described except in general terms, and as in nowise necessary to character- ize the affection. The symptoms of the original disease causing the pneumothorax, in great part remain, but are in some degree modified by it; thus the cough and expectoration diminish when perforation supervenes, for the difficulty of breathing and pain prevent a full expiration, which is necessary to a complete cough; the cough which is proper to pneumothorax is even shorter and drier than that of. pleurisy, for the respiration is less complete and more painful. Of course no expectoration can arise from the pneumothorax; if there be any, it must depend upon accompanying disease of the lungs or bronchial tubes. Diagnosis and Prognosis.—The diagnosis of pneumothorax, since the discovery of physical exploration, is amongst the most certain of those of diseases of the chest, for in a lesion of this kind the physical signs are pathognomo- nic; without them, the lesion may be sus- pected, but cannot be certainly recognised or distinguished from acute pleurisy. Physical exploration goes much farther than the mere recognition of the disease; it points out its different degrees and stages, and the gradual passage of it into empyema. The prognosis is more uncertain ; in the large majority of cases it is unfavourable, and speedily fatal; but this rapid termination depends less on the lesion it- self than upon the disease which has given rise to it, or on the combined influence of the two ; If, for instance, one lung be almost unfitted for respiration, and the perforation happen in that which is comparatively healthy, respira- tion is almost interrupted, for both lungs are rendered nearly useless, and the patient dies in a few hours or days from exhaustion and or- thopncea : hence the condition of the lung which is not the seat of the perforation has much influence upon the prognosis. If the pa- tient does not labour upder any immediate dan- 120 DISEASES OF ger from the interruption to the respiration, the prognosis is still almost necessarily fatal if the phthisis be at all advanced; but if it be confined to a few scattered tubercles, it has lit- tle influence upon the course of the pneumo- thorax, which seems rather to retard than has- ten the progress of tubercles. If the disease assume the latter form, and arise merely from the accidental rupture of a small tubercle into the pleura, the prognosis is for the present much less unfavourable, but after the pleura is completely filled with pus instead of air, the patient still incurs the risk attendant upon a severe empyema, and, of course, under the best of circumstances, the prospects of ultimate re- covery are doubtful. Duration and Termination.—The duration of pneumothorax is not fixed. It may terminate fatallyin ashort period, (in one case I witnessed a fatal termination in less than an hour,) or it may last many months; in two cases I found the fa- tal termination not to occur until the lapse of fifteen and eighteen months; in the latter of these cases, the patient made two long voyages, and did full duty as a seaman. It is in this va- riety that the lesion is followed by empyema, and the possibility at least of recovery must be admitted. Treatment.—The treatment of perforation of the pleura is extremely limited. The indica- tions are to subdue the secondary inflammation, or rather to keep it within moderate bounds, and to relieve the pain. But as the patient is already much debilitated by previous disease, there is little to be done in the way of active treatment. Bleeding is quite inadmissible, but an occasional application of cups may be allow- ed, although with great reserve, and only in those cases in which the inflammatory excite- ment is very high. Blisters are much more frequently of benefit; in fact, they are the most certain remedies for checking the inflammatory action, and often relieve the pain; they should be applied to the affected side, near the seat of pain, which does not correspond in most cases with that of perforation. Besides blisters, the only remedy which promises much is an opiate; especially Dover's powders, given in doses THE LUNGS._______________ sufficient to tranquillize the agitation of the pa- tient ; and if not to secure sound sleep, at least to relieve the incessant restlessness and suffer- ing. This treatment I have long pursued in cases of pneumothorax, and it is nearly simi- lar if not altogether identical with that recom- mended by Dr. Graves for the treatment of in- testinal perforation in typhoid fever. The opi- ate should be continued for some days in a full dose, and in diminished quantity during the whole of the case, discontinuing its em- ployment when the oppression increases, or the digestive powers become much enfeebled. The proper anti-phlogistic treatment of pleu- risy is scarcely adapted to cases ofpneumotho- rax; for as the cause is a permanent and mecha- nical one, it cannot be removed by antiphlogis- tic or alterative remedies, and, therefore, the progress of the secondary pleurisy cannot be retarded; but the inflammation may be modified and the empyema, which is almost necessary to the cure of pneumothorax, should after- wards, if possible, be brought to a favourable issue. The operation of paracentesis is sometimes allowable in two different stages of the dis- order; to favour the escape of the gas, or the pus which is afterwards secreted. Immediately after the perforation of the pleura, the dyspnoea may suddenly become so great that immediate death is to be feared; the side may then be punctured in the usual way, and the gas be allowed to escape; but as in this case, the subsequent dangers of the disease are certainly increased by exposing the cavity of the pleura so freely to the air, the operation cannot be justified except it be a mea- sure of absolute necessity ; at best, it relieves the patient only for a short time. In the cases of advanced empyema which follow pneumo- thorax, paracentesis may be performed where the oppression is extreme, and the intercostal spaces are much bulged out. The operation is, however, very far from being devoid of dan- ger, for the free entrance of the air into the ca- vity tends to increase the inflammation, and to aggravate the hectic fever. The usual precau- tions should be carefully attended to after the operation. LECTURE XIV. Pulmonary I. Haemorrhage from the lungs, in most in- stances, consists merely in an exudation of blood from the bronchial membrane, and is symptom- atic of deeper seated diseases of the lungs; but as it arises from several different causes, and may depend upon simple excitement of the cir- culation, or disease of the heart, as well as upon positive lesion of the lungs, it requires, on some accounts, a separate examination. The connection of haemoptysis with different stages of tuberculous disease has been already ex- plained in the lectures upon phthisis; the ob- ject of the present remarks is, therefore, hae- moptysis itself, considered as a separate disor- der, and not a mere symptom of other pulmo- nary affections. It may be divided into the haemorrhage which is purely external, in which the blood comes directly from the mucous membrane, and is dis- charged externally; and into another variety, in which a portion of the blood escapes into the cellular tissue of the lungs, and forms little nuclei, which are of a deep red colour, and of almost a uniform appearance. These nuclei constitute the disease known under the name of pulmonary apoplexy, which is nothing more or less than haemorrhage from the vessels of the smaller bronchial tubes and vesicles, into the cellular tissue of the lung. It is, in general, attended with a flow of blood externally; but in some cases the effusion is strictly internal, and the disease is then indicated only by the dyspnoea and obstruction to the circulation. There is some difference as to the causes of the slighter varieties of haemoptysis and pul- monary apoplexy. The latter follows, in most cases, the sudden and violent congestions of the lung, which a disease of the heart or aorta naturally produces; or it arises from some other equally decided obstruction to the circulation; but the haemorrhage which finds its way en- tirely to the surface, depends, in most cases, upon a less severe, but more persistent cause of irritation, seated in the lungs themselves. In either variety of haemorrhage there is, therefore, something more than a mere flow of blood to the head; there is a cause, either ge- neral or local, or both united, which determines the raptus toward the lungs, and then a dis- charge into the cellular tissue, and upon the surface of the bronchial membrane, or upon the latter alone. The first stage in the morbid chain is the congestion which may occur with- out the effusion of blood, or with haemorrhage, into the cellular tissue, but not externally. Hence, the discharge of blood is in itself of no importance, except in the rare cases in which it is so considerable as to enfeeble the patient very much; the real mischief is the effect pro- duced upon the pulmonary tissue. If there be an apoplectic extravasation, the mischief is more considerable, and the secondary irritation greater than when there is simply an arterial congestion, giving to the lung a bright vermil- lion-red colour. The secondary irritation may be merely a moderate inflammatory action in in the part, or there may be in addition a tuberculous deposit; should the latter exist before the haemorrhage, the congestion of the lung is simply afavouring cause,which increases the number, and favours the growth and soften- ing of tubercles. The symptoms and mode of attack of pul- monary haemorrhage may begin in several ways. A patient may be using strong and even violent exercise, which determines a sudden rush of blood towards the lungs, and the haemorrhage then ensues,—or it may occur while the patient is perfectly quiet. Either of these modes of occurrence may coincide with tuberculous disease, but the latter is more fre- quently connected with it than the former. There is no difference in the symptoms of the haemorrhage connected with tubercles or tuber- culous diathesis, and that dependant upon other causes. The cases vary only according to the severity of the bleeding, and the previous health of the patient. 122 DISEASES OF THE LUNGS. The general symptoms are perfectly the same as those of other haemorrhages; hence they re- quire but little special attention in a lecture de- voted to pectoral disease. The heart is throb- binff and quick, its contraction is accompanied, in many instances, with a bellows sound,which is extremely loud and strong. As the haemor- rhage is almost always of an active character, the face is unduly flushed, and the capillary circulation excited. These symptoms gradu- ally decline after the flow of blood, except the action of the heart and arteries, which remains for a considerable time in its former state. The local or pectoral symptoms are more im- mediately connected with our subject. If the haemorrhage be slight, the patient complains only of a slight sense of tickling at the upper part of the trachea and the large bronchial tubes. If the haemorrhage be considerable, the tickling is more constant and severe, and a sense of op- pression is felt across the sternum, which seems to prevent the full expansion of the chest. As the haemorrhage generally lasts for some time before it finally ceases, the tickling sensation continues, and even after the flow of fresh blood has completely ceased, the coagula continue to be expectorated, and keep up the same sensa- tion of tickling, with the short irritated cough which naturally results from it. There is no pain from the haemorrhage proper; the pain, if it exist, depends only on the accidental inflam- mation which sometimes follows the haemor- rhage ; for the effused blood left in the cellular tissue of the lung may prove an irritating cause like other foreign bodies. The signs of auscultation are merely a loose sub-crepitant rhonchus, heard not only at the seat of the haemorrhage, but throughout the bronchial tubes which contain blood. The bubbles are even looser and of thinner liquid than those formed by mucus. The percussion is rendered slightly dull if there be a large apo- plectic extravasion, or much congestion of the surrounding tissue. The evidence of haemop- tysis does not rest, however, upon physical signs, but on the external discharge of blood ; and in those rare cases in which the blood is extravasated into the cellular tissue of the lungs without appearing externally, no certain con- clusions can be drawn from auscultation. The course of haemorrhage is rarely towards a fatal termination, unless the first gush of blood should prove fatal: even this is not com- mon, except in advanced phthisis, when the haemorrhage comes from a large vessel crossing a cavity, and is not the result of exudation from smaller vessels and the finer bronchial tubes. This accident is then strictly dependant upon phthisis. The treatment of haemorrhage from the lungs does not differ materially from analogous affec- tions, excepting that it is connected with other diseases of the lungs, especially pulmonary phthisis, in which case the treatment is a mere appendage to that of this disease. There is generally little difficulty in suppressing the bleeding; but after this has been brought about, our object is to prevent its return, and check the subsequent fever, which is not only attended with some danger in itself, but is a favouring cause of tubercles. TUBERCLES OF THE BRONCHIAL GLANDS. The bronchial glands are, at the early pe- riods of life, more subject to tuberculous depo- sit than the lungs themselves. This tendency to tubercle exists in the bronchial glands to a much higher degree than in any other of the lymphatic ganglia. It is highly developed in children, but gradually declines as individuals advance in life, and in old age the bronchial glands are scarcely ever affected, except as a consequence of previous disease of the lungs. The relative frequency of tubercles in the bron- chial glands of children compared with the lungs, is not less than five to four ; this is of course more than reversed after the age of pu- Derty. The development of tubercles in the bron- chial glands occurs nearly as in other solid structures of the body ; scattered points of tu- berculous substance are gradually deposited in the structure of the glands, surrounded by the original tissue, which remains for a considera- ble time nearly in the healthy state; some- times, however, it is swollen and more vascular than usual, but more frequently it is quite pale, and infiltrated with the gelatinous substance which is in many cases the early stage of tu- berculous matter. As the quantity of tubercle increases, that of glandular structure gradually becomes less, until the whole tissue of the gland is absorbed, and is replaced by tubercle. It is then much larger than the original gland, and the capsule which encloses it gradually TUBERCLES OF THE BRONCHIAL GLANDS. 12$ thickens during the process of softening. Af- ter softening has followed, adhesion occurs be- tween the glands and the adjacent large bron- chial tube, until the contained matter is evacu- ated by an ulcerated opening. In most in- stances, however, no softening occurs, bnt the tuberculous matter becomes hard and dry, and is converted into a calcareous substance, surround- ed by the capsule. This substance often becomes extremely hard and solid, and generally remains in this state during life. The tuberculous dis- ease of the bronchial glands is, therefore, much less unfavourable than that of the lungs, and is essentially curable. The symptoms of tubercles in the bronchial glands are extremely obscure. Indeed they cannot, in the large majority of cases, be recog- nized except by the signs of a general scrofu- lous diathesis. As this rarely occurs in chil- dren without a deposit of tubercle in the bron- chial glands, we may safely infer that the lo- cal disease exists, if we discover the symptoms of the general disorder. In such cases no pos- sible disadvantage results from the difficulty of diagnosis, for the disease is without influence upon the lungs. In other cases the tubercu- lous glands attain a considerable size, and press upon the trachea, obstructing the respiration, and irritating the bronchial mucous membrane. The symptoms of catarrh, however, differ a little from those of ordinary bronchitis; the cough is frequent, but occurs in paroxysms, very much resembling, in many cases, the fits of whooping cough, and, on auscultation, it is found that the respiration is extremely feeble in one or both lungs, while the percussion is quite sonorous. The feebleness of respiration is the only permanent sign, and depends upon the contraction of the larger tubes from the pressure upon them. The expirations are at times wheezing, and, as it were, protracted, but not permanently so. As these are the only symptoms of tubercles of the bronchial glands, and are by no means limited to this lesion, the diagnosis depends at last upon the comparison of these comparatively unimportant local signs with the general indications of a tuberculous diathesis. The treatment of tubercles of the bronchial glands consists entirely in those means which tend to counteract the scrofulous or tuberculous diathesis, and chiefly in the use of iodine and ve- getable alteratives. The use of these remedies shouldbe continued for a long period, if thesto-- mach of the individual be not irritated by their employment; if it should be, they must be im- mediately discontinued, and, after a time, re- newed; free exercise in the open air, and a healthy invigorating diet, are necessary adju- vants in the treatment. DISEASES OF THE HEART. LECTURE XV. General Considerations. The signs of the diseases of the heart are more easy, but less precise than those of the lungs. The structure of the heart is extremely simple, and its functions are very limited; while each of its surfaces is covered by a se- rous membrane which is the subject of much fewer lesions than the complex tissue of the lungs. The little complexity of the structure of the heart has its disadvantages for diagno- sis ; there is no expectoration from a mucous surface, and not the numerous combinations of rhonchi met with in the diseases of the lungs, which, although sometimes difficult to recog- nise, are generally sufficient to point out with great accuracy, the exact nature and seat of the lesion. So far as the signs of disease of the heart go, they are, therefore, very easy of recognition; but, beyond a certain point, they do not indicate the nature of the lesion with much precision, and the diagnosis is then ap- proximative only. The gradual researches of • late pathologists have, however, removed much of this difficulty, and although we have not yet reached precision, it is more nearly attained than it formerly was; and many disorders, such as inflammation of the lining membrane, and some valvular diseases, are now much more ea- sily recognised than they once were. This ac- curacy in diagnosis will probably extend a lit- tle further, although we doubt whether it will attain absolute perfection, so as to enable us to recognise the slighter organic lesions; this, however, is not, in most cases, of great practi- cal importance. The discovery of auscultation has probably done still more for the study of the diseases of the heart than of the lungs; that is, they were almost totally unknown, except the description of some of the pathological lesions. The symptoms of the different affections are so nearly allied, and so often obscured by those of various'disorders of the lungs that it was ex- tremely difficult to distinguish them one from the other, or even in many Cases to decide that any affection of the heart existed. The united influence of accurate observation aided by phy- sical exploration, and of pathological anatomy, has removed these difficulties as much as the nature of the subject will admit; and, as a ne- cessary result, the progress of investigation has been directed to the causes which precede cardiac affections, and to the numerous secon- dary disorders which result from them. Hence, the disease of the heart is taken as a starting point; and the secondary affections are either lost sight of, or are properly regarded as mere effects, not as separate disorders. Thus, the congestions of the lungs, and the serous effu- sions into the chest, are, comparatively speak- ing, rarely mentioned; and hydrothorax, and asthma—when they are mere consequences of heart disease—now attract little attention. The investigation as to the causes of heart disease has produced some unlooked for re- sults, and has shown very conclusively that in a large majority of cases, especially in young persons, they result directly from in- flammation ; and that even in the aged,' inflam- mation is a secondary cause which adds very much to thfe slow alterations of nutrition, which arise merely from advance in years. As the causes are now better known, the treatment of these affections has become more definite,— that is, the early treatment employed with per- severance during the early or inflammatory period, before those fixed organic lesions are formed which are beyond the reach of art. After this period our resources are more li- mited, and are strictly palliative, so far as the cardiac lesion itself is concerned, and our ob- ject is then rather to prevent the increase of the lesion and to relieve its effects upon other GENERAL CONSIDERATIONS. 125 organs, than to remove it. We regard organic alterations when fixed, and, as it were, establish- ed, very nearly in the same light as original vices of conformation, from which they differ very little. The curative treatment is then applicable only to the reactive inflammatory stage, or to the early periods of the disease, in case it is not inflammatory at its commence- ment. Treatment may then be active and po- sitive in its results. Although in those stages in which the orga- nic lesion is fixed and has become a mere pe- culiarity of nutrition, we cannot directly re- move it, the mere prevention of increase often allows the natural powers of the system to re- cover the balance to which they are perpetual- ly tending. In this way a considerable en- largement of the heart will sometimes gradual- ly diminish, until the organ is little by little re- stored to its natural dimensions. These cures, however, must be limited to those cases in which the diseased part is enlarged, and the new superfluous portion of structure may then be absorbed ; but when there is a destruction of an important part, or an entire perversion of its tissue, a cure can in no case be expected, and the treatment is then absolutely pallia- tive. Symptoms of Diseases of the Heart.— These are to some extent common to all those affections, whether functional or organic, but they vary extremely in intensity, and are by no means directly proportioned to the seve- rity or the danger of the affection.' The prin- cipal symptoms which occur in most diseases of the heart are irregular and disordered action of the organ, sometimes amounting to that de gree of violence which is commonly called pal pitation; painful or disagreeable sensations in the region of the heart; and impediments to the circulation, causing congestions of blood, and effusions of serum. Palpitation of the heart is more constant and troublesome to the patient in simple nervous disorder than in or- ganic disease; in the latter case it is usu- ally provoked only by violent exercise, or by some sudden effort. In the acute inflammato- ry cases the symptom is often totally absent. Painful sensations in the chest are very varia- ble, one of the most distressing is an acute pain felt near the left nipple, or at the extremity of the sternum; this pain, it is true, does not al- 16 ways coincide with any positive symptoms o' cardiac disease, but, in many cases, is plainly connected with a mere nervous disorder, or with dilatation, or with both these conditions combined. The pain is not accompanied with dyspnoea, as in angina pectoris, but it will sometimes extend across the chest or pass down the left arm. Both palpitations and pain are as often connected with nervous disease as with organic lesion; but this is not the case with the impediments to the circulation and their effects;"these are almost always dependant upon organic disease, or, at least, much more frequently, and to a much greater degree than upon organic lesion. They occur in muscular de- rangements of structure, as hypertrophy and dilatation, but are much more decided if the valves are at the same time diseased. As a ge- neral rule they are more severe in proportion as the valves are narrowed, so as to prevent the free passage of the blood, forcing it, as it were, backwards, and thus producing congestions and anasarcous effusion, or hydrothorax. When the symptoms of heart disease have for a long time preceded the dropsy, they maybe regard- ed as almost pathognomonic of a grave lesion, which is in these cases most frequently hyper- trophy conjoined with valvular disease. Irregularity and intermittence of the pulse attracted more notice before the discovery of au- scultation than it does at present; for although this symptom is not without its value, and in reality often attends various heart diseases, it is necessarily uncertain, and sometimes occurs during the convalescence of acute diseases in which the heart is in no wise involved, while it is a congenital peculiarity in some in- dividuals, lasting through a long life, but apt to terminate in decided heart disease. It is clearly not owing directly to the obstruction, but to the enfeebled action of the heart, which is no longer proportioned to the column of blood which it has to propel, and works in a hesitat- ing irregular manner. Now this may arise from causes totally independent of actual dis- ease of the heart, but it is more apt to occur in connection with heart disease than independent- ly of it; and in other cases where no actual dis order is developed, the chances of future affec- tions of the heart are certainly increased. Causes of Heart disease. —The inflammations of the membranes of the heart not only consti- 126 DISEASES OF THE HEART. tute a frequent form of disorder, but give rise to a large proportion of organic lesions; this is more especially the case with the inflammation of the internal membrane, for pericarditis has comparatively little influence in producing per- manent derangement of structure. The causes of these inflammations resolve themselves in those which ordinarily produce the phlegmasiae, and into the peculiar connection known to exist between them and rheumatic disease. Besides inflammation, there are, however, other causes of heart disease; the muscular tissue of the or- gan may increase in thickness from the con- stant activity into which it is thrown, and organic disease is in this way developed as a consequence of long continued nervous excite- ment. Enlargement of the heart may also arise from a sudden injury inflicted upon it, as a violent strain or effort, or some other sudden propulsion of the blood towards the organ which is strained beyond the power of com- plete recovery. The gradual advance of age has also a tendency to 'produce a slow en- largement of the heart and the formation of os- sific deposits in the valves or its internal mem- branes ; and in these cases there is at least no evidence of direct inflammatory action. The causes of functional diseases of the heart are, of course, as various as those of all nervous dis- orders, and are sometimes the most opposite in their character ; in general, the nervous disor- ders are apt to arise in cases of anemia, or of deficient muscular power, or are directly de- pendent upon spinal irritation or chronic gas- tric disorder. Terminations of Heart disease.—The acute inflammatory affections of the heart may ter- minate in recovery, and the patient may be re- stored to entire health ; but in many cases the disease gets well so far as the acute affection is concerned, but the organic lesion continues. Chronic organic affections, as a general rule, do not terminate in recovery ; they may end in death, or they may be prolonged without caus- ing more than mere discomfort to the patient, or shortening the natural duration of his life. The former case arises from the severity of the lesion, which is often sufficient to seriously im- pede the circulation of the blood ; or from the enfeebled state of the patient, and the thinness of the blood, which favours the dropsical effu- sions of the latter stages of these diseases. These aggravated cases vary in duration, bur they generally prove fatal of themselves, or they merely increase the severity and the dan- ger of some intercurrent disease, so that death results from the combined influence of the chro- nic and of the acute disease. The structure and peculiar functions of the heart increase the mortality from the chronic diseases ; they are rarely single, or, at least, do not long remain so, but tend not only to increase from the con- tinued play and action of the heart, but one will produce another; hypertrophy will give rise to valvular disease and inflammation of the endocardium, while the converse is also true, and to a much greater degree. Function- al diseases of the heart have in themselves lit- tle power in shortening life, but as they are at times causes of the organic affections, their in- direct influence is at times very pernicious. Influence of age and sex.—The age has a strong influence in favouring the development of heart disease, while the masculine sex is also not without its influence. Men are much more exposed to the causes of inflammation than women, and therefore suffer more from all the disorders which arise from it; nutrition is also more active in them, favouring, of eourse, the development of hypertrophy, and of other affections in which nutrition is in excess. As regards the influence of age, it may be readily analysed ; cardiac diseases must be proportion- ably more numerous as we advance in life; 1st, because they areof slow growth, and form, as it were, insensibly, so that they only reach their full development after many years; 2d, because the lesions of nutrition are in them- selves more frequent in the old than in the young, as is proved by the invariable and natu- ral increase of the heart as we advance in years, even if no absolute disease be developed. Males are, therefore, more subject to cardiac diseases than females, partly from the greater ex- posure to the causes of inflammation, and part- ly from the violent efforts to which the heart is subjected in many of the laborious occupa- tions of the male sex. This, however, holds good only with the organic diseases of the heart, for the nervous functional disorders are vastly more frequent in women, especially in those in whom the nervous susceptible charac- ter is most developed. General Diagnosis and Prognosis. —Although GENERAL CONSIDERATIONS. 127 accurate or special distinctions as to the precise seat of heart disease and its probable termina- tion, can only be made by studying carefully the physical conditions of this organ, and the precise part affected, there are certain general characters of heart disease which are well known in their applications to' the study of these affections. Besides the special symptoms of organic dis- eases of the heart, they are generally known by some decided signs which indicate that some serious mischief has attacked the organs. These are orthopncea, a feeling of weight and of stricture in the praecordia, fulness of the cer- vical veins, and great increase of dyspnoea in ascending a height or a steep flight of stairs. Blueness or lividity of the lips is also an ex- cellent sign. A thrilling pulse, and oedema- tous effusions are also often characteristic. The irregularity of the pulse and the violence of the palpitations are common to both nervous and organic diseases. Pain confined to a li- mited spot near the apex of the heart is much more common in nervous affections ; the same is true of a sensation of fluttering at the heart, of shortness of breath, proportionate merely to the palpitation, and differing from the violent dyspnoea of organic disease. The probability of nervous disorder is rendered much greater if the patient present other signs of a nervous tempera- ment, especially if called into action by the usual exciting causes. The mode of origin of the disease is also important for diagnosis ; if at first inflammatory, it is probably organic; or if the patient be stout and muscular, and of a family in whicli diseases of the heart are here- ditary, or the gouty and rheumatic diathesis is very strongly developed. On the other hand, both original constitution and the previous ex- istence of a disease capable of disordering the innervation, render the existence of nervous dis- ease probable. An affection of another organ, especially of the lungs, may act in the same way, and give rise to severe disease, which at times may appear to be organic, but will be quickly dissipated if the original disease be re- moved : this is very frequently the case with affections of the lungs, especially if the left lung be much indurated, and thus impede the action of the heart, and conduct the sounds and impulsion both to the ear of the observer and throughout the chest. The general prognosis of heart disease is commonly understood to be highly unfavoura- ble ; hence, in ordinary language, a person who is labouring under an affection of the heart is supposed to be incurably diseased. Thi3 is no doubt true, as regards the extreme disorgani- zation of the valves, and of the internal mem- brane of the heart and aorta, as well as very decided hypertrophy and dilatation; but it is not true of acute inflammatory affections of the heart, or of the moderate degrees of hypertro- phy, and still less of the sympathetic nervous disorders which so frequently require medical aid, and often excite the greatest apprehension. Even in those forms of disease in which a strict cure is not expected, the symptoms may, after a time, cease to increase, and even posi- tively decline, without apparently shortening life. Hence the prognosis really depends upon a special diagnosis, and is, in fact, included in it; and if the nature of the disease of the heart is once ascertained, and its rate of increase or diminution settled, the prognosis may be de- fined—provided no circumstances of a disturb- ing kind should arise. EXAMINATION OF THE HEART. The heart requires to be examined under se- veral different points of view. The most im- portant of these are its position in the thorax, and the relative situation of the parts of it; the size of the heart, as ascertained by per- cussion ; the impulsion ; the sounds, and their rhythm or succession; lastly, the mode in which the heart acts, whether in a regular or in a spasmodic, ill-defined manner. Besides these signs, which are strictly physical, we learn much as to the diseases of the heart from the sensations complained of at the praecordial region, the respiration and the impediments to it, the capillary and venous circulation, and, lastly, the surrounding disorders of the whole body, which arise from the cardiac region. 1. Position of the Heart.—In general terms, it may be stated that the heart is situated at the lower portion of the sternum, including nearly the whole breadth of this bone, and ex- tending to the left of it, a short distance with- in the nipple; in height, the heart reaches from the intercostal space between the third and fourth ribs, to the base of the thorax. It occupies, therefore, the anterior and lower por- tion of the left side of the thorax, in a definite 128 DISEASES OF THE HEART. extent, and this portion so occupied is called the praecordial region, or, in other words, the region of the heart. The exact situation of the heart, and the relative position of its different parts and valves, are readily seen by reference to the annexed plate. 2. Size of the Heart.—The size of the heart is known by two phenomena, the anormal pro- minence formed at the cartilages of the fifth, sixth, and seventh ribs, and the dulness on per- cussion, which may become greater or less than it should be in the healthy state of an in- dividual of a given fever and embonpoint. By the size of the heart we understand the whole taken collectively; hence, an enlargement of the muscular substance does not differ from the more external distension caused by effusions of pus or serum into the pericardium. When the increase in dimensions is very considerable, the chest is thrust forwards, but the form of the prominence is different; when there is an effu- sion into the pericardium it is pyramidal, the apex of the pyramid at the upper portion; when it depends upon a real increase of the muscular structure, the projection is in general less marked, but more diffused, and forms an oval, the long diameter of which extends late- rally, instead of vertically, as in the former case. The more exact mode of estimating en- largement of the heart is, however, by percus- sion. This is readily enough practised, but to render it of practical benefit, the observer should retain an accurate recollection of the average normal dimensions in an individual of the ge- neral health and condition of the patient. It is true that the general health may have a very decided effect upon the heart, as well as upon the rest of the organs, but it here suffers with the rest, and the change is limited to a slight augmentation or diminution, corresponding with that of the muscular structure in general. The real advantages of percussion are much more decided when we desire to learn the con- dition of the heart, and its state as an indivi- dual organ. To do this, we must recollect that in the healthy individual the heart is not en- tirely overlapped by the lungs, but that a por- tion of its structure, as is seen by the plate, which is chiefly composed of the anterior sur- face of the right ventricle, is in immediate con- tact with the parietes of the chest. This por- tion varies in extent, partly from changes in the condition of the heart and pericardium, partly from lesions of the lungs and pleura. Thus, without any actual change in the heart, the percussion at the praecordial region may be rendered very dull from induration of the lungs, or pleuritic effusion, while emphysema may enlarge the lungs, and render the sound pre- ternaturally clear in the region of the heart. A little attention to the condition of the lungs will in creneral obviate the chances of er- The heart itself, when diseased, often pro- duces a decided change in the results of per- cussion, which then depend upon alterations of form. In the natural state, the extent of dulness does not exceed a space of about two inches in length, measured along the sternum, and an inch and a half laterally; that is, the dulness extends to a short distance within the nipple, and about the middle of this space, just at the right margin of the sternum, it amounts in most persons almost to flatness. If the heart be enlarged, or if an effusion of liquid has taken place into the pericardium, the dulness is of course increased in proportion to the degree of enlargement or increase. When the dulness results from hypertrophy of the heart, it is more rounded in its shape than when it depends upon pericardial effusion; in the latter case, the original shape of the serous sac is still pre- served, and the space in which the dulness is most evident is pyramidal, the apex of the py- ramid being towards the upper part of the chest. The mathematical exactness of this mode of measuration is readily ascertained by a process which was very carefully pursued by Dr. Pennock a few years since; that is, forc- ing long needles at the limits of the dulness, and examining the parts perforated by them after the body was opened. Impulsion—The impulsion of the heart fur- nishes one of the least complicated sets of signs connected with this organ. It is pro- duced, as is well known, by the contraction or systole of the heart, during which the point of the organ is quickly impelled against the ribs, striking near the cartilages of the fifth and sixth ribs a little within the nipple. In the healthy state of the heart, the blow or impulse is given almost exclusively by the point of the heart; hence the sensation is sharp and decided, as would naturally be caused by the quick stroke of a small surface against the thoracic parietes. GENERAL CONSIDERATIONS. 129 If the heart is thrown into violent action by quick exercise, or by nervous irritability, the impulsion is increased in force, but the surface upon which it falls is still very limited in ex- tent ; should the bulk of the heart and the quan- tity of muscular tissue be increased, as in cases of hypertrophy, the momentum of the impul- sion is much increased, but it is diffused over a much larger surface than in the normal con- dition of the organ, and the mass of the heart is applied slowly against the chest, as it were point after point, so as to give it a heaving or waving motion, instead of a sharp, clear im- pulsion. In low fevers, and in other diseases in which the powers of life and the strength of the patient aTe much diminished, the impulsion of the heart is decidedly lessened, and its force nearly destroyed. The diminished impulsion is then a good guide in therapeutics, and af- fords us one of the first indications for a sup- porting treatment. The impulsion of the heart, it is evident, can only serve as a diagnostic sign, when the patient is still possessed of a moderate degree of strength ; hence, in cases in which the muscular substance is really much increased, the force of the blow may be so much diminished by general exhaustion that no stronger impulsion is made upon the parietes of the thorax than would result from a heart which is not at all enlarged. The sounds of the heart furnish us with one of the most important means of diagnosis, but require to be studied in the healthy state before becoming of practical use as signs of disease. The sounds of the heart are two in number, and are designated as first and second sound. The first occurs during the systole or con- traction of the heart, and is synchronous with it; it is the longer of the two, and occu- pies very nearly one-half the whole period of the heart's action, and consequently the first sound may be heard during one-half of the life of each individual. It is described as pro- longed but dull, and it may be very readily learned by placing the ear over the heart, While the hand is applied to the pulse of the patient; the vibration of the artery and the sound are perceived at the same time,although the sound of the contraction precedes a little the pulsation of the wrist, but the difference is so slight as to be scarcely perceptible. The cause of this sound is differently explained; probably it is not a single cause, but a combination of two, which may in part account for any difference of opinion. The principal cause is certainly the muscular contraction of the heart, which is abundantly capable of producing a sound, as may be verified by experiments upon the hearts of animals. Take the heart of a calf or sheep from the body after sensation has been destroy- ed, but before the animal is quite dead, and by applying a stethoscope upon it, a sound will be distinctly heard, which is identical with, al- though weaker than the first sound of the heart; in this there is of course no cause for the sound but pure muscular contraction. But in the liv- ing body it is very probable that the sound is in part produced by the friction of the blood afainst the semilunar valves of both aorta and pulmonary artery ; this cause, however, which is not so easy to demonstrate, is by no means so powerful as the muscular contraction. The second sound is the proper valvular sound, and is shown by direct experiment to be caused by the quick contraction of the semilunar valves, especially those of the aorta, which are much stronger than those of the pulmonary artery. If these valves be tied by passing a needle through them in the heart of an animal deprived of sensation, but still living, the second sound is immediately destroyed. The character of the sound is totally different from that of the first; it is very short and sharp, and is proper- ly designated by the term clacking. It follows immediately after the first, and is synchronous with the diastole of the heart; when the semi- lunar valves are diseased, or prevented from acting by the excessive turgescence of the heart with blood, the second sound is weaken- ed or destroyed. After the second sound, a period of repose, occupying nearly one-fourth of the time of each complete action of the heart, succeeds, and is again followed by the first sound. The sounds of the heart are, as may readily be seen, very regular in their succession and proportion, and when these are deranged, a disturbance of the heart's action may be fairly inferred. Should the change be very decided and permanent, the cause must nearly always be sought in the valves themselves; but if slight and temporary, it is often a mere mus- cular or functional disturbance, not dependant on organic disease. The sounds of the heart may be altered in several ways: they may be changed in cha- 130 DISEASES OF THE HEART. racter, or merely diminished or increased in in- tensity. The alteration of the sounds may be limited to a slight harshness, or the natural tone may be totally changed ; these characters, however, differ only in degree, and not in any really important respect. The first sound is most frequently altered. When simply increased in loudness, it de- pends either upon a temporary condition of the heart, that is, a simple febrile movement or nervous action, in which case the sound will after a time subside to he natural state, or it arises from a hardening of the muscular structure of the heart, perhaps conjoined with slight obstruction of the semilunar valves. In the latter case the increased loudness, or, to use an equivalent expression, the roughness of the sound may continue for a very long period. If the roughness is increased, it passes into the bellows or rasping sound. The former of these is less marked than the latter, but a bel- lows sound may be defined, and it is ge- nerally described, as a prolonged and pur- ring sound, generally heard in the fir3t sound of the heart, and therefore produced chiefly by muscular contraction, although it may arise from alterations at the auriculo-ven- tricular valves, and then it occurs during the diastole of the heart. Like all sounds, it is much more easy to point out than to describe in words. As a short definition, the term bel- lows sound, which is given to it, from resemb- ling the sound produced by blowing strongly in a bellows, is probably as good a description as any other. The bellows sound is often pro- duced by simple nervous disorder of the heart, especially in those cases in which it is connect- ed with anemia or chlorosis, and it then is very loud and almost musical in its tone ; and far from being confined to the heart, it may be dis- tinguished along the whole of the large arte- ries, especially the carotids and subclavian, by applying the stethoscope opposite to them. The pressure of the stethoscope has probably some influence in favouring the production of the sound at the carotids, but is insufficient to account for it; so that we are obliged to ascribe it to the peculiar motion impressed upon the thin and watery blood by the spasmodic action of the heart. When the bellows sound de- pends either on a hypertrophied ventricle urg- ing the blood very rapidly through a narrow or non-dilated semilunar valve, or driving it back through a dilated auriculo-ventricular opening, it is more persistent, more uniform, and is less musical, but more harsh than when it arises from a mere nervous disorder; the same character is found when the sound is heard during the diastole from regurgitation through the semilunar, or contraction of the au- riculo-ventricular valves. Still it is in many cases difficult to distingush between the bel- lows sound of mere functional disorder and that dependant upon organic disease, unless there are some other signs of a permanent lesion. The rasping sound of the heart is much rougher than the bellows sound, and is tolera- bly well described by the term which desig- nates it—resembling the sound of a rasp forced through soft wood more than any other sound. It never depends upon simple functional dis- order of the heart, but arises from some actual obstruction to the circulation of the blood, seat- ed at the orifices of the heart, and therefore de- pendant upon changes in the valves. It may arise from acute as well as chronic disease; when the obstruction is acute, it is the result of endocarditis, and the thickening of the valves is partly caused by depositions of lymph, and partly by thickening of the- fibrous tissue, which forms the body of the valve, and, as the inflammation declines, the sound will gradual- ly increase, provided the morbid product has not become completely organised, in which case the rasping sound may be permanent. The sign is scarcely ever heard during the diastole of the heart, for it requires a considerable force in the current of blood, and the act of dilatation is rarely sufficient to produce this at the valvu- lar orifices. Such is not, however, the case when the aorta is much dilated, for the reflux of the blood is almost as powerful as its for- ward current, and the rasping is therefore dou- ble, like the forward and backward motion of a saw rather than of a rasp; hence it is then called the sawing (bruit de scie) instead of the rasping sound, and is one of the best diagnos- tic characters of aneurism of the aorta. The double movement and the accompanying sound are so peculiar that it can scarcely be mistaken for any other sign. The saw-sound is heard also at times when the mitral valve or the tri- cuspid is much altered, so as to destroy its functions and convert the auriculo-ventricular opening into a rough passage for the blood. GENERAL CONSIDERATIONS. 131 Not only the sounds of the heart, but the] rhythm or succession offer points of interest for diagnosis. It i3 very clear that as the sounds are, in a normal state, separated by well marked divisions of time, a disorder of the rhythm or succession can only arise from some material obstruction to the action of the heart, and the play of its valves, or from some decided functional disorder. The latter can produce only a moderate disturbance; such as ir- regularity in the relative rapidity of the pulsa- tion, with occasional interruption of a single beat; or, at most, the heart may pulsate in an intermittent manner, a pulsation being from time to time absent, at intervals which recur with some regularity. The distinction be- tween an irregular and an intermittent action of the heart is mainly the recurrence as to time of the latter symptom, and the variableness, of the former. An intermittent pulsation of the heart is congenital or nearly so with many individu- als, lasting through a long life without much disorder of the general health ; but if we watch these individuals narrowly, we shall find that most of them at last suffer in some way from organic diseases of the heart. The temporary irregularity of the pulsation is much less im- portant. Under many circumstances it is rather a favourable symptom, and occurs frequently at the termination of acute diseases, especially of those which have a definite dura- tion, such as the exanthemata. There are other cases in which the irregularity is really a pathological symptom, but refers to ano- ther organ than the heart. This is the case with inflammations, or other diseases of the brain, which in many stages of their progress are at- tended with irregularity of the pulse. There is, however, another set of cases in which the irregular action of the heart is a sign of dis- ease of the organ itself, and if it be connected with other and more decided indications of in- flammation, or more permanent organic altera- tions, it has its value. But as in itself, ir- regularity is insignificant, the importance of the symptom in the study of heart disease is extremely slight. There is another alteration of the rhythm very different from those just alluded to, and of much graver moment. In fact, it is almost confined to organic valvular disease, and main- ly to concretions at the mitral valve: the pro- portion, as well as the peculiar character of the sounds, is then nearly destroyed, and we have a confused churning or purring sound, without any distinction of the first or second. So complete a destruction of the ordinary sounds of a healthy heart indicates the gravest lesions, and is generally connected both with dilatation of the cavities and disease of the valves. The purring sensation (fremissement ca- taire) often felt as well as heard at the region of the heart, belongs almost as appropriately to this part of the subject as to any other. It is a sign of gravity, because the total change in both impulsion and sound which accompanies it can scarcely occur without both valvular and muscular disorder, and a free passage is open- ed for the blood, which is thus broken into ma- ny currents. The regular action of the heart is broken up, because there is no longer a uni- form point of resistance, nor of repose; for the stream of blood is no longer cut off by the valves. The purring is quite characteristic of the sign, both as descriptive of the sensation of touch and of sound. Another important sign of the diseases of the heart is derived from the mode of its con- traction. Instead of the natural contraction, we may find it to be quick, jerking, and spas- modic, or it may be confused and indistinct. These are peculiarities very difficult to de- scribe, and only to be appreciated by one who has been lon^ practiced in the observation of the healthy heart. After a knowledge of the natural contraction is acquired, any deviation from it becomes very apparent. When the in- ternal membrane of the heart is inflamed, the contractions lose their sharpness and distinct- ness, and succeed each other in a confused, jerking manner: the sign is much the same in cases in which the valves are much diseased, especially when there is great dilatation of the auriculo-ventricular openings. Indeed any de- cided organic lesion of the heart modifies the natural action, and even functional disturbance of it to a certain extent produces the same ef- fect, but in a less degree, and for a less period of time. The next part of our subject leads us natu- rally to the study of the individual diseases of the heart. LECTURE XVI. Pericarditis. The frequency of pericarditis has been known only of late years. It was formerly supposed that it was a very rare disease, and attended with symptoms of great severity, terminating in most instances fatally. The late investigations have, however, proved that such is not the case, but that pericarditis is an extremely fre- quent disorder, not much more severe in many instances than pleurisy, and very often not re- cognisable by any rational symptoms. The most important of these researches were those of Dr. Louis, published in the year 1826. He then thought that the only conclusive evidence of previous pericarditis was adhesions between the two surfaces of the serous membrane, but it is now ascertained that in most instances of slight pericarditis, there is merely a deposit of white opaque lymph in patches upon the sur- face of the heart, and not an actual adhesion ; the observations of Dr. Louis did not, therefore, in all probability, include more than a very small proportion of cured cases of the dis- ease. At first, the only evidence that pericarditis was curable, depended upon the traces left be- hind it, and discovered in the bodies of pa. tients dead of other diseases ; but as the symp- toms of pericarditis became better known, it was recognised in most cases during life, and could be traced throughout its whole course unto complete recovery. As before attention was directed to the subject, it was believed that it was always, or nearly always, attended with severe and dangerous symptoms; it is now known that, in the great majority of cases, the symptoms are but slight, and that not unfre- quently it cannot be recognised; or, in other words, it is latent, except through the aid of the physical signs. There are even some slight cases in which the latter are by no means con- clusive, so that very few disorders are as often more necessary to pay close attention to those signs which can be detected, otherwise the slighter forms of the disease may pass almost insensibly into the more severe and dangerous varieties. The anatomical lesions of pericarditis are si- milar to those of other serous membranes, with slightdifferences depending npon the peculiar structure and situation of the membrane. At first the natural serous secretion is but little al tered, and is even less abundant than usual; almost at the same time, or soon after, a slight formation of lymph takes place, at first in the form of little points or dots scattered over the surface of the membrane, which gradually be- come more and more numerous, until they unite in one uniform membrane, and cover the whole surface of the pericardium. The lymph is in this stage soft, not much thicker than wrap- ping paper; when it becomes more abund- ant, certain portions sink in the form of shreds to the lower part of the liquid, and the coat- ing which remains attached to the heart becomes roughened, and assumes a honey- combed appearance, which depends upon the continual motion of the heart, and the drawing asunder of the two coats of false membrane. After the process of cure commences, the se- rum is first absorbed as in other cases of in- flammation of serous membranes, and the false membranes become consolidated into new form- ed tissue. This assumes the appearance of ordinary serous membrane when it forms par- tial adhesions between these two surfaces of the membranes ; of cellular tissue when the ad- hesion is so extensive as to block up the whole or a large part of the cavity, and prevents the passage of serum between the two opposing portions of the pericardium; of opaque white patches of firmer tissue, sometimes semi-carti- laginous which form a close adhesion to the overlooked as pericarditis. It is, therefore, the membrane, but may still be removed from it by PERICi strongly scraping with a knife. or lastly, of a simple opacity of the membrane depending not upon a deposit on its surface, but on the effusion of new matter in its substance, or be- neath its adherent surface. The process of absorption, after the more acute periods of the inflammation are passed, is generally more slow than that of effusion; but if there is little lymph, and a large propor- tion of serum, it sometimes takes place with great Tapidity. If the quantity of effused li- quid continue to increase, the disease generally terminates fatally, from the excessive dyspnoea and the impediment to the action of the heart. If the disease pass into the chronic form, the condition of the liquid is changed, and be- comes gradually purulent, as in other cases of serous inflammations. • The injection of the vessels of the pericar- dium is similar to that of other serous mem- branes. At first it is confined to a few dots and arborizations in the membrane, but gradually increases, until nearly the whole surface is of a bright arterial redness, covered with a fine vascular net-work. If these vessels be minute- ly examined, they will be found to be situated in that part of the serous membrane which ad- heres to the cellular tissue ; the serous surface is still smooth and nearly transparent; in the same stage the lymph may be removed from the surface, and leave it transparent until adhe- sions begin to form; then the transparency and smoothness of the surface are gradually de- stroyed; and blood, and afterwards vessels, are formed in the lymph, and inosculate with those of the membrane. It is evident, therefore, that the question whether the serous membrane is really thickened or not, depends merely upon the application of the term membrane ; if it be confined to the external layer, it is very certain that it is not rendered opaque until a late period of the disease; but there is an actual thicken- ing of the internal or adherent layer. The inflammation of the pericardium is not in general of a tuberculous nature; this com- plication is, however, occasionally met with, and the anatomical characters are then quite similar to those of tuberculous pleurisy. Pericarditis, like other pectoral affections, is recognized in part by local and physical, and in part by general symptoms. The physical signs of pericarditis are quite as conclusive as those of any other pectoral affection, when well 4.RDITIS. 133 developed; but when the disease is slight, and attended with but little serous effusion, they are often insufficient for accurate diagnosis. These cases, however, constitute but a small proportion of the whole number. The signs depend upon the physical properties of the ef- fused liquid, and the changes in the action of the heart proper. As the physical lesions are greatest in those cases in which the liquid is most abundant, the signs are then the most decided. They are as follows: 1. Signs of conforma- tion. The liquid, if in large quantity, will of course distend the walls of the chest, and give rise to a fulness in the praecordial region. This is rather pyramidal than oval in shape, and ex- tends from the diaphragm, or base of the chest, to the third rib, if the quantity of liquid amount to a pint or more ; laterally the fulness extends to the nipple, or a short distance beyond it. The rise is very gradual; hence it requires careful inspection, in many cases, to disco- ver it. 2. Percussion. The evidence furnished by this mode of investigation is much more con- clusive. If there be a decided prominence in the praecordial region, the percussion is of course flat to the same extent; for the promi- nence depends upon an effusion of liquid be- tween the walls of the chest and the heart, thus forcing the lung aside, and destroying the healthy resonance of the chest. Percussion is, therefore, of immense value in those cases in which the effusion is large; but when there is little or no liquid, and the effusion consists almost entirely of lymph, there is comparatively little dulness, at least no more than would be caused by a heart moderately hypertrophied. 3. Auscultation. The necesssary effect of a large effusion of liquid is to compress the heart and impede the freedom of its action; the organ is also removed to a greater distance from the walls of the chest, which, of course, makes the sound less distinct to the observer. Hence the natural effect of pericarditis is to render the sounds of the heart distant and feeble; in some cases to so great an extent that they can scarce- ly be distinguished. The sounds are most feeble in those cases in which the effusion is greatest, for if there be lymph and no serum, the diminution of the sounds is much less per- ceptible, and, in some cases, the first becomes really louder, but more or less altered, and of a LRDITIS. 134 DISEASES OF THE HEART. bellows or rasping character. The bellows sound is, however, rarely produced by pure pe- ricarditis, but depends, in most cases, upon the inflammation of the internal membrane, though not in all, for any great disturb- ance of the action of the heart may give rise to a bellows sound. The rasping sound is not found in pure pericarditis. The sounds of the heart gradually resume their ordinary distinct- ness as the inflammation abates, and the effu- sion is absorbed. In certain stages of pericarditis another sound occurs, which is similar to that heard in pleurisy under the same circumstances ; it is a slight friction sound, compared by some wri- ters to that produced by the bending of two pieces of new and rather stiff leather. This de- scription is as exact as any other, and if atten- tion be paid to the termination of the systole, and the commencement of the diastole of the heart, it will be readily detected when present. At first it requires some attention to distinguish the creaking from thepropercardiac sounds, for it is not very loud in many instances. In other cases it is so distinct as not only to be readily heard, but even to communicate to the hand a decided quivering sensation. The sound may of course occur either in those stages of peri- carditis where the liquid is almost absorbed, or in the early stages of the disease, when no se- rous effusion has taken place. The local symptoms of pericarditis, other than the physical signs, are extremely irregu- lar ; in many cases the pain, which is often so severe in inflammations of the serous mem- branes, is totally absent, hence pericarditis has been so frequently overlooked ; or the pain may be limited to a very slight feeling of unea- siness, not causing any decided suffering. In a few cases the pain is much more severe, and may become extremely acute, oppressing the action of the heart, and preventing the free mo- tion of the organ; these cases are the severe ones which at one time passed as the type of pe- ricarditis. The dyspnoea is extremely variable, but, as a general rule, is much more moderate in simple cases than in those which are com- plicated with inflammation of the internal mem- brane of the heart. As the symptom is not at all limited to pericarditis, it is of little value in diagnosis, and does not often reach an intense degree, except in those cases in which the in- flammation is not only extended to both mem- branes of the heart, but includes the lungs or their membranes. Cough is a symptom which is rarely ab- sent in the inflammations of the serous mem- branes of the chest, but it is very slight and short in all of them, and especially in pericar- ditis, which, of course, involves the lungs on- ly indirectly, and has comparatively little ac- tion on the bronchial mucous membrane. The local signs of pericarditis are, therefore, remarkable for their great irregularity and total want of proportion with the progress of the in- flammation or its extent In this respect, pe- ricarditis resembles other serous inflamma- tions, and is even yet more uncertain in its symptoms. The general symptoms are still more obscure; indeed, no diagnosis can be made from them. In all serous inflammations they are not propor- tioned to the severity of the local disease ; and in pericarditis, the connection of the organ affect- ed with the pulse destroys the value of the symp- soms dependant upon it. Obscure and doubt- ful as it is, the pulse is the only one of the general symptoms which furnishes a guide in pericarditis; the thirst, the loss of appetite, and cerebral symptoms are completely secondary, and often totally absent; when present, they depend merely on the degree of fever, and are strictly proportioned to it. They may, there- fore, be properly passed over without special notice, unless in a monograph which must con- tain all the symptoms met with in the course of the disease. The circulation may be perfectly regular, and present nothing anormal, both in the arte- ries and capillary vessels. In a number of cases of pericarditis, especially if of a sub- acute or scrofulous kind, the pulse does not rise above eighty in the minute, and is soft and regular, while the capillary circulation is equa- ble, and the face scarcely flushed. In other cases of pericarditis, a different effect is pro- duced upon the circulation, the pulse is ex- tremely irregular and very small; these cases are, it is true, generally complicated with en- docarditis, but this connexion is not invariable, for pericarditis itself will sometimes so much impede the action of the heart, that the pulse is scarcely felt. Between these opposite condi- tions of the pulse, there are many intermediate degrees, and often slight irregularity ; but, as a general rule, the pulse is smaller than in most PERICARDITIS. 135 other inflammatory diseases, because there is a direct impression made upon the muscular action of the heart. The capillary circulation is at times much loaded, and the face extreme- ly flushed, or even livid, as in other cases in which the circulation through the heart and lungs is much impeded. There is, therefore, nothing peculiar to pericarditis in this condi- tion of things ; but, on the contrary, as the va- riety of symptoms is great, and as the differ- ence in their intensity is such that the disorder varies from a really trifling and latent affection to one attended with the greatest oppression and the most intense anguish, we are obliged, as has been already stated, to look to the phy- sical signs as the only certain means of diag- nosis. The other symptoms serve to confirm or to limit the diagnosis, but cannot form the foundation for it. The prognosis in pericardititis is in general favourable, a very small proportion of cases proving fatal. The exact number cannot be ascertained with accuracy, because so many of the slighter varieties pass unnoticed. Taking the severe and mild forms together, five per cent, would probably be a near approach to an accurate estimate of the fatal cases. The effects of pericarditis are not in general productive of much ultimate mischief, if the disease is not complicated with endocarditis. In this case the real mischief depends upon the latter affection, which leaves behind incurable affections of the valves of the heart. If the pericardium be but slightly inflamed, no possi- ble mischief can result from the slight deposit of lymph or opacity upon its surface; but if the inflammation be extensive enough to leave behind considerable adhesions, they will, to some extent, impede the action of the heart, and thus may favour the formation of organic muscular disease. The causes of the disorder are either those of ordinary serous inflammations of the chest, or acute articular rheumatism. The latter dis- ease is the more frequent cause of those severe varieties in which there is much pain and other obvious symptoms; but the slighter cases are generally produced by exposure to cold and damp. The renewal of the causes of the dis- ease is apt to produce a repetition of the attacks, until at last the inflammation becomes compli- cated with endocarditis, or organic alteration of the heart. The treatment of pericarditis is simple, more so, perhaps, than of pleurisy, as the extent of surface involved is less considerable, and the membrane is removed to a very little distance from the surface, which renders the action of local depletion much more certain. The treat- ment in severe cases which are generally com- plicated with endocarditis must be extremely active; that is, a large and full blood-letting should be followed by a free cupping or leech- ing within an hour or two, provided the pa- tient has reacted. If the patient had been in pre- vious good health, and the circulation of the skin active, I prefer cups ; under other circum- stances leeching is necessarily prescribed in pre- ference. The uneasiness is generally relieved, though rarely removed by these first applica- tions. If the pericarditis predominates, it will then be better to continue local bleeding by re- peated applications of cups, instead of venesec- tion; but if the inflammation of the internal membrane plays a prominent part, repeated venesection is often necessary in the early pe- riods. In no disease can we trace the power- ful and immediate effect of cupping so clearly as in pericarditis ; the effusion often diminishes immediately, and the action of the heart be- comes fuller and more equable. The greatest benefit does not appear, however, in those cases in which there is much effusion, but rather in the early or dry stages of pericarditis, when there is merely intense vascular excitement, and some secretion of lymph, but very little serum. If the effusion be large, blisters are a much more effectual means of removing it than cups, or any other vascular depletion. They exert the same power in pericarditis as in other cases of serous effusions, and tend, at the same time, to check the further progress of the inflamma- tion, and favour the absorption of the effused fluid. If the disease become chronic, they may be re-applied at short intervals. The internal medicines are generally less potent than those applied externally. They differ little from those used in other serous in- flammations; the most powerful are, of course, the preparations of mercury, pushed so as to produce a rapid ptyalism. In my own prac- tice, I have preferred the combination of calo- mel, ipecacuanha and opium, to any other form. 136 DISEASES OF THE HEART. The ipecacuanha and opium are soothing, and tend to give temporary relief to the patient, while they do not interfere with the action of the mercury, which is the strictly curative agent. The usual dose is a grain of calomel and one of ipecacuanha, with a quarter of a grain of opium, every two hours. If the dis- ease is not violent, the mercury need not be given so frequently. With the commencementof ptyalism, or just before it, there is usually a de- cided diminution of the symptoms; and often ara- pid absorption of the effused liquid takes place. Digitalis has long been used in the treatment of pericarditis; and with considerable advantage in the chronic forms of the disease, when there is much liquid of a thin serous character. In cases complicated with endocarditis, the digi- talis also acts well; but it is so difficult to produce a full and rapid action of the remedy, that it is not safe to trust to it, except as an aid to more efficient means. Tartarized antimony is also of benefit; but as its action is less cer- tain than that of mercury, it should be used only in connection with it, to favour its action, or to diminish the activity of the circulation before the mercury has had time to produce a full impression. Like the digitalis, it is not fitted for those cases in which the internal membrane of the heart is involved. These measures will generally succeed in violent cases of pericarditis; the slighter ones are relieved by the same treatment, and, in- deed, terminate favourably under almost any circumstances. The hygienic measures necessary in pericar- ditis are simple enough. Entire rest, absti- nence from all stimulants, and almost from food, with a careful avoidance of mental emo- tions, are necessary in the acute cases. Even in the less violent or more chronic varieties, the patients should carefully avoid such exci- tants as act especially upon the heart. The treatment of chronic pericarditis differs but little from that of the acute. General blood- letting is, however, inadmissible, except in a few rare cases, in which the excitement rises nearly to acute inflammation. Repeated cup- ping, blisters, and occasionally other counter- irritants, are more useful than any other reme- dies. The repeated, but careful administration of digitalis, is, in this case, of more benefit than when the disease is more acute. Lastly, mercurials in small doses will generally com- plete the cure. LECTURE XVII. Hypertrophy < The heart, like all hollow organs, is subject to thickening or hypertrophy. The disease is rather one of slow nutrition than of any ac- tive disturbance, never occurring in a very short time, and resulting either from the effects of various acute diseases which have left more or less permanent lesions after them, or from some long continued stimulant acting slowly upon the organ. Hypertrophy is divided into three varieties, The first, or simple hypertrophy, is that in which the thickness of the muscular tissue is increased, without much alteration of the valves, or dilatation of the cavities. This va- riety lasts for a very long period, and in many cases seems scarcely to shorten the life of the patient, or to produce much disturbance of the functions. It is rather a favourer of diseases of other organs than a cause of death by the derangement of the action of the heart. The second variety is neither common nor very im- portant. It is termed concentric hypertrophy : the thickness of the walls of the heart is in- creased, but only in the interior, so that the size of the whole organ does not appear at all or, at least, much greater than usual, while the walls are found to be much thickened if they are cutinto.and the cavities proportionally diminish- ed, the thickening taking place mainly at their expense. If this lesion is carried to a great degree, it will produce a decided impediment to the circulation ; but, practically, this degree of alteration is rarely met with. The third and last variety is hypertrophy combined with di- latation, the most severe and the most intracta- ble variety of this disease. The danger partly arises from the direct effects of the lesion, and partly from the complications which generally precede and aggravate the hypertrophy. Like the other, this variety is slow in growth, but from time to time it takes on a sudden and ra- of the Heart. pid increase from attacks of acute inflamma- tion of its serous membrane. The anatomical characters of hypertrophy va- ry so far as the size and conformation of the heart are concerned ; but they possess several characters in common. The tissue of the heart is not always increased in thickness, but it be- comes harder and more resisting than the natural muscle,—in some cases nearly as firm and as difficult to cut as cartilage. The colour of the heart is redder than usual, and even in those cases in which the patient has become anemic, the redness persists for a very long period after the other tissues of the body. The shape of the heart remains nearly natural in concentric hypertrophy, but in the simple, and still more in the dilated variety, the organ becomes more rounded, and approaches to the spherical form. Causes.—These vary according to the nature of the lesion. In the simple variety the cause is generally mild and slow in its action, pro- ducing a gradual increase of nutrition. Some- times the heart is disproportionately large from original conformation, or from some unknown cause acting in early life; but in general no variety of the disease occurs until puberty, and the proportion of cases becomes greater and greater as the patient advances in life. Active muscular exertion, especially if conjoined with powerful action of the muscles of the chest, which impedes the respiration and circulation, frequent attacks of slight muscular rheuma- tism, nervous disorder of the heart, and acute inflammation of the organ badly cured, may all give rise to this variety. The causes of the second are unknown, but they are more fre- quently referrible to inflammation, or to slow rheumatic attacks, than to any other. The third variety is nearly always more or less de- pendent upon inflammation; sometimes it com- 13S DISEASES OF THE HEART. mcnces during an attack of endocarditis, but in most instances it is caused by the obstruc- tion to the circulation which results indirectly from the valvular thickening occurring during the acute attack. The heart is thrown into violent action by the effort necessary to force the blood through the thickened valves, or to repel it backwards when the opening is per- manently dilated. There are other cases, al- though less frequent, in which no acute cause can be discovered, and the hypertrophy results either from long continued muscular efforts, or from slowly acting irritation, especially gout or muscular rheumatism. Signs and Symptoms. The physical signs of hypertrophy are generally quite conclusive. In the simple varieties, they belong exclusive- ly to the lesion itself, but, when the heart is dilated, the signs are more or less mingled with those of valvular disease and of dilatation. In simple hypertrophy we have three well-de- fined physical signs : the first of these is the increase of the impulsion. The force of im- pulsion depends partly upon the quantity of muscle, and partly on its power or activity; and, as in hypertrophy, the size is necessarily increased, while the tissue of the heart be- comes stronger and firmer, there is necessari- ly an increase in the power of impulsion, which is only lost when the energies of all the mus- cles decline on the near approach of death. The impulsion is not only increased in force, but in extent, the heart evidently applying it- self over a larger surface, and raising itself gra- dually against the ribs with a heaving motion, which is totally different from the short, quick stroke of nervous or functional disturbance. In other words, the observer feels that there is a positive increase of momentum dependant upon a large mass pressing against the walls of the chest. In all the varieties of hypertro- phy the increased impulsion forms one of the most characteristic signs, but it is of course less in the concentric than in the other varie- ties, in which the size of the organ, considered as a whole, is increased. It is greatest in some cases of hypertrophy with dilatation, in which the walls of the heart are excessively thick- ened. The increased force of impulsion may be readily calculated by a reference to a nor- mal and a hypertrophied heart; in the natural state the thickness is not usually more than a third to half an inch measured at the middle of the left ventricle, which we generally take as the standard. The normal thickness of course varies, just as that of any other muscle of the body, depending upon the general development of the individual, the sex, stature, &c. Hence the heart is rather thicker in males than in fe- males, and in those who have followed la- borious employments than in persons who have led an idle, inactive life; in the well-nou- rished, than in those whose digestion is im- paired, or diet insufficient. The mode in which the impulse is formed is also peculiar; instead of a short decided stroke, it is heaving; that is, point after point of the heart is applied against the walls of the chest, which gives to the observer the sensa- tion of a large massive organ, and not simply increased energy and rapidity of blow. As the total size of the heart is greater in hypertrophy with dilatation than in any other variety, the heaving motion is then of course most percep- tible. The sounds of the heart are more or less changed in hypertrophy : even in the most simple variety the sounds become less sharp, especially the second, and the first is more or less prolonged, approaching insensibly to the bellows sound. In some cases the second sound disappears entirely; in others it retains its natural distinctness; and in the third variety it may even become louder than natural; for, as the necessary effect of dilatation is to in- crease the loudness and sharpness of the se- cond sound, the deadening effect of the hyper- trophy is more than neutralized. In such cases we often find a prolonged and rough bellows sound, while the second is clear and distinct, but the valves must of course remain in the nor- mal condition. The degree of hypertrophy may also be mea- sured by percussion, and by the prominence which is almost always produced after a time. The prominence is most readily formed in young persons whose cartilages are elastic, and yield readily to the long continued effects of the heart. Like the enlarged heart, the pro- minence is more or less oval in shape, and is of course much greater in those cases in which hypertrophy is conjoined with dilatation, than in the simpler varieties. The results of per- cussion are much more satisfactory; not only do we ascertain the actual limits of the heart, but we can, with much accuracy, ascertain if HYPERTROPHY OF THE HEART. 139 the thickening is great at the centre of the or- gan. In such cases the dulness of sound is replaced by complete flatness over the centre, and although the extent of dulness which is naturally observed may not be increased, it may become so much more evident, and so much greater in degree, that our diagnosis is equally sure. In cases where there is no dilatation, the degree of dulness at the centre of the heart is a much better indication than the mere ex- tension of it. The sensations felt by the patient in the chest are at times a good guide for the diagnosis. If the chest should happen to be narrow and the heart more or less compressed, the strong im- pulsion is proportionably much more distress- • ing to the patient, who then complains of the violent throbbing; but a full, capacious thorax with firm ribs, is by no means so apt to feel the impulsion, and the thickening may go on to a great degree without causing much unea- siness. Besides the palpitation, there is often much suffering from dyspnoea, which arises, partly from the difficulty in expelling the blood from the heart, if the auriculo-ventricular valves should be patulous, or the semilunar valves contracted, and partly from the secondary ef- fects of this impediment, which congests the lungs and prevents their full expansion. Pains are also complained of from time to time; these are directly dependent upon the disease, and are vague and wandering, sometimes extend- ing down the left arm, as in other diseases of the heart, or they are secondary, and depend upon the accidental attacks of inflammation of both serous membranes of the heart, which are almost sure to recur from time to time. In many patients there is scarcely pain, but merely a vague sense of uneasiness, at times scarcely felt, at others more resembling that of a weight pressing at the region of the heart. The vascular system is necessarily affected in cases of hypertrophy. The arteries are strong- ly distended by the powerful action of the en- larged heart, unless the aortal valves are con- tracted, when the pulse may become small and irregular; this, however, results from the latter cause, and not from the hypertrophy it- self, which always tends to increase the firm- ness and fulness of the pulse. The capillary system feels the impulsion as-well as the arte- rial, and congestions often occur at different parts of the body; hence the subjects of hy- pertrophy are liable to haemorrhages, especial- ly from the nose and the lungs, to haemorrhoids, and to apoplexy of the brain and lungs. The haemorrhages become less frequent as the strength of the patient declines, and the conges- tions connected with them become more passive in their character; but in the early periods of the disease the natural effect of a strong impulsion of the heart is nearly always perceptible upon the capillary system. The passage of the blood through it becomes obstructed, and ex- ternal haemoirhage is a natural mode of relief; but if internal, though a similar effort of nature to relieve the vessels, it is often a cause of death. The veins are very little distended in simple hypertrophy; like the rest of the vascular system, they are generally well sup- plied with blood in the early stages of the dis- ease, but they do not present any marked pul- sations unless the tricuspid valve should yield to the continual stretching of its fibres, when regurgitation is apt to take place, and, of course, pulsation of the veins follow. The dilatation of the valve is most apt to occur in the third variety of hypertrophy, because it must participate after a time in the general en- largement or the cavities of the heart. The disorders of other organs than the heart nearly all depend upon the anormal condition in which the whole vascular system is placed ; and result mainly from the fulness of the ca- pillary system. Thus cephalalgia is a very frequent accident; when it occurs, it is usual- ly contusive, deep seated, and accompanied with giddiness, flushing of the face, and other signs of active congestion. But as soon as the blood has become watery, congestion of the brain scarcely takes place except after ex- ercise, or other causes which excite the circu- lation. Absolute rest will almost always pre- vent it. The tendency to congestion of the lungs has been already mentioned as a thoracic symptom : still it is secondary to the disorders of the heart proper, and only indirectly con- nected with the disease. The viscera of the ahdomen rarely escape. The disorder of the liver is much more frequent than that of any other organ of this cavity; in its simplest form it is a mere engorgement, the distension of the vessels of the organ arising from the difficulty in the venous circulation; hence the organ enlarges, is indurated, and of 140 DISEASES OF THE HEART. course interferes with the due performance of digestion, and, to a certain extent, impedes res- piration. But if the engorgement continue, the usual change in the condition of the liver takes place, its nutrition is deeply altered, the acini in part enlarge, and become indurated, and in part are pressed upon by those which are already increased in size ; it loses the deep-red colour of early congestion, and assumes a yel- lowish tint; in other words, decided cyrrhosis is formed. The symptoms proper to the liver, as jaundice, &c., are often developed, and the case might be mistaken for one of original dis- ease of this organ, unless the attention is drawn to the history of the symptoms and their evident starting point in the heart itself. Fla- tulence is apother frequent symptom; it seems to arise from the disordered digestion which often accompanies hypertrophy, and is more marked than in other affections, because the im pediment to the action of the heart, which arises from the distended abdomen, causes extreme dyspnoea. The kidneys frequently participate in the disorder; generally they are not diseas- ed until the liver has previously suffered, and the affection then becomes a triple one, which is almost always followed by dropsical effusion much earlier than the uncomplicated disease of the heart. The disease of the kidneys ends, if it does not begin, by the peculiar alteration of the cortical substance known under the name of granular degeneration, which is singu- larly analogous to the cyrrhosis of the liver, and seems to depend much upon the same causes. Progress and termination.—In most cases, hypertrophy, if once developed, especially if of the least simple kind, tends to pass to a more advanced stage, and the progress of the disease is, therefore, towards a fatal termination. This is almost always the case, unless the patient remains for a long time at perfect rest; death may then take place in one of the two ways, either suddenly, or more slowly, from gradual exhaustion and dropsical effusions. In the simple varieties, the progress of the disease may be arrested, and, at most, it is so slow that it scarcely shortens the ordinary duration of life, unless it should produce some seconda- ry disorders of other viscera. Diagnosis and Prognosis.—This evidently depends mainly on the physical signs ; for, all though the oppressive palpitations and disa- greeable sensations of the patient, are all more or less indicative of the disorder; none of these signs are sufficient; even when taken to- gether, they are rather uncertain. The physi- cal signs depending on measurement of extent, and of impulsion, are much more easy and cer- tain, and can rarely lead into error. The chances of mistake are, in fact, reduced almost to nothing, if the physician examine the patient at several times, and find that the signs vary but little. For the strong impulsion of a hy- pertrophied heart is very different from the quick jerking motion of one that is merely ex- cited by some temporary functional disturbance. The prognosis of hypertrophy is so completely dependent upon the progress of the disorder as to require very few remarks. If the patient retain a full vascular system, without suffering from extreme dyspnoea on moderate exercise, and without a constant tendency to visceral en- gorgements, the prognosis is least unfavoura- ble. If he become anemic, and still suffer from much palpitation and oppression, the prognosis becomes extremely grave, for the strength declines while the local disease con- tinues unabated. The rapidity of increase of the heart, and the ossification of the coats also increase the danger, especially if the latter occur in the valves of the heart, as well as in the arteries. Treatment.—Hypertrophy being either ori- ginally a disease of nutrition, or becoming so after a previous inflammatory disorder, it is very clear that no active antiphlogistic treat- ment can be decidedly curative. Indeed all treatment is simply moderative, designed to check the stimulation of the heart, and allow the natural powers to recover themselves, and, if possible, to regain the balance which is lost. The principal indication is/therefore, to keep the heart as quiet as possible, by withdrawing all unnecessary stimulants, and by moderating that excess of action and of nutritive life which it has already acquired. Many of our most important means are, therefore, strictly hygie- nic, and these are amongst those whose utility is unquestionable. A patient who is affected with hypertrophy, must be informed that no sudden cure is possi- ble, and that the amelioration of his symptoms must depend in a great measure upon the ener- gy of his will, and his perseverance in watch- ing the influence of stimulating agents upon DILATATION OF THE HEART. 141 the heart. He should carefully avoid all ac- tive violent exercise, all extreme mental agita- tion, the use of stimulating drink, or of an ex- citing highly animalized diet, coffee, tobacco and other nervous excitants, amongst which ex- cessive venereal indulgence is one of the most pernicious. Moderate exercise by walking, driving, or riding at an easy pace, is not to be forbidden, except for a short period during some temporary excitement of the heart, and the diet should not be extremely rigid ; it must be plain, but sufficient, with animal food in moderate quantity once daily. In moderately severe cases, the hygienic treatment, with the occasional application of cups to the region of the heart, will best ensure the comfort of the patient. Cups may be used whenever the action of the heart becomes op- pressed, or its impulsion decidedly increased. General blood-letting will produce relief under the same circumstances, and is habitually re- sorted to by many patients ; but there are some decided objections to its employment. If pre- scribed frequently for the relief of slight car- diac disturbance, it must be again resorted to whenever the necessity returns; and it will be required more and more often as the patient becomes more feeble, and the blood less rich ; for it is a general law, that venesection will re- lieve a chronic disease of the heart by lessen- ing the quantity of blood which obstructs the action of the organ, while it increases its irrita- bility, and enfeebles the patient. It is, there- fore, really a necessary evil. The objections to the use of cups are by no means so strong, nor does the application of them produce the same necessity of frequent repetition. In all cases in which the disease is not po- sitively active, we restrict our remedies to those just mentioned, but from time to time the hy- pertrophy seems to advance rapidly, the pa- tient suffers more, and the throbbing is almost incessant. This results from accidental in- flammation, or from temporary excitement. Bloodletting is then sometimes necessary to relieve the oppression, but it must be regarded as a purely temporary remedy, not to be re- peated unnecessarily, or carried to a large amount. After a moderate bleeding to dimi- nish the violent throbbing of the heart and ar- teries, the patient should keep as quiet as pos- sible during the attack, not taking active exer- cise of any kind. By these means the tem- porary excitement may in general be speedily removed. The use of digitalis is at times indicated, but, like bloodletting, it is better adapted for the re- moval of temporary attacks of palpitation and excitement, than for the radical cure of the disorder. If it be administered for a long period, it either loses, in a great degree, its peculiar control over the heart, or it must be urged to an extent which is dangerous, from the uncer- tainty of its action when accumulated in the economy. For these reasons I have in a great measure abandoned the digitalis as a perma- nent remedy, restricting it to a few cases in which it acts powerfully, in small doses; and even in these cases I prefer giving it with assafoetida or camphor, to prescribing it alone. But when the hypertrophied heart is excit- ed, either from inflammation or other causes, digitalis is safe and highly useful as an adju- vant to more certain antiphlogistic means. It may be prescribed in the usual doses of ten drops of the tincture four times a day, or two- thirds of a grain at the same intervals. I have never in these doses seen any inconvenience re- sult from it where its action was watched. The infusion as usually prepared is extremely un- certain, but if it be made carefully, and of given strength, with the addition of a sufficient quantity of sugar to make it into a syrup, it is preferable to the tincture. After the tempora- ry excitement of the heart is quieted, the digi- talis may be laid aside for a time, and again resumed when a lilce necessity arises. The object, then, of the treatment, is to re- move the causes which increase the tendency to hypertrophy ; to keep the heart as quiet as possible, and to arrest the causes which hasten the progress of the disease by giving a new activity to the growth of the heart. The clothing of the patient must be carefully at- tended to ; without being oppressively warm, it should obviate as much as possible the rheu- matic attacks which favour heart diseases* DILATATION. This is enlargement of the cavities of the heart. One variety of it is, as we have alrea- dy seen, connected with thickening of the pa- rietes of the heart, and is, therefore, properly considered as belonging to hypertrophy rather than to dilatation; but it also occurs as a dis- 142 DISEASES OF THE HEART. tinct lesion, and then the parietes of the heart are in general not only free from thickening, but are rather thinner than natural. It is in itself by no means a formidable disease, but as it often is connected with different organic lesions, or with embarrassing nervous disorder, it may indirectly prove to be a source of great annoyance and even danger to the patient. The causes of dilatation are nearly the same as those of hypertrophy, but, in the latter dis- ease, the general state of the individual is more disposed to active nutrition of a semi-inflam- matory kind, while in dilatation the force of resistance of the heart is in a great degree lost, and the organ becomes thinner and weaker. Hence it is more frequent in anemic individu- als, especially in chlorotic girls, than in any other class of persons, just as hypertrophy is most frequent in males. The tissue of the heart is paler and more flaccid than in thicken- ing, and there is very rarely that complication of endo or pericarditis which renders the mem- brane of a hypertrophied heart so often opaque and thickened. The degree of dilatation is very various ; it never, in the simpler variety, reaches nearty to the degree observed in the cases complicated with hypertrophy, for the plain reason, that the powers of the mus- cular structure of the heart would yield to the continued, stretching unless it were increased in thickness : hence there is a natural law of the economy that a dilated hollow organ tends to hypertrophy. Dilatation then often ceases to be simple, from the natural operation of this law. The organic lesions most frequently conjoined with dilatation, are the disorders of the valves, especially the auriculo-ventricular. These are more frequently extreme patescence than thickening and contraction, and in some cases of dilatation the symptoms begin so sud- denly, and with so much force from the first, that it would seem that one or more of the chordiae tendineae had given way, producing a sudden inability of using the valves. Symptoms.—The physical signs are less marked than those of hypertrophy. The per- cussion is rarely dull to the same extent, as it depends merely upon the blood contained in the heart, and not on the addition of solid mus- cular structure: it must, however, necessarily be more dull than usual, and the dulness will extend over a greater space. There is no pro- minence, for the heart has not force enough to act upon the ribs and oblige them to recede. The chief signs, however, of dilatation are the changes in the sounds of the heart. The thin- ness of the parietes increases the sharpness and loudness of the first sound, much as the thickening of hypertrophy renders it dull and less distinct; it therefore approaches, to a cer- tain extent, the sharpness of the second sound. The latter is also increased, and becomes much more clacking than it is in the healthy heart. The rapidity of the heart's action is in most cases increased, sometimes to a very great de- gree, and slight causes produce palpitation. Pain is not unfrequently complained of by the patient; sometimes it is sharp, but in ge- neral it is like the pain in most cases of orga- nic disease of the heart, that is, dull and indis- tinct. When the pain is most severe, the case is generally complicated with functional dis- ease of the heart. The disturbances of the ca- pillary circulation of various organs, which are so apt to occur in hypertrophy, rarely take place in simple dilatation, so that the vascular symptoms of this disease are less evident. General Symptoms.—As dilatation occurs chiefly in individuals of a nervous tempera- ment, often more or less anemic, many dis- turbances are apt to occur in the nervous con- dition of the patient; hence neuralgia, in its various forms, and hysteria are frequent com- plications. There is no other symptom pro- perly dependant upon the disease, but a large number of functional disorders may either pre- cede or accompany it, and modify the action of the heart. Hence complications of this kind are purely or nearly accidental. The most im- portant is the general feebleness of the patient; as long as this continues, the action of the heart is rarely restored to its normal state, for the functional disturbance keeps up, as it were, the symptoms of dilatation. Diagnosis and Prognosis.—The diagnosis of dilatation, and the organic diseases of the heart, is not very difficult, but it is often ex- tremely embarrassing to decide between it and nervous disorder, that is, to ascertain how much of the symptoms is owing to each of these causes. The distinction depends on the signs of dulness found in dilatation, and the perma- nent loudness of the sounds of the heart; still it will often be exceedingly difficult to decide whether a heart which is the subject of great functional disorder is dilated or not. A hasty DILATATION opinion must not be formed under such cir- cumstances; but by attention to the progress of the disorder, its true character will be de- veloped. In this as in other diseases of the heart, the functional affections are more or less temporary, the organic alterations are much more permanent, and although they may sub- side for a time, they do not entirely disappear unless a real recovery should occur. The prog- nosis of the disorder offers little of interest; it is scarcely fatal of itself, but as connected with other disorders, it may undoubtedly ex- ercise a certain agency in favouring and has- tening their progress. A patient scarcely ever dies of simple dilatation. Treatment,—In dilatation, as well as in hy- pertrophy, the treatment is not active, so far as our means of acting directly upon the heart extend. Our object is to tranquillize the action of the heart, and to support the strength of the patient, if, as often happens, it be much en- feebled. The pain which sometimes attends dilatation may be relieved by small blisters over the region of the heart, and to the spine in those cases in which the action of the heart is in a great degree kept up by spinal irrita- tion. Blistering, or other revulsives to the spine, may cure the patient of the palpitation, and the dilatation will then present few symp- toms of importance. The action of the heart in dilatation is not powerful enough to require the use of large doses of digitalis ; if this re- medy be administered, it should be given only for a short period, and in very minute doses, conjoined with aq. camphorae, or lac assafce- tidae. Hoffman's anodyne answers very well for the same object, as a temporary tranquilliz- *" THE HEART. 143 ing remedy. The use of these various reme- dies is readily learned when it is remembered that the power of the heart should not be di- minished, but that its irregular action merely should be checked. For the same purpose a rigid adherence to hygienic rules becomes ne- cessary, and they should be nearly the same as those required for the treatment of hypertro- phy. But as the nervous stimulants are more to be dreaded in dilatation than the more per- manent excitants of the heart, the patient should carefully abstain from tobacco, tea, cof- fee, and avoid the mental and physical ex- cesses which disturb the regular cardiac ac- tion. Those which act through the passions, or debilitate the nervous power by excessive fatigue from indulgence in sensual gratifica- tion, or undue culture of some of the faculties, are the most injurious. If anemia complicates dilatation of the heart, a long continued use of tonics, especially the chalybeates, constitutes the best mode of treat- ment. The prescription which I prefer as a general rule is Valet's proto-carbonate of iron, in doses of two or three grains, with half a grain of rhubarb and a grain of ginger; of these pills the patient may take from three to four daily. The infusion of the Prunus Vir- giniana is an adjuvant to the chalybeate reme- dies of great value, and often succeeds in quieting the action of the heart. Cold bath- ing, sea bathing, and other tonics of this na- ture, are all necessary from time to time, and may be prescribed with advantage, as they tend to strengthen the general muscular sys- tem, and to increase the nutrition, without ex- citing the irritability of the heart. LECTURE XVIII. Diseases of the Valves. The valves of the heart are subject to de- rangements, either from the direct effect of in- flammation, or chronic alterations of nutrition, or the combined influence of these causes. When the valvular lesion occurs during the active progress of endocarditis, it is evidently a mere part of the inflammation, produced by the same action of the bloodvessels as other alterations of structure of serous membranes. The valves are altered by deposition of lymph upon their free surface, under the form of vegetations or granulations, and by thicken ing from an albuminous deposit between their thin laminae ; lastly, from bony degeneration, which follows cartilaginous thickening. The vegetations produce not only thickening, but also roughness of the surface of the valves; while deposits between the laminae of the valve in- durate and thicken Without destroying its po- lished surface. These changes produce altera- tions of function; that is, as the valve changes its form, it becomes incapable of closing com- pletely and preventing the reflux of the blood ; or it becomes morbidly contracted, forming a projection inwards towards the cavity of the heart, obstructing more or less the circulation of the blood. In most cases it can scarcely be said that the opening of the valve is simply contracted or dilated; for a permanent thick- ening destroys both the form and functions of the valve, and converts it into a rigid abut- ment, which does not yield itself completely either to the movements of dilatation or con- traction ; hence, the orifice of an indurated valve is generally both dilated and contracted, neither closing or opening so as to give a free passage to the blood. The form assumed by the lymph, when first thrown out, during inflammation is very various; sometimes it is in small points or granu- lations, at other times forming excrescences, singularly like, in form, to venereal warts; hence they are sometimes called cauliflower vegetations, while in a third variety the lymph is spread out on the internal membrnne, with which it is intimately combined, giving to it an opaque white tint. In other cases, the ef- fused matter is secreted into the thickness of the valves, and, of course, is situated between the folds of the membrane which forms it. This matter is replaced, in many instances, by ossific deposits, which are formed in the usual way beneath the lining membrane, which often ulcerates, leaving the bony spiculae projecting towards the cavity of the heart. The struc- tural alteration of the valve, in some cases, takes place immediately after, or even during the inflammatory process; in others it is only formed after the inflammatory action has sub- sided, and the affection becomes limited to a mere alteration of nutrition. In both cases the action of the vessels is the same; and when the lesion is once formed, it scarcely dimin- ishes afterwards. The valves of both sides of the heart are lia- ble to disorder; but there is a great difference in this respect. Those of the left side, accord- ing to the usual law as to the relative fre- quency of inflammation, are diseased in the large majority of cases, especially in those cases in which the alteration is positive or ac- tive in its nature, and depends upon increased nutrition. The giving way of the valves, which follows long continued dilatation, is quite as apt to take place on the right side in the tricuspid, as in any other valve. The valves of the left side are often both affected at the same time; hence the semi-lunar and mitral are usually both diseased ; in other cases, one is decidedly altered, while the other nearly escapes, but it is very rare to find it in a normal state. They both participate in the disorder, because, as the lesions are the result of inflammation in most cases, and as it extends usually over the greater part or the whole of the ventricle, there- fore neither valve absolutely escapes. Still, as DISEASES OF THE VALVES. 145 a trifling lesion is not sufficient to give rise to much or any notable disturbance, the symptoms very generally depend on the affection of the valve only which is most altered. The dis- order of either semi-lunar or mitral will pro- duce grave results, if carried to an extreme degree; but the mischievous effects are in general more severe in affections of the mi- tral than of the aortic valves. When the semi- lunar one is contracted or dilated, the cav- ity of the left ventricle remains full; for the blood is either prevented from passing slowly into the aorta, and thus accumulates in the ventricle, or it regurgitates into it; but if the mitral valve be much altered, the supply of blood becomes at once irregular, and the ven- tricle no longer contracts in a steady, uniform manner. In such cases, the pulse is most frequent and irregular, and the dyspnoea is most excessive. The physical signs of valvular disease vary according to the valve affected, and the nature of the lesion. When contraction of the semi- lunar valves of the aorta predominates over di- latation, the blood is driven with difficulty through them by the contraction of the ventri- cle; hence we have a bellows, or rough rasp- ing sound developed, according to the degree of contraction, and the surfaces offered to the passage of the blood. The bellows sound de pends chiefly on the increased violent muscu lar contraction produced by the resistance at the valves, and the rasping sound upon the ir- regular surfaces, when there is actual ossifica- tion. Dilatation of the auriculo-ventricular valves produces the same result during the systole as contraction of the semi-lunar valves ; that is, roughening in various degrees of the first or systolic sound, from the strong muscu- lar effort necessary to free itself of blood; hence, this symptom is so frequent in valvular diseases of the heart. The second sound is much less frequently roughened than the first; it is very often diminished in loudness by the disease of the semi-lunar valves, but it can only be rough- ened by their permanent dilatation, allowing the blood to regurgitate into the ventricle in such away as to produce a harshness of sound. Now the simple reflux is not, in general, suf- ficient to produce this, the blood passing back almost noiselessly, it only takes place where there is a rough projection towards the cavity, interrupting the current of blood. Permanent contraction of the auriculo-ventricular valves, especially of the mitral, is sometimes carried to so great a degree as to interrupt the current of blood during the dilatation of the heart; and it then gives rise to a rough sound, re- placing the natural second sound, or mask- ing it. The roughened sounds of valvular disease are not heard over the valves only, but they are conducted by the columnae carneae to the muscular portion of the heart; still, they are heard most loudly at a point nearest the valve affected. If several of the valves be simultaneously diseased, and the muscular substance of the heart be at the same time altered, the distinc- tion between the first and second sound is, in a great measure, lost, and there is little more heard than a confused purring: when this oc- curs, there is usually a thrilling sensation perceived by laying the hand on the exterior of the chest. This indicates a grave condi- tion of the heart, constituting one of the most severe forms of disease of this organ, and scarcely ever allows the patient to survive long. The valvular diseases, like other organic af- fections, are attended with many painful sensa- tions in the chest. As they are, in general, complicated with disease of the muscular sub- stance, it is difficult to say what portion of their symptoms should be ascribed to the val- vular, and what to the muscular disease. If the valves are so much diseased as to mate- rially impede the action of the heart, it is rea- sonable to infer, that the pectoral symptoms depend chiefly upon them. If the valvular disorder be less, the action of the two lesions is a joint one, and it is impossible to separate them. In some patients, angina pectoris or a painful stricture of the chest, extending down the left arm, complicates the disease, and may cause intense suffering. In nearly all, do we find that dyspnoea follows exercise, or any other stimulants of the action of the heart, or distur- bance of the pulmonary circulation. When the heart is calm, the suffering of the patient is very slight, and is often limited to a mere disagree- able sensation at the chest, with occasional at- tacks of palpitation, which are much more se- vere, when the mitral valve is affected, than any other. The complication of acute inflam- mation of the internal membrane of the heart 146 DISEASES OF THE HEART. is by no means infrequent, and will always give rise to considerable pain, and great in- crease of the dyspnoea. Congestions of the lungs are favoured by disease of the valves, especially of the right side of the heart, more than by any other lesion of the organ, and are often the chief cause of the violent oppres- sion. Of the secondary affections, dropsical effu- sions in the chest, and in the cellular tissue generally, are the most frequent. It has been previously mentioned that these are confined to no form of heart disease, but may occur in connection with any of them; most frequently however with those which are severe enough to impede the circulation, as one cause of the effusion is certainly the difficult passage of the blood through the cavities of the heart. Some observers have gone so far as to deny the oc- currence of dropsy, except as a consequence of valvular disease : this is clearly erroneous, but it shows that these lesions must, at least, be one of the most frequent causes of effusions. If the anasarca be not hastened by inflamma- tion of the heart, it takes place rather later, after the disease of the valves has lasted a long time, and the red globules of the blood begin to be deficient. In some cases, the effu- sion occurs first in the serous cavities of the chest, both in the pleura and pericardium ; but in the majority of cases, anasarca precedes the thoracic dropsy. The general aspect of the patient is more characteristic of heart disease when the valves are affected, than in any other variety, because the obstruction to the circulation, which gives rise to these symptoms, is the most severe. Hence, the bluish tint of the lips, the promi- nence of the eyes, slight puffiness of the face, and the peculiar physiognomy of cardiac dis- eases, are most apt to be developed ; these are uncertain, but probable indications of the dis- order. Congestions and haemorrhages are less apt to occur when the valvular lesion predomi- nates, than when the muscular tissue is hy- pertrophied, because the blood globules are least altered in the latter case, and congestion therefore often occurs, instead of serous effu- sions. When the case is one of extreme valvular disease, the whole body suffers as in other cases of cardiac disorder, the digestion fails, and emaciation and extreme pallor of the com- plexion usually follow. The diagnosis of valvular diseases cannot be determined with certainty, except by the assistance of physical exploration. We may infer that the valves are diseased if the patient complains of great oppression, and distressing, fatiguing palpitation, and at the same time becomes cedematous; but unless the altera- tions of the sounds of the heart, characterizing the disease of the valves, should be heard, the diagnosis is still uncertain. The prognosis of the disease is uniformly a grave one ; if the disease occur very late in life, and depend ra- ther upon ossification than upon a cartilaginous deposit, it does not shorten life, unless carried to an extreme degree ; but when the function of the valves is interrupted, we have then not only to anticipate a fatal termination, but one much earlier than would be expected in other heart disorders. Death may take place sud- denly by an abrupt cessation of the action of the heart, or occur slowly from the exhaustion and dropsical effusions which follow protracted cases of this disease. The treatment is necessarily purely pallia- tive ; it is therefore totally different from en- docarditis, in which directly curative means are to be looked for. Our object is to prevent as far as possible, the frequent return of the fits of palpitation and dyspnoea, and to check the further increase of the morbid deposits. A little knowledge of the usual causes of the pa- roxysms is soon acquired by the patient, and will in general prevent him from needlessly exposing himself to them. He must learn to lead a quiet unexcited life, and if his temper be placid, a simple attention to hygienic rules will often effect something very nearly ap- proaching a cure, that is, if the disease be not excessive. Many individuals, however, are unfortunately so situated in life, and of such temperaments, that it is scarcely possible for them to avoid a renewal of the attacks of dysp- noea ; hence the disease is hastened in its pro- gress by causes which are not inherent in it. When the attacks occur and cause great op- pression, nearly the same treatment should be adopted as in other cases of irregular action of the heart. There is, however, rarely occasion for bloodletting, nor, indeed, are there many cases in which it would not be positively in- jurious ; for, as the pallor of the blood is ex- tremely apt to follow protracted valvular disease, we should carefully nbstain from any DISEASES OF THE VALVES. 147 treatment at all fitted to hasten this change. Cupping is extremely useful where a recent attack of cardiac inflammation supervenes: un- der other circumstances it is unnecessary. Com- plete repose, sinapisms on the chest, and re- vulsive pediluvia, are extremely beneficial, and are often sufficient to relieve the attack. As internal remedies, Hoffman's anodyne, with a few drops of the aromatic spirit of ammonia, in the proportion of half a drachm of the former to fifteen drops of the latter, is one of the best means of quieting the action of the heart, and of gen- tly stimulating the capillary circulation. As- safoetida, with other similar anti-spasmodics, such as two grains of camphor, and two or three of Dover's powder every two or three hours, are often useful. Often, when the at- tack is passing off, digitalis may be advan- tageously administered, either alone, or, as is still better, with assafoetida or the anodyne. The principles of treatment are, therefore, plain enough, and so far as our means extend, they will be found efficacious; unfortunately we are soon arrested. But as the most severe organic disorders of the heart do not neces- sarily shorten life, if they are not thrown into action, the case is not always attended with such imminent danger as might at first be sup- posed. The best test of an approaching ter- mination is the condition of the capillary circu- lation. There are several organic affections of the heart which are rarely met with, and never present symptoms sufficiently well defined for us to recognize them; hence they rather be- long to pathological anatomy than to pathology, properly so called. Amongst these are ulcers of the substance of the heart, gangrene of its tissue, pouch-like aneurisms formed by digital cavities beginning at the heart and ending in short cul de sacs at a little distance from it. To the practical student of disease they are, therefore, not of more interest than suppuration of the muscular tissue of the heart, which is extremely rare, and not susceptible of recogni- tion. Atrophy of the heart is a frequent consecu- tive disorder; that is, it often accompanies cases of phthisis and other disorders, attended with great emaciation, in which the heart par- ticipates, like other organs of the body. Soft ening of the tissue of the heart is also but a part of general softening of the muscular sys- tem ; it takes place in cachectic conditions of the system, in which the blood is more or less altered, especially in low forms of fever. The softening diminishes the force of impulsion of the heart; and auscultation is under these cir - cumstances, a good means of estimating the extent and development of the lesion. Cases in which the heart becomes softened, bear and often require the liberal use of stimulants; hence, in a therapeutic view, it is often impor- tant to ascertain when this condition exists. LECTURE XIX. Functional Diseases of the Heart. of venery: disorders ot the stomach, tempo- rary indigestions, &c.,are all capable of bring- ing on violent attacks of palpitation, which cease soon after the immediate cause. These attacks come on frequently at night, when the patient is often kept awake by them for a long period, and the extreme distress they then oc- casion, constitutes one of the most unpleasant forms of cardiac disease; they are thus usual- ly connected with great disorders of the whole nervous system. Excesses in the use of to- bacco have more influence than any single cause in producing this peculiar variety. If the ear be applied to the chest of a patient la- bouring under nervous palpitations, the two sounds are quite distinct; the second rather sharper than usual,and the first has occasionally more or less of the bellows character, espe- cially if the patient be anemic. The impul- sion of the heart is quick and decided, but there is no positive increase of force, no sen- sation similar to that of a large body striking against the walls of the chest, which is one of the best indications of hypertrophy. These are extremely frequent, and, strange to say, often appear more severe to the subjects of them than the organic alterations. They are usually connected with an excitable nervous temperament, which renders the sufferer irri- table, watchful of slight sensations, and apt to complain of the least aberration from the healthy condition: organic diseases of the heart, on the other hand, acquire new inten- sity, and are doubly distressing to the patient, if a functional disorder be added to the organic lesion. The functional disturbance of the heart is extremely protean in its character; sometimes it is not sufficiently defined to ad- mit of classification as a distinct symptom or group of symptoms; at other times the ner- vous disorder is perfectly well marked, and retains its characters for a long period. As a general rule, we apply the term nervous dis- order to many different states. The principal are: 1. Palpitation. This may be, as mentioned, a sign of a true organic disease; but when it is really most troublesome, it is often not con- nected with a permanent lesion. In these cases it occurs suddenly, chiefly from mental impressions, or other causes, acting directly upon the nervous system. It is most violent when dependant upon anemia, which is, of course, readily recognized by the pallor and general aspect of the patient. Violent exer- cise will produce the palpitation as much as it does in those cases which are dependant upon organic disease, but to a much less degree than moral causes. The tendency to palpita- tion is congenital with some individuals, and may last through a long life without the de- velopment of positive cardiac lesions. Ner- vous palpitations are readily excited by sti- mulants acting directly upon the spinal axis, as excess of tobacco, coffee, and sometimes 2. Fainin the heart and near it, is frequently a pure nervous symptom. It has been al- ready stated that this, when acute, is more frequently a mere nervous sensation than a sign of organic disease. It is in some cases a pure neuralgia, sharp and lancinating, and ex- tending from the spine to the neighbourhood of the heart, or along the ribs and to the epi- gastrium. Sometimes it alternates with pain at the latter situation, or with other disagree- able sensations. In other instances there is general soreness about a large portion of the chest, especially in the neighbourhood of the heart. All, or any of these sensations, may coincide with positive organic disease, but not necessarily so; they may be perfectly inde- FUNCTIONAL DISEASES OF THE HEART. 149 pendent of it, and of no real danger, although causing extreme annoyance to the patient. 3. Inter mi ttence. Irregularity of the pulse is, as was before mentioned, both a functional and an organic symptom. It may exist through- out a long life without the development of any organic lesion. In some persons the symp- tom assumes an extreme intensity, and may amount to positive syncope—the patient faint- ing under slight impressions, totally inade- quate, under ordinary circumstances, to pro- duce such a result. This condition, like the other symptoms alluded to, may occur as a mere attendant upon organic disease, but it is more frequently a purely nervous symp- tom. 4. Angina Pectoris is ranked in most works as a separate disease, that is, as having a de- finite train of symptoms capable of being se- parated from other affections of the heart. This view of the subject is not, however, at present regarded as the most tenable one; on the con- trary, angina pectoris is understood to depend upon a functional disease of the heart, allied closely to gout, or upon various organic lesions, especially ossification of the valves, which is often dependant upon a gouty more than upon a rheumatic diathesis. The symptom, it is well known, consists in an intense feeling of dyspnoea, with pain extending down the arms, usually the left arm only. The dyspnoea comes on very suddenly in most instances, usually after some excitement of a mental kind, or after active bodily exertion. If the attack be extremely severe, death may occur during the paroxysm, but in most cases the at- tack passes off in a few minutes, leaving the patient comparatively well after intense suf- fering. The extension of the pain down the left arm is one of the most remarkable features of the disorder; the same symptom may oc- cur when there is pain of a mere neuralgic character, but then it is comparatively slight. Angina pectoris is most readily relieved by diffusible stimulants, as Hoffman's anodyne, ether and the like. The usual revulsions to the spine and anterior part of the chest, which relieve so many of the neuralgic diseases of this cavity, are also of great benefit. The principal object of our treatment, however, is certainly to prevent the recurrence of the symptoms ; to effect this object, the treatment must be directed to the removal of the cause. The organic affection, on which it commonly depends, is, unfortunately, incurable in the majority of cases, but a careful atteution to the exciting causes of the disease, will exer- cise at least some control over the recurrence of the paroxysms. Although no one treatment can be adopted in the management of functional disorders of the heart, nevertheless, certain general indica- tions are well settled. If functional disease is not connected with organic, a debilitating treatment is injurious; the best means are the application of counter-irritants, especially of 9 the milder superficial irritants, such as re- peated weak sinapisms, frictions with hot salt and the like, from time to time; when there is a sharp pain at the heart, small blis- ters, frequently reapplied, will remove it sooner than almost any other remedy: the deeper counter-irritants, as tartar emetic, issues and setons, do not seem so well fitted for these cases as those whose action is more diffused, but more equable. Amongst the internal re- medies suitable for those cases in which to- nics are necessary, the infusion of the wild cherry is one of the most agreeable to the sto- mach, at the same time that it exerts a directly calming action upon the irritability of the heart; in no disease is this remedy of so decided be- nefit as in cases of nervous palpitation con- nected with feebleness of the system. Cha- lybeates are not necessary, and scarcely use- ful, except in palpitations dependant upon anemia, especially if occurring in chlorotic girls. Assafoetida and Hoffman's anodyne, camphor, in doses of one to two grains three or four times daily, answer very well in certain cases of nervous disorder. A careful avoidance of excesses of all kinds, night watching, all sti- mulating drinks, including tea and coffee, and of tobacco, will often suffice to cure a nervous dis- order. A change of residence, and the aban- donmentfor a time of an absorbing occupation, the removal, if possible, of mental causes of uneasiness with gentle exercise, country resi- dence, and simple nourishing diet, are in se- vere cases indispensable. Marriage is often followed by a complete removal of the symp- toms, much to the surprise of the patients, who are often more uneasy on account of mere ner- vous palpitation than real organic lesion. *E XX. the Aorta. Diseases of AORTITIS. Inflammation of the aorta has been scarcely studied, except of late years; but it is now known that it is by no means an unfrequent dis- ease. The aorta participates in the liability to inflammation, which is so characteristic of the red blood cavities of the heart. In many in- stances the inflammation merely extends from the left ventricle downwards into the aorta, and the disease remains the same, but a larger portion of the arterial tissue is affected than in cases of endocarditis, where the reservoir alone is inflamed. The anatomical characters of the affection are less decided even than those of endocar- ditis ; for the force of the current of blood is greater, and, of course, the lymph which is thrown out during the inflammation adheres with more difficulty to the membrane. There is the usual redness of inflammation, not re- gularly diffused over the membrane, as in cases of mere cadaveric redness from imbibi- tion, but shaded in different degrees of inten- sity, and in irregular patches; like the other signs of inflammation, it is most evident about the arch of the aorta, where the disease is ear- liest developed. The redness sometimes allows the minute vessels and fine dots, of which it is composed, to be distinctly traced; in other cases they are confounded with the general shading. The lymph, in part, adheres to the membrane, that is, those portions of it which are early organized, and form, as it were, a continuous whole with it; sometimes there are granulations and irregular vegetations, as in cases of endocarditis; they arise merely from the irregular deposition of the lymph. In a few rare cases, ulcers are developed at the bot- tom of the deposits of lymph, and the internal membrane is afterwards gradually removed by the ulceration; but they are not common, ex- cept in the more chronic forms of the disorder, when cartilaginous matter has replaced the original secretion of lymph, and ulceration takes place below it. All the coats of the aorta are in some cases thickened. The in- ternal membrane is, in bad cases, softened, often of a dull yellowish tint—a condition which indicates an approach to gangrene. I have often seen these patches of softened tissue extend throughout the greater part of the aorta; but in most instances they are confined to the arch of the aorta and the thoracic portion. The products of inflammation are, therefore, nearly similar in inflammation of the lining mem- brane of the aorta and of the left ventricle; but as the office of the artery is simply to serve as a channel for the blood, instead of an active propelling power like the heart, the distress produced by arteritis is less considerable. Symptoms. — The symptoms of aortitis are often very obscure. In many cases there is unusual uneasiness deep in the chest, rarely amounting to defined pain, often a mere sense of oppression, or of extreme dyspnoea; these symptoms, however, vary in an extreme de- gree, and though scarcely ever totally absent, are sometimes so badly defined that they al- most escape the attention of the physician, and are, at least, badly described by the patient. In some cases the orthopncea is quite as into- lerable as in any other affection of the chest; but this is not the case with the majority of patients. The palpitations are at times per- ceptible by the patient, but not as a general rule; the impulse of the aorta may usually be felt by pressing the finger behind the top of the sternum, and by applying the stethoscope or the ear upon the upper third of the sternum, the impulsion is quite distinct. The circu- lation is nearly always more or less disturbed; AORTITIS. 151 few patients escape entirely without fever, and in some the fever is very intense, and one of the most marked symptoms of the affection; and though not always a well developed symptom, it i9 so in many instances. The heart itself participates in the affection, and the impulsion is often nearly as strong as that of the aorta, but it is chiefly in cases more or less compli- cated with inflammation of its lining mem- brane. Cough and expectoration scarcely be- long to inflammation of the aorta; the former may exist in a slight degree, but the symptoms rather belong to some associated affection of the lungs than to the aorta. As in all cases of fever, many secondary symptoms, such as loss of appetite, cephalalgia and constipation, may accompany aortitis, and if the abdominal aorta be inflamed, some local uneasiness, corres- ponding to this part, may be felt, but as the symptoms are not at all peculiar, and are very irregular, little attention is generally given to them. Besides the mere increase of impul- sion, a sawing sound, that is, the double Tasp- ing sound may often be heard distinctly at the upper portion of the sternum; one part of the sound corresponding with the onward motion of the blood, and another with the partial re- flux which seems to occur in these cases, from what cause would be easy to imagine but difficult to prove. This sign, however, is chiefly heard when the inflammation has pro- duced a partial disorganization of the coats of the artery, if not amounting to aneurism, at least to thickening. The termination of a case of aortitis is of course two-fold; the large majority of cases recover, but if the aortitis occur as secondary to some other disease, or if it be very violent, either from unusual extent, or peculiar consti- tution of the patient, it may be fatal at a very early period. Like endocarditis, it may ter- minate in recovery from the acute period, but thickening of the aorta, cartilaginous deposits, and other alterations, may remain long after the cessation of the febrile excitement, and at last terminate in aneurism from the giving way of the weakened internal coat. The diagnosis of the disease is in many cases involvedin much difficulty. As the pain is extremely irregular, at times quite insigni- ficant, at others severe, but generally not li- mited to a particular portion of the chest, and not accurately corresponding with the position of the aorta, it is of little value as a diagnos- tic sign, unless it is seated at the upper part of the sternum, that is, very near the arch. The fever and disturbance of the circulation are of much value if conjoined with strong throbbing, or a sawing sound at the region of the arch. In some cases there is serous effusion throughout the body, as in other cases of disease of the circulation. Lastly, we have negative signs as regards most other affections of the heart or lungs capable of producing ana- logous symptoms; hence the diagnosis, by way of exclusion, is then of great assistance to us. If, however, the heart or lungs be af- fected at the same time with the aorta, we can only rely upon the positive indications of aor- titis, few as they may be, and the diagnosis is therefore often uncertain. A careful exami- nation of the symptoms and estimate of their relative value, will, however, generally make the case clear. The prognosis is in general not unfavourable. If the dyspnoea be very violent and does not yield to blood-letting, it is an unfavourable sign; lividity of the countenance, and large serous effusions throughout the body, are among the worst symptoms. Where aortitis occurs in persons much enfeebled, or suffering under previous disease, it is always a severe disease, and the prognosis must be modified. Treatment. The treatment is of course de- cidedly antiphlogistic. If the affection be dis- covered at an early period, full blood-letting is of course the best means of subduing the in- flammation and of removing the condition of the blood which accompanies it. It may be ne- cessary to repeat the bleeding more than once. Leeches above the sternum approach very near the arch of the aorta, and produce a much more decided influence than could be supposed apri- ori. The usual antiphlogistic treatment must ac- company the depletion, antimony in small doses, opium and ipecacuanha, mercurials, and finally, when the inflammation has almost subsided, digitalis is indicated in the declining stages of the disease, and must be administered ac- cording to the usual rules on this subject. Absolute rest should be insisted upon for a long period, and the diet should be as simple and as light as possible. Both aortitis and endocarditis are sometimes associated with acute or inflammatory phthisis, 152 DISEASES OF THE AORTA. and the tuberculous disease may be at first overlooked, or not developed until the excite- ment of the circulation diminishes. The treat- ment of such a complication does not offer any thing peculiar in its character; after the sub- sidence of the acute symptoms, however, the patient must be watched with great care for a considerable period. ANEURISM OF THE AORTA. One of the terminations of aortitis is in aneurism, especially of the arch; this usually supervenes on the giving way of the internal membrane, so that the blood passes be- tween it and the middle coat; in some rare] instances the blood finds its way for a long distance between the two coats, constituting a variety of dissecting aneurism ; this is, how- ever, an exception. Although aneurism of any portion of the aorta is regarded as a strictly medical disease, yet that of the thoracic por- tion alone belongs to our present subject, and in the majority of cases will be found to de- pend directly upon inflammation and softening of the internal coat. In some cases, however, the influence of inflammatory action either can- not be traced at all, or so remotely that the cause becomes at last doubtful; this is espe- cially the case with persons much advanced in life, whose aorta is studded with bony and cartilaginous plates, the origin of which in a good proportion of cases we have every reason to believe inflammatory, like that of the same de- posits in the internal membrane of the heart. The distension of the aorta from the stretching of all its coats, is by no means infrequent at the arch; it never reaches the size observed in false aneurism, and unless it should afterwards be converted into the latter variety, does not as a general rule endanger the life of the pa- tient. The anatomical characters of aneurism of the aorta are so well known as scarcely to require a complete description. In the true variety the aorta reaches various degrees of distension, with thickening of its coats; the openings of the arteries 'leading from the arch are occa- sionally much contracted, so as to admit with difficulty the passage of the blood; in one case I have seen the current of the blood di- verted from the three arteries of the arch and urned into collateral channels; in this case aneurism be large enough, the trachea is often pressed upon, and the respiration becomes dif- ficult. The heart may remain in the healthy condition, or may participate in the original in- flammation and the results of it. When dis- eased, it generally presents the traces of pre- vious endocarditis, and various degrees of thickening and other alterations of the lining membrane. In the variety which is much more common and is usually styled false aneurism, the ap- pearances on dissection are similar to those so fully described in surgical works, that it is not necessary to enter into a minute description. The internal membrane gives way from soften- ing and ulceration, and the blood percolates through the opening; the lining membrane is gradually absorbed as the aneurismal tumour enlarges, while a portion of sac is gradually filled with fibrine, which is deposited in layers, until it forms a mass which may attain a very large size. The blood passes by the side of, or through an opening in the fibrinous mass, which is irregular in size and more or less obstructed, so that a smooth passage is no longer left for the blood. The disease terminates in two ways; by the gradual pressure upon the trachea and lungs producing disorder of these organs, often of a tuberculous variety, and by rupture of the tu- mour causing sudden death from haemorrhage. In a few cases death may follow from para- lysis, caused by the caries of the spinal co- lumn. Absorption of the bones of the chest always takes place if the tumour comes in contact; they may be the sternum and the anterior portions of the ribs, or the bodies of the vertebrae, if the' tumour happens to en- large in that direction. If the anterior parts of the chest are absorbed, a tumour forms which sometimes yields a distinct pulsation, but to- wards the spine an external pointing of the tu- mour can scarcely take place. In many instances death does not result from the aneurism, but the patient is carried off by some accidental dis- ease not immediately connected with the lesion of the aorta. Symptoms. The symptoms of aneurism are chiefly the physical signs —those connected with the obstruction to the passage of the blood, and lastly, the secondary symptoms produced by the immediate pressure or the ob? struction of the circulation upon other oroans. there was no pulsation at the wrist. If the! The growth of the aneurism itself is attended ANEURISM OF THE AORTA. 153 with little or no pain ; for the aorta, when at- tacked by a chronic disease, is scarcely suscep- tible of painful sensations. The physical signs at first are limited to a strong pulsation at the arch of the aorta, which may be felt by pressing the finger downwards behind the top of the sternum, or may be recognized by applying the ear or the stethoscope at the upper part of the sternum. The percussion is affected to so slight a degree at the commencement of aneur- ism, that it is not a sign of much value; as the lesion increases in size we find that the sound becomes dull sometimes over a considerable extent at the upper third or even half of the sternum. The pulsation usually increases in force, but not invariably, for the current of blood is not always propelled in such a way as to strike forcibly against the sternum. In most cases, too, there is a very evident bruit de scie, or sawing sound, easily distinguished from the simpler rasping sound heard at the region of the heart. With these sounds there is often a decided thrill. It would be very easy to recognize aneurism of the aorta if all these signs were present in every case, but this is not so, the only permanent one is the dull percussion, and even that may be difficult to recognize if the aorta enlarges on its poste- rior and not its anterior surface. Although the signs are often obscure, they are rarely al- together absent, and with attention. they may generally be detected from time to time, the percussion being always permanently dull. The general symptoms are in some cases almost as imperfect as the physical signs. Those most directly connected with the aneur- ism are the disturbance of the circulation, both at the heart and in the arteries. The pulse is in some cases thrilling, which is almost a pathog- nomonic symptom when present to a well mark- ed degree of aneurism, but it is often quite regu- lar and natural. The uneasiness of the chest is at times very slight, but when the trachea is pressed upon, the dyspnoea becomes extreme, and a convulsive cough occurs in paroxysms, having some resemblance to attacks of pertus- sis. The pain in the chest is often neuralgic, from pressure on the sides of the dorsal verte- brae, and from the same cause, instead of being confined to the thorax, it may extend through- out a large portion of the body. The effects of pressure on the neighboring organs are so be involved, and the diagnosis of the disease rendered much more obscure, in consequence of the secondary disturbance of viscera not im- mediately connected with the heart. They are therefore of little diagnostic value, except as connected with some local indications of aortic disease. The other organs than those of the chest have no direct connexion with the en- largement of the aorta, and sympathize only as the disorder of the circulation extends itself throughout the system. Termination and Prognosis. This is natur- ally fatal, that is, the disease is at least prac- tically incurable, but the patient may live for a long series of years and at last die of a dis- ease not connected with aneurism. This is most frequently the course of the disease if the patient be of a quiet placid turn of mind, and be placed in such situations of life as to free him from anxiety or laborious-exertions. The diagnosis of aortic aneurism, it is plain from the symptoms, must often be difficult. If the disease be so far advanced and so near the surface as to produce all its physical signs, then the diagnosis is plain enough; but even in this case groups of enlarged lymphatic gan- glions and induration of the anterior portion of the lung may give rise to signs not very dis- similar to those of aneurism. If the tumour has perforated the bony parietes of the chest, the diagnosis is of course evident enough. But it is most essential to recognize the dis- ease at an earlier stage, when there are as yet no strongly marked signs. The diagnosis is then mainly founded on that nice balancing of slight symptoms which we term medical tact; hence, the presence of any of the physical signs of aneurism, with some of the local symptoms, such as dyspnoea, pain, &c, will make us sure of the existence of the disease, provided no indications of other disease of lungs or heart, which could explain the symp- toms, are found. If the aneurism be compli- cated with other thoracic diseases, then our diagnosis by exclusion fails us, and we must trust mainly to the direct signs, and then exa- mine whether the symptoms are not more con- nected with a lesion of the circulation than of the lungs. If we ascertain that the seat of the disease is the heart and aorta but not the lungs, there is little further difficulty in set- tling the diagnosis as one of aneurism, either various, that all the viscera in the thorax may simple or complicated with heart disease 1 54 DISEASES OF Treatment. In a disease of this nature, the treatment is obviously palliative. When an aneurism is once formed, we possess no means capable of curing; all that we can attempt to do is, to prevent as far as possible the further rupture of the coats of the artery, and to favour the formation of coagula in the sac. The patient should, as he values his life, remain as quiet as possible, if not in a state of absolute repose ; he should take no severe exercise, es- The proposition that inflammation of the lining membrane of the heart gives rise to the greater number of diseases of the valves, and indirectly to alterations of the muscular struc- ture, is now well demonstrated. This has been proved in two ways; first, because a large number of cases of inflammation of the heart which have ended in partial recovery, have given rise to valvular diseases in indivi- duals who were before in the enjoyment of good health: secondly, because the traces of previous inflammation can be detected in most instances upon the examination after death of the bodies of those who have died of various valvular diseases, or of hypertrophy. A large number of cases verify this conclusion, and we are therefore not only induced to modify our opinions as to the treatment of these affections, but to study the phenomena of inflammation of the lining membrane with more interest than * In the usual order of lectures, that on Endo- carditis should have immediately followed Pericar- ditis. By some unaccountable accident the manu- script was transposed, and no better place was left for the lecture than the one now assigned to it. THE HEART. pecially none which produces much excite- ment of the circulation, or strong efforts of the muscles of the upper part of the body. The diet should consist of the simplest and least stimulating articles of food, not only because they exercise a directly injurious effect on the circulation, but because indigestion and flatu- lence always increases the severity of the symptoms of diseases of the heart or aorta. it would perhaps require, if its consequences did not extend further than the immediate at- tack. The anatomical characters of inflammation of the lining membrane or endocarditis, are not so distinct, because the products of the inflam- mation are not contained in a closed sac which retains them until their absorption,on the contra- ry they are exposed to the washing of the current of the blood, which removes all those deposi- tions which are not either intimately combined with the membrane, or formed beneath it. Hence, we can have no collection of pus or serum, hut we find some traces of the more solid portion of the lymph, and we may find other alterations of structure which result from inflammation, such as thickening or ulceration. When inflammation begins, the membrane is highly injected like other serous tissues, the injection depending upon minute vessels and extravasated points of blood immediately be- neath the surface of the membrane, that is, in its thickness. A cloudiness of the membrane is soon perceptible, and it gradually becomes of a dull whitish tint, from a thin coating of fine lymph, which adheres so completely to the LECTURE XVIII. Endocarditis.* ENDOCARDITIS. 155 membrane as to become almost a part of its substance. Upon the valves we often find the lymph thrown out in a different form; in that of granulations or vegetations of a cauliflower form, which were at one time absurdly enough supposed to depend upon syphilitic causes ; these are the depositions, which are most apt to become organised, and to form different kinds of valvular diseases. Over the cavity of the heart the lymph is nearly always thrown out in the form of delicate laminae, which give a whitish appearance to the membrane after the cure of the endocarditis. Ulceration is by no means unusual at the valves, and sometimes takes place at other portions of the lining membrane. The ulcer appears to arise from a small abscess formed beneath the lin- ing membrane, which gives way after a time, leaving an opening with irregular everted edges, of an intensely red colour. When these ulcers take place at the valves, they often give rise to an irregular vegetation, partly consist- ing of lymph, partly of calcareous matter. I have sometimes seen them projecting towards the interior of the heart to the length of half an inch or more; one or even two of the divi- sions of the semilunar valves are sometimes destroyed by the ulceration. On the right side of the heart the valves are subject to an- other alteration, which in some cases seems to be connected with inflammation; they become thin, give way to the pressure of the blood, and their fibres separate. The structure of the heart in all probability, suffers during a severe attack of endocarditis, but it is difficult to demonstrate what the le- sion is, for the disease is evidently of a rheu- matic character, and does not tend to the for- mation of pus. The heart, however, evidently increases in consistence immediately after the inflammation of the membrane. Symptoms. The physical signs of endocar- ditis are in some cases extremely well marked. In the most severe forms of the disease the heart is distended with blood, which forms coagula, often becoming completely organized before death. Hence the sound of percussion becomes duller than usual, but of course it is never so dull as in those cases of pericarditis in which there is a large serous effusion. The impulsion of the heart loses its sharpness, the contraction becoming spasmodic and confused. The sounds are always changed in character, the first usually roughened, and either bellows or rasping; the second dull and indistinct. In many instances the heart acts so languidly, and the coagula obstructs the passage of the blood so much, that the sounds are scarcely heard; but if the muscular force be but little impaired, the first sound is almost always of a bellows kind, but usually more dull or veiled than in simple valvular obstruction. This is particularly the case where there are large coa- gula, but as there are cases of endocarditis in which the quantity of blood contained in the heart is, comparatively speaking, small, the disease is then chiefly limited to the valves, and we may have an intense bellows or even rasping sound. The same circumstance, that is, the distension of the heart by coagula, is one cause of the feebleness of the impulsion, that is, if the muscular energy of the heart be once impaired so as to permit a larger quantity of blood than usual to accumulate, a much greater energy would be required to free itself of the mass which interposes a new and me- chanical obstacle to muscular contraction. But if the heart be not much distended, or if there be not a sudden diminution of power from the violence of the inflammation, the con- traction is often strong and exaggerated in en- docarditis, but there is generally something anomalous in its character, and it differs from the equable action of a healthy heart. The general symptoms of endocarditis are often very obscure, quite as much so as those of pericarditis ; that is, in extreme cases they may be violent, but in the larger number they are moderate, and scarcely to be recognized without physical exploration ; in another class they are so slight, that the disease is nearly if not quite latent. The pain may attend it like other inflammations, but if there is no accom- panying pericarditis, and no extreme obstruc- tion to the passage of the blood, it is often quite slight, or even absent: when there is pain it varies much in its character, sometimes it is very acute, and referred directly to the heart, that is, it is a true serous pain, but in other cases it is diffused over a large portion of the chest. Dyspnoea is also a frequent symptom, often violent, and causing intense suffering, with lividity of the lips and nostrils, and other signs of obstructed capillary circula- tion. In such cases, which are few in number, the patient has a haggard, wild expression, and 156 DISEASES OF THE HEART. the suffering may be more intense than from any other form of orthopncea. The pulse sometimes affords very decided signs of endo- carditis ; it is then very small and irregular, but generally tense. This may be termed the type of the pulse in this disease, but how many excep- tions do we find? The irregularity generally indicates a severe form of the disease, and usually depends upon valvular concretions. No other symptoms than those just mentioned, are at all frequent in endocarditis; the organs of the body, other than those of the chest, scarcely sympathize in the disease, except at a very late period, or when the fever is much more severe than usual. The brain is there- fore quite clear in most patients. The termination of endocarditis is favourable in the large proportion of cases ; we know that such is the result, not only from the symp- toms in those cases which have recovered, but because the internal membrane bears evident traces of previous inflammation in many indi- viduals who have died of various acute dis- eases unconnected with the heart. In severe cases, that is, when the valves are much al- tered the disease is highly dangerous and often fatal. Diagnosis. The inflammation of the inter- nal membrane may be confounded with that of the pericardium, or of other serous membranes of the chest. When endocarditis is the only disease the diagnosis is comparatively easy ; for the dyspnoea, which is extreme under such circumstances, not being accounted for by any other disease except inflammation of the inter- nal membrane of the heart or aorta, may be re- ferred to one of these sources. When complica- ted with pneumonia or other inflammations, the only symptoms of endocarditis which can guide us in the diagnosis, are the physical signs and the local symptoms, such as pain, intermittence of the pulse, &c. These are sufficient when both sets are present, but if one or two symp- toms only are developed, the diagnosis is merely probable. It is not, however, so diffi- cult as might be imagined; for as the disease is generally severe enough to give rise to a certain number of symptoms which are limited to the heart, the question is at last reduced to that of deciding between pericarditis and endo- carditis. In many cases these diseases cannot be se- parated, for they co-exist, and we may have the physical signs of both affections, or if the pericarditis be dry, the signs are simply those of endocarditis. The distinction then becomes unimportant, for the disease, at least as far as both prognosis and diagnosis are concerned, is identical. Treatment. The treatment of the disorder in the early stages, or in every stage, provided the powers of the heart have not sunk, is very simple ; that is, full bleeding will produce re- lief in almost every case of moderate inflam- mation ; in the more severe varieties the relief from blood-letting is not less decided. If the pain or dyspnoea persists, the bleeding may require to be repeated several times, es- pecially if the first bleeding be not well borne at first, although relief afterwards follows ; for the heart will support the loss of blood with comparative difficulty until it is relieved of the congestion, then the bleeding may be propor- tioned to the degree of the inflammation. In violent cases of endocarditis, bloodletting can- not be dispensed with, except at the certainty of extreme suffering, "and the probability of danger; in mild cases the remedy is less posi- tively necessary, for patients get well without being bled and without much suffering. Still, a depletory practice is certainly the surest means of preventing the consecutive diseases of the valves, which is the most constant dan- ger in endocarditis. Local depletion is not quite so efficient as in pericarditis, but it is still capable of relieving patients who are too feeble for bleeding; in mild cases it is often quite sufficient, especially in those of chronic hypertrophy, in which the patient is from time to time attacked with inflammation; such per- sons are often accustomed to have recourse to repeated cupping with the certainty of relief. Cups bear repetition much better than blood- letting. As to the counter-irritants, as blis- ters and the like, the advantages of them are much more problematical; except towards the decline of the inflammation, where there is pain remaining after the oppression has in a great degree ceased, they are comparatively of little benefit; but under the circumstances just men- tioned, they are of unquestionable service; a blister sometimes dissipates the remains of the disease with extreme rapidity. The usual internal remedies for the treat- ment of endocardial inflammation are nearly similar to those already mentioned under the ENDOCARDITIS. 157 head of pericarditis. As the disease is more obstinate and more deeply seated, the usual remedies are less certain in their action. As in pericarditis, in the early stages of the dis- order we trust mainly to antimony and opium as the best adjuvants to the immediate anti- phlogistic agents, provided the force of impul- sion of the heart be strong; otherwise anti- mony is a dangerous remedy. The good ef- fects of mercury in the declining stages of the disease, are nearly similar to those of this re- medy in pericarditis, the constitutional im- pression should be induced slowly with small doses, unless the disease become extremely acute, when decided treatment of any kind may be necessary. There is another class of internal remedies, not directly antiphlogistic, but of great service in the management of endocarditis. These are the antispasmodics, combined in some cases with digitalis. The latter remedy should be used cautiously; the advantages of it are almost limited to those cases in which the ac- tion of the heart is tumultuous and spasmodic, but not deficient in force; but in many cases and stages of endocarditis, the muscular power of the heart fails, and digitalis is totally inap- propriate. In these cases the lac assafcetidae, with twenty drops of Hoffman's anodyne, or a few drops of the ammoniated tincture of Vale- rian will often calm the action of the heart, and at the same time assist it to relieve itself of the blood which is constantly accumulating, menacing the patient with death by asphyxia. After the active period of the disease has 20 been safely passed, there still remains in many cases some evidence of disturbed action in the heart; the pulsation may be irregular and spasmodic, and a slight exciting cause may give rise to palpitation and other disagreeable feelings at the heart. This condition arises partly from the nervous disturbance which re- mains after the inflammation has been subdued, and partly from the real alterations of struc- ture which must remain after an organ has been inflamed. There is, therefore, a double line of treatment to be pursued; the action of the heart should be kept as quiet as possible by a careful abstinence from all ordinary ex- citants, whether moral or physical, and if the inflammation should return, a new resort must be had to local means, with digitalis conjoined with an antispasmodic. But a very simple diet, and avoidance of exciting causes, will be usually of themselves sufficient to prevent any serious mischief from such slight returns of the symptoms. An error is sometimes committed in the treatment of endocarditis as well as of other affections of the heart. Depletory measures including abstinence, are sometimes too long persisted in; there is an irritable condition of the heart which often remains after inflamma- tion, and is necessarily aggravated by very low diet and bleeding. The remedies are well known, a moderate diet, with some vegetable tonic, especially the cold infusion of the wild cherry bark will generally relieve it. Gentle exercise should be allowed after the disease has almost entirely subsided, but not before. EXPLANATION OF THE PLATE. h, Vena cava descendens. t, Line of direction of the mitral valve; the dotted portion is that part of it posterior to the right ventricle. i', Needle introduced perpendicular to the plane of the thorax, three inches from the left margin of the sternum, at the lower edge of the third rib, and passing in the mitral valve at its extreme left. k, Line of tricuspid valve. m, n, Needles introduced perpendicular to thorax, at points where the dulness of percus- sion of the heart ceases, and which being pro- jected, pass to the borders of that organ. o, Trachea. The heart is represented with the pericar- dium removed — the lungs drawn backwards by hooks, leaving its entire anterior surface exposed—the cartilages and ribs in front of it, indicated by dotted lines. S, Outline of the Sternum. C, Clavicle. 1, 2, 3, 4, 5, 6, &c, The ribs. 1', 2', 3', 4\ 5', &c, The cartilages of ribs. 4", Right and left nipples. a, Right ventricle. by Left do. c, Septum between the ventricles. d, Right auricle. e, Left auricle. /, The aorta;/', needle introduced through middle of sternum, perpendicular to its plane, opposite cartilages of third rib, passing into the aortic valves. g, The pulmonary artery; gf, needle intro- duced between the second and third cartilage half an inch to the left of the sternum, (per- pendicular to the plane of the thorax,) passing into the valves of the pulmonary artery. Note.—By the expression *' perpendicular to the plane of the thorax" used in the pre- ceding explanation, is meant, lines passing at right angles to the tangents of the various curved surfaces existing at different points of the chest. Erratum.—Page 136, bottom line of first column, for « it is not," read it is most. h4 * vmim John f'ol'hris del •Sinclair's Litli June, 1843. OK ANATOMY, MEDICINE, SURGERY, AND THE COLLATERAL SCIENCES. PUBLISHED B? Ep. HARRINGTON & GEO. D. HASWELL, Medical Publishers and Booksellers, PHILADELPHIA. HTEW W03B3KS AiTO WMW 3EEOT1EONS. ANDRAIi'S CLIi\IC, Complete. THREE VOLS. 8vo. Consisting of—DISEASES OF THE ENCEPHALON, DISEASES OF THE ABDOMEN, DISEASES OF THE CHEST. Eitherof the works can he had separate,—each forming a distinct volume. » The « Clinique Medicate' is the great work of its distinguished author. It is an iimmense storehouse of invaluable information in pathology and therapeutics. No medical library can bT™iete without it; and every physician, wfth the smallest pretensions to scient fie at- WinS; or who is desirous of discriminating disease accurately, and of treating it skilfully, should study its pages by day and night." EVANSON 6l 3YEATJNSEI.L. PRACTICAL TREATISE ON THE MANAGEMENT AND DIS* EASES OF CHILDREN. By Richard T. Evanson, M.D., Professor of Medicine,-and Henrv Maunsell, M.D., Professor of Midwifery in the Col. of Surgs. in Ireland. From the 4th Dublin edition. Edited by D. F. Condle, M.D. 1 vol. 8vo STANDARD MEDICAL WORKS fUSB.FEB.AL FEVER. THE HISTORY, PATHOLOGY, AND TREATMENT OF PUER- PERAL FEVER AND CRURAL PHLEBITIS. By Drs. Gordon, Hey, Armstrong, and Lee; with an INTRODUCTORY ESSAY by Charles D. Meigs, M.D., Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College, Philadelphia. 1 vol. 8vo. "We have peculiar satisfaction, in announcing the publication of this very judiciously arranged serii s of treatises, on one of the most important and interesting diseases, which demand the attention of the physician." "Dr. Meies'Introductory Essay is concise and iudi- cious, and will be read with profit. He speaks in the highest terms of commendation of Dr. Gordon's invaluable treatise — a treatise which cannot be too generally diffused and studied. Altogether this volume presents the most acceptable and useful compend of the doctrines and practice of the best authorities, with regard to ' Puerperal Fever,' with which we have ever met."—N. Y. Lancet. I " We are pleased to see the republication of these valuable monographs upon Puerperal Fever. As they are all of them Essays founded upon an extensive observation, and contain a very large number of recorded cases, ihey must always be valuable."—New England Jour. Med. Scien. " Taken in connexion, the treatises it comprises present an invaluable mass of facts in relation to Child-bed Fever, without an acquaintance with which no one can, with propriety, be considered fully qualified to undertake its management."—Jour. Med. Scien. DERANGEMENTS, PRIMARY and REFLEX, of the ORGANS of DIGESTION. By Robert Dick, M.D., author of " A Treatise on Diet and Regimen." 1 vol. 8vo. " Tt is the fullest, most comprehensive, and decidedly the best account of derangements of the digestive organs that we have encountered. While it embraces all that is important or interesting to be found in the writings of other authors, it contains much original informa- tion, which the physician will find of great practical usefulness.''—Western and Southern Medical Recorder. " We recommend this volume most warmly to the attention of our readers.—London Lancet, No. 937. " This volume may, in fact, be denominated with no small degree of propriety, an ency- clopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and comprehensive treatise on this class of diseases with which we are acquainted."—N. Y.Lancet. " We have perused this work with pleasure and instruction. It is decidedly the best compilation in the English language on the extensive class of disorders and diseases comprehended under the term dyspepsia, united with a very large proportion of original matter, both in the form of able comments on other writers, and practical information derived from the author's own experience.—Johnson's Medico-Chirurg. for Jan. 1842. SEX&EZGEgOCra. OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated from the German of Professor Schill. With copious notes by D. Spillman, M.D., A.M., &c, &c. 1 vol. 8vo. " An elegant and accurate translation of a very ingenious and instructive work. We do not know any other source from which we can so easily and profitably obtain all that is really useful in the semeiology of the ancients; and the erudite translator and editor has so very creditably supplied the deficiencies of the author's abrige of the labors of modern workers, in this most important department of modern science, that we can in good con- science commend the book as one of unequivocal merit.—New York Lancet. MEDICAL EXPERIENCE. CURIOSITIES OF MEDICAL EXPERIENCE. By J. G. Mil- lingen, Surgeon to the Forces, Member of the Medical Society of the Ancient Faculty of Paris, etc., etc. " Curiosities of Medical Experience. By J. G. Millingen, Surgeon to the Forces, etc. The Author or Compiler derived the idea which prompted him to write this work from D'Israeli's'Curiosities of Literature;' and, in our view, he has made a book equally curious in its way with that one. The heads of his chapters are numerous and varied and all his subjects are treated in an agreeable and comprehensible style to the genera! feader. The drift of the Author, too, is decidedly useful. We shall endeavour "to give some extracts from this work."—Nat. Gaz. PUBLISHED BY BARRINGTON AND HASV^ELL. 3 MATERIA 1VTEDICA. A PRACTICAL DICTIONARY OF MATERIA MEDtCA, includ- ing the Composition, Preparation and Uses of Medicines ,- and a large number of Extemporaneous Formulae: together with important Toxi- cological Observations- on the Basis of Brande"1s Dictionary of Materia Medica and Practical Pharmacy,- by John Bell, M.D., Lecturer on Materia Medica and Therapeutics, &c. &c. 1 vol. 8vo. _ "Mr. Branded is an excellent work, and with the retrenchments, additions, and altera- tions of Dr. Bell, may be regarded as one of the most valuable works on the Materia Medica we now possess. It has an important advantage over many of the treatises on this subject, ingiving a large number of prescriptions for the administration of the principal articles. This renders it especially valuable to the young practitioner." —Bait. Jour. A THERAPEUTIC ARRANGEMENT and SYLLABUS of MATERIA MEDICA. By James Johnstone, M.D., Fellow of the College of Physi- cians, and Physician to the General Hospital, Birmingham. " This book cannot but be particularly useful to those who intend to lecture or write upon the Materia Medica; as well as to the students for whose particular use it is pre- pared."—Brit, and For. Med. Rev. LIVER. AND SPLEEN. DISEASES OF THE LIVER AND BILIARY PASSAGES; by William Thomson, one of the Physicians of the Royal Infir- mary of Edinburgh; and CLINICAL ILLUSTRATIONS OF THE LIVER AND SPLEEN, by William Twining; Surgeon of General Hospital of Calcutta, &c, &c. 1 vol. 8vo. " The work before us is an excellent compilation of the subject of hepatic affections, functional and structural; and, as such, it is infinitely more valuable to practitioners and students, than any original essay, however ably executed. We cannot do better, therefore, than strongly recommend the work as the best in the English language, on the important subjects of which it treats.—Medico-Chirurg. Rev., October, 1841. " These two works, when united, form, we may safely say, one of the most valuable and attractive volumes on this important class of diseases which have been issued from the press. We may, en passant, remark, that the volume is got up in a very superior style."— N. Y. Lancet, March 26,1842. CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS PRESENTING EXTERNALLY. By John G. Malcolmson.M.D. Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and the Geological Society, London, 1 vol. 8vo. VENEREAL. HUNTER'S TREATISE ON THE VENEREAL DISEASE. With Notes by Dr. Babington. With Plates. 1 vol. 8vo. "Under the hands of Mr. Babington, who has performed his task as editor in a very exemplary manner, the work has assumed quite a new value, and may now be as advantageously placed in the library of the student as in that of the experienced sur- geon."— Brit. 8c For. Med. Rev. A PRACTICAL TREATISE ON"VENEREAL DISORDERS, AND MORE ESPECIALLY ON THE HISTORY AND TREATMENT OF CHANCRE. By Philippe Ricokd, M.D., Surgeon to the Venereal Hospital at Paris. 1 vol. 8vo. GRAVES & &EEHARD. CLINICAL LECTURES; by Robert J. Graves, M.D.,M.R.S.A., Professor of the Institutes of Medicine in the School of Physic. Trinity College, Dublin, with additional Lectures and Notes, by W. W. Gerhard, M.D., Lect. on Clin. Med. to the Univ. of Penn., Physician to the Philadelphia Hospital, Blockley, etc. 1 vol. 8vo. " In the volume before us, a series of clinical lectures by Dr. Gerhard is given, and forms a most appropriate and acceptable addition to those of Dr. Graves. Between these two dis- tinguished physicians we can trace many points of resemblance. We find in both the same professional zeal,— the same powers of close and correct observation,—the same discrimi- nating tact, —the same disregard of idle theory,—and the same decision in the application of right principles. No student or practitioner should be without this volume. It is in itself a library of practical medicine.'''—N. Y. Lancet. 4 STANDARD MEDICAL WORKS DISEASES OF CHILDREN. A TREATISE ON THE DISEASES OF CHILDREN; WITH DIRECTIONS FOR THE MANAGEMENT OF INFANTS; by the late Michael Underwood, M.D. From the ninth English edition, with Notes, by S. Merriman, M.D., and Marshall Hall, M.D., F.R.S., etc. ; with Notes, by John Bell, M.D.. etc., of Philadelphia. 1 vol. 8vo. JBTIOLOGY. ARET.EUS ON THE CAUSES AND SIGNS OF ACUTE and CHRONIC DISEASE. From the Greek, by T. F. Reynolds, M.B., F.L.S., &c, &c. 1 vol. 8vo. " The correct detail of symptoms, the nervous style, the graphic delineation of disease, displayed in this author's work, the poetic and quaint fancies scattered throughout, give a certain value and interest, that may fairly excuse an attempt to reinvest part of them in a vernacular garb." " We certainly have no hesitation, in recommending this curious volume to the notice of our readers. Its price is a mere trifle."—New York Lancet. EYES. A MANUAL OF THE DISEASES OF THE EYE. By S. Litteli, Jr., M.D., one of the Surgeons of the Wills' Hospital for the Blind and Lame, &c, &c. "We confidently recommend the work of Dr. Littell to the senior, as well as to the junior, members of the profession. It is replete with information ; yet so terse in style, and compressed in bulk, as at once to entice and repay perusal. It is no small triumph to the author to be able to say that he has introduced almost all that is valuable, and everything absolutely neeessary to the student within the compass of 200 pages, and we would deliberately recommend our young friends to read this work."— Br. 8c For. Med. Rev. GUP/IS. THE GUMS; with late Discoveries on their Structure, Growth, Connections, Diseases, and Sympathies. By George Waite, Member of the London Royal College of Physicians. 1 vol. 8vo. TEETH. A TREATISE ON THE TEETH. By John Hunter. With Notes by Thomas Bell, F.R.S. With Plates. 1 vol. 8vo. " The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his art. Mr. Bell has studied his subject with the greatest minuteness and care; and in ap- propriate notes at the foot of the page correets the author with the air of a gentleman, and the accuracy of a man of science. The matter contained in these short notes forms an ample scholum to the text; and without aiming at the slightest display of learning, they at the same time exhibit a ready knowledge on every point, and an extensive in- formation both of comparative anatomy and pathology.—Med. Gazette. CONSTIPATION. A TREATISE on the CAUSES and CONSEQUENCES of HABITUAL CONSTIPATION. By John Burne, M.D., Fellow of the Royal College of Physicians, Physician to the Westminster Hospital, &c. 1 vol. 8vo. " For some interesting cases illustrative of this work, the author is indebted to Dr. Williams, Dr. Stroud, Dr. Callaway, Mr. Morgan, Mr. Taunton, Dr. Roots, Sir Astley Cooper, Sir Benjamin Brodie,Mr. Tupper, Mr. Bailer, Dr. Paris, Mr. Dendy, Dr. Hen. U.Thomson," kc—Preface. PUBLISHED BY BARRINGTON AND HASWELL. CHEST. LECTURES on the PHYSIOLOGY and DISEASES of the CHEST, including the Principles of Physical and General Diagnosis, illustrated chiefly by a rational Exposition of their Physical Signs: with new re- searches on the sounds of the heart. By Charles J. B. Williams, M.D. Third edition, 1 vol. 8vo. "Evidently written by a man thoroughly acquainted with his sul ject."—Lancet. We strongly recommend this work to the attention of auscultators."— Med. Chir. Rev. I gladly avail myself of this opportunity of strongly recommending this very valuable work."—Dr. Forbes's Translation of Laennec. ''Of all the works on this subject, we are inclined much to prefer that of Dr. Williams."— Med. Gaz. J LECTURES ON THE DIAGNOSIS, PATHOLOGY, AND TREAT- MENT OF THE DISEASES OF THE CHEST. By W. W. Gerhard, M.D., Lecturer on Clinical Medicine in the University of Pennsylvania, etc., etc. 1 vol. 8vo. " A series of clinical lectures — concise, lucid, and eminently instructive. We have no more able expositor of diseases of the chest than Dr. Gerhard, and any work of his on these important subjects is certain of grateful acceptance by his professional brethren."—New York Lancet. "To our readers, therefore, we recommend the book of Dr. Gerhard as the fullest and most judicious manual, in relation to the diseases of the chest, which they can procure."— Western and Southern Recorder, June, 1842. "These lectures constituts a useful and practical digest of the existing knowledge of the diseases of the chest (lungs and heart)."—Bulletin of Medical Science. A PRACTICAL TREATISE on~the PRINCIPAL DISEASES of the LUNGS. Considered especially in relation to the particular Tissues affected, illustrating the different kinds of Cough. By G. HumeWeatherhead, M.D., Member of the Royal College of Physi- cians.Lecturer on the Principles and Practice of Medicine, and on Materia Medica and Therapeutics, &c. &c. 1 vol. 8vo. PRACTICAL OBSERVATIONS on~DISEASESof the HEART, LUNGS, STOMACH, LIVER, &c, OCCASIONED by SPINAL IRRITA- TION: AND ON THE NERVOUS SYSTEM IN GENERAL, AS A SOURCE OF ORGANIC DISEASE. Illustrated by Cases. By John Marshall, M.D. 1 vol. 8vo. CUTANEOUS DISEASES. A PRACTICAL TREATISE ON DISEASES OF THE SKIN, arranged with a view to their Constitutional Causes and Local Character, &c. By SAMUEL PLUMBE, lale Senior Surgeon to the Royal Metropolitan Infirmary for Children, &c. Illustrated with Splendid Coloured Copper- plate arid Lithographic Engravings. 1 vol. 8vo. Plumbe on Diseases of the Skin.—" This excellent Treatise upon an order of diseases, the pathology of which is, in general, as obscure as the treatment is empirical, has just been republished, edited by Dr. John Bell, of this city. We hail with pleasure the appear- ance of any new work calculated to elucidate the intricate and ill-understood subject of skin-diseases. The late Dr. Mackintosh, in his Practice of Physic, recommends it as the ' best pathological and practical treatise on this class of diseases, which is to be found in any language.'"—Phil. Med. Exam., Jan. 17, 1838. ,*.»,. ., -n ,- u " This work is one of the most excellent on the Diseases of the Skin in the English language."— West. Jour, of Med. and Pliys. Sciences, Jan. 1838. PHYSICAL AGENTS. ON THE INFLUENCE of PHYSICAL AGENTS on LIFE. By W. F. Edwards, M.D., F.R.S., etc. Translated from the French, by Drs. Hodgkin and Fisher. To which are added, some Observations on Elec- tricity, and Notes to the work. 1 vol. 8vo. » This is a work of standard authority in Medicine ; and, in a physiological point of view is pre-eminently the most valuable publication of the present century ; the experi- mentalinvestigation instituted by the author, having done much towards solving many wob ems hUherto but partially understood. The work was originally presented in parts & the RoyalAcadem/of Science of Paris, and so highly did they est.mate the labours of [he Sor and ^o fully appreciate the services by him thus rendered to science and ?o humanity" that they awarded him, though a foreigner, the prize founded for the promotion of experimental physiology. 0 STANDARD MEDICAL WORKS TETANUS. A TREATISE ON TETANUS, being the ESSAY for which the Jackson ian Prize was awarded by the Royal College of Surgeons in London. By Thomas Bli/.ard CuRLiNG,Assistant Surgeon to the London Hospital,&c. " This book should be in the library of every surgeon and physician, it is a valuable work of reference. It does not pretend to originality, for originality on such a subject was not wanted. But a compendium of facts was wanted, and such a compendium is this volume. We cannot part from Mr. Curling without thanking him for the information we have received in reading his work, and for the matter it has enabled us to oft'er to our readers."—Medico- Chir. Rev. BLOOD, INFLAMMATION, ETC. TREATISE ON THE BLOOD, INFLAMMATION, AND GUN-SHOT WOUNDS. By John Hunter, F.RS. With Notes, by James F. Palmer, Senior Surgeon to the St. George's and St. James's Dispensary, &c, &c. 1 vol. 8vo. LECTURES ON BLOOD-LETTING. By Henry Clutterbuck, M.D. 1 vol. 8yo. HISTORICAL NOTICES ON THE OCCURRENCE OF INFLAMMA- TORY AFFECTIONS OF THE INTERNAL ORGANS AFTER EXTERNAL INJURIES AND SURGICAL OPERATIONS. By William Thompson, M.D., &c. &c. 1 vol. 8vo. A TREATISE ON INFLAMMATION. By James Macartney, F.R.S., F.L.S., &c, »fec. Member of the Royal College of Surgeons, London, &c, &c. 1 vol. 8vo. LECTURES ON THE BLOOD, and on the CHANGES which it undergoes during DISEASE. By F. Magewdie, M.D. 1 vol. 8vo. ANIMAL (SSONOMY. OBSERVATIONS ON CERTAIN PARTS OF THE ANIMAL CECO- NOMY, Inclusive of several papers from the Philosophical Transactions, &c. By John Hunter, F.R.S., &c, &c. With Notes by Richard Owen, F.R.S. 1 vol. 8vo. MIDWIFERY. LECTURES ON THE PRINCIPLES AND PRACTICE OF MID- WIFERY. By James Blundell, M.D. Edited by Charles Severn, M.D. 1 vol. 8vo. Just published. " The eminently fluent and agreeable style—the large and accurate information —the great experien e — and original mind of Dr. Blundell have secured for him a very enviable reputation as a public lecturer. It is impossible to read these lectures without being delighted — it is equally impossible to avoid being instructed. Were these discourses more generally diffused and studied here — were their sound and judicious directions recollected and their salutary cautions observed, we would hear of fewer cases of malpractice. This work forms a complete system of midwifery, with the diseases of tho puerperal state and ol the infant.''— N. Y. Lancet. A PRACTICAL TREATISE on MIDWIFERY; Containing the Results of Sixteen Thousand Six Hundred and Fifly-four Births, occurring in the Dublin Lying-in Hospital. By Robert Collins, M.D., Late Master of the Institution. 1 vol. 8vo. " The author of this work has employed the numerical method of M. Louis ; and by accurate tables of classification, enables his readers to perceive, at a glance, the conse- quences of the diversified conditions, in which he saw his patients. Avast amount of information is thus obtained, which is invaluable to those who duly appreciate precision in the examination of cases."—Bait. Chron. A PRACTICAL COMPENDIUM OF MIDWIFERY; being the Course of Lectures on Midwifery and on the Diseases of Women and Infants delivered at the St. Bartholomew's Hospital by the late Robert Gooch, M.D. Prepared for Publication by George Skinner, Member of the R. Coll. of Surg., Lond. 1 vol. 8vo. PUBLISHED BY BARRINGTON AND HASWELL. 7 ARMSTRONG'S LECTURES. LECTURES on the MORBID ANATOMY, NATURE, and TREAT- MENT of ACUTE and CHRONIC DISEASES. By the late John Armstrong, M.D.; Author of " Practical Illustrations of Typhous and Scarlet Fever," &c. Edited by Joseph Rix, Member of the Royal Col- lege of Surgeons. ] vol. 8vo. The British and Foreign Medical Review says of this work: "We admire, in almost every page, the precise and cautious practical directions; the striking allusions to instructive cases; the urgent recommendations of the pupil to be careful, to be diligent in observation, to avoid hurry and heedlessness, to be atten- tive to the poor. Nothing can be more excellent than the rules laid down for all the parts of the delicate management of fever .patients: nothing more judicious than the general instructions arising out of the lecturer's perfect knowledge of mankind...... His prudent admonitions respecting the employment of some of the heroic remedies, as mercury, arsenic, and colchicum, attest his powers of observation and his practical merits." " The pious office of preserving and publishing his Lectures has been performed by Mr. Rix, with singular ability." INSANITY. A TREATISE on INSANITY and other DISEASES AFFECTING the MIND. By James Cowles Prichard, F.R.S. M.D. Corresponding Member of the Institute of France, &.c. 1 vol 8vo. " The author is entitled to great respect for his opinions, not only because he is well known as a man of extensive erudition, but also on account of his practical acquaint- ance with the subject on which he writes. The work, we may safely say, is the best, as well as the latest, on mental derangement, in the English language."—Medico-Chir. Rev. --- A TREATISE ON MENTAL DISEASES. By M. Esquirol. APHORISMS on the TREATMENT and MANAGEMENT of the INSANE: with considerations on Public and Private Lunatic Asylums, pointing out the errors in the present system. By J. G. Millingen, M.D., late Medical Superintendent of Lunatic Asylum, Hanwell, Middlesex, &c. 1 vol. 8vo. "Dr. Millingen, in one small pocket volume, has compressed more real solid matter than could be gleaned out of any dozen of octavos on the same subject. We recommend his vade mecum as the best thing of the kind we ever perused."—Dr. Johnson's Review. CLINICAL MEDICINE. MEDICAL CLINIC; or, Reports of Medical CASES: By G. Andral, Professor of the Faculty of Medicine of Paris, etc. Condensed and Translated, with Observations extracted from the Writings of the most distinguished Medical Authors: By D. Spil- lan, M.D., etc., etc.; containing Diseases of the Encephalon, &c. with Extracts from Ollivier's Work on Diseases of the Spinal Cord and its Membranes. 1 vol. 8vo. MEDICAL CLINIC: DISEASES OF THE ABDOMEN. By G. Andral, M.D., Professor to the Faculty of Paris, Member of the Royal Academy of Medicine etc., etc. Condensed and Translated, with Observations, by D. Spill'an, M.D., Fellow of the King and Queen's College of Physicians in Ireland, Member of the Association of the Fellows and Licentiates of the College of Physicians, and Formerly Physician to the Dublin General Dispensary. 1 vol. 8vo. MEDICAL CLINIC: DISEASES OF THE CHEST. By G. Andral, M.D., etc., etc. Translated by D. Spillan, M.D., etc. 1 vol. 8vo. LECTURES on Subjects connected with CLINICAL MEDTCINE. By P. M. Latham, M.D. Fellow of the Royal College of Physicians and Physician to St. Bartholomew's Hospital. "We strongly recommend them [Latham's Lectures] to our readers; particularly to pupils attending the practice of our hospitals."-Z,»nc/. Med. Gaz. 8 STANDARD MEDICAL WORKS SURGERY. ELEMENTS OF SURGERY, in Three Parts. By Robert Liston, Fel- low of the Royal College of Surgeons in London and Edinburgh, Surgeon to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for the City and County of Edinburgh, Professor of Surgery in the London University, &c. &c. Third American, from the Second London Edition, with upwards of one hundred and sixty illustrative engravings. Edited by SAMUEL D. GROSS, M.D., Professor of Surgery, Louisville Medical Institute. Author of Ele- ments of Pathological Anatomy, etc., etc. 1 vol. 8vo. " We must not forget to mention that the volume is rendered still more attractive by the addition of numerous wood engravings (some of them introduced by Dr. Gross), all finely executed. These will be found of very considerable advantage to the student, materially assisting him in comprehending the explanation of morbid structure. Another admirable feature, is the printing of the notes in type of the same size as that of the text. This obvi- atesalmost entirely, whatever objections can be alleged against foot-notes."—Western Jour. of Med. and Surg., Dec, 1642. " We are here presented with a republication of Mr. Liston's admirable and much praised work on Surgery, which has been subject to the alembic of a critical and learned friend, Dr. Gross. He has added ' copious notes and additions,' such as the progress of surgery in the United States demands in order to meet the wants of the surgeon. Professor Gross has also given an entire article on Strabismus, and another on Club Feet, which were wholly omitted in the English copies. They may be regarded important, inasmuch as they give a completeness to an otherwise unfinished treatise. The execution of the book is good ; the paper firm, and well secured in the binding. The plates are uniformly well executed, and the impressions distinct."—Boston Med. and Surg. Jour. "In another essential feature this edition is greatly improved. With the principles is taught also with it the practice of surgery; and both morbid structure and operations are douhly described ; first by the author and editor, and next by the graver of the artist."— Bull. Med. Scien. " Mr. Liston has seen much, thinks accurately, and speaks independently. From a volume written by such a man, more really valuable practical instruction is to be derived than from all the books that were ever compiled."— Western and Southern Med. Recorder. " This is a work of established reputation. It has gone through two editions in Great Britain, and the same number in this country. The additions of the American edition are copious, and add materially to the value of the work."—Amer. Jour. Med. Sciences. "The author is bold and original in his conceptions, accurate in deductions, plain and concise in style; a combination of good qualities not often found united in a single volume. The notes and additions, by Prof. Gross, are well arranged and judicious, sup- plying some evident deficiencies in the original work."—Western Lancet. LECTURES OF SIR ASTLEY COOPER on the PRINCIPLES and PRACTICE of SURGERY, with additional Notes and Cases. By Frederick Tyrrell, Esq., Surgeon to St. Thomas's Hospital, and to the London Ophthalmic Infirmary. 1 vol. 8vo. LECTURES ON THE PRINCIPLES OF SURGERY. By John Hunter, F.R.S. With Notes by James F. Palmer, Senior Surgeon to the St. George's and St. James' Dispensaries, &c. <&c. With Plates. 1 vol. 8vo. " We cannot bring our notice of the present volume to a close without offering our testimony to the admirable manner in which the editor and annotator has fulfilled his part, of the undertaking. The advancements and improvements that have been effected, up to our own day, not only in practical surgery, but in all the collateral departments, are constantly brought before the reader's attention in clear and concise terms."— Brit. 8c For. Med. Rev. ___________________________ JOHN HUNTER'S WORKS. THE COMPLETE WORKS OF JOHN HUNTER, F.R.S., 4 vols. 8vo., comprising his Lectures on the Principles of Surgery; A Treatise on the Teeth; Treatise on the Venereal Diseases; Trea- tise on Inflammation and Gun-Shot Wounds; Observations on Certain Parts of the Animal CEconomy ; and a full and comprehen- sive Memoir. Each of the Works is edited by men of celebrity in the Medical Science, and the whole under the superintendence of Jas. F. Palmer, of the St. George's and St. James's Dispensary. This is the only complete edition of the works of the distinguished physiologist ever published in this country. " One distinctive feature of the present edition of Hunter's works has been already mentioned, viz: .in the addition of illustrative notes, which are not thrown in at hazard, but are written by men who are already eminent for their skill and attainments on the particular lubjecta which they have thus illustrated. By this means, whilst we have the PUBLISHED BY BARRINGTON AND HASWELL. views entire of John Hunter in the text, we are enabled by reference to the accompanying notes, to see wherein the author is borne out by the positive knowledge of the present day, or to what extent his views require modification and correction. The names of the gentlemen who have in this manner assisted Mr. Palmer, are guarantees of the successful performance of their task." —Med. Gaz. g) HYSTERIA. AN ESSAY ON HYSTERIA, being an analysis of its irregular and aggra- vated forms; including Hysterical Hemorrhage and Hysterical Ischuria. With numerous Illustrative and Curious Cases. By Thomas Laycock, House Surgeon to the York County Hospital. 1 vol.8vo. UTERUS- LECTURES on the FUNCTIONS and DISEASES of the WOMB, by Charles Waller, M.D., Bartholomew's Hospital. ON DISEASES of the UTERUS and its APPENDAGES, by M. Lisfranc, La Pitie Hospital. ON DISEASES of the PUERPERAL STATE, by J. T. Ingleby, Edinburgh. 1 vol. 8vo. " We can very cordially recommend them as affording a concise and practical exposition of the pathology and treatment of a most important class of diseases, and which cannot be too attentively studied."—N. Y. Lancet. " The present volume contains a short and succinct practical account of the principal mor- bid states either of the functions or the structure of the womb, the best methods of dis- tinguishing them, and the means which experience has shown to be the most effectual in removing them. The reader will find that he obtains, in a small compass, a distinct view of the nature and treatment of each disorder.''—Edinb. Med. and Surg. Journ. URINARY DISEASES. URINARY DISEASES and their TREATMENT. By Robert Wil- lis, M.D., Physician to the Royal Infirmary for Children, &c. &c. "We do not know that a more competent author than Dr. Willis could have been found to undertake the task ; possessing, as it is evident from his work that he does nossess an accurate acquaintance with the subject in all its details, considerable per- sonal experience in the diseases of which he treats, capacity for lucid arrangement, and a style of communication commendable in every respect."—Brit. 8c For. Med. Rev. AMUSSAT'S LECTURES on the RETENTION of URINE, CAUSED by STRICTURES of the URETHRA, and on the Diseases of the Prostate, translated from the French by James P. Jervey, M.D. EPIDEMICS OP THE MIDDLE AGES. EPIDEMICS of the MIDDLE AGES. From the German of I. F. C. Hecker, M.D., &c &c Translated by R. G, Babington, M.D. F.R.S.— No. I.—THE BLACK DEATH IN THE 14th CENTURY. "Hecker's account of the 'Black Death,' which ravaged so large a portion of the globe •n thP fourteenth century, may be mentioned as a work worthy of our notice, both as ' ^J^J^nvSeMnT^tt' of this tremendous pestilence, and as exhibiting a curious specimen of mS hypothesis.'-C^^a „/ Practical Medicine-History of Medicine by Dr. Bostock. No. II—THE DANCING MANIA. » Medical History has long been in need of the chapter which this book supplies; and the deficiency could not have been remedied at a better season On the whole, the volume ought to beT popular; to the profession it must prove highly acceptable, as con- volume ougiu '"."fFP ' tnlir,hin M.D., Lecturer at the Medical School, Fark Street, Dublin : Physician to the Meath County Hospital, etc., etc., and John Bell, M.D., Lecturer on Materia Medica and nerapeutics : Member of the College of Physicians, Philadelphia, and of the American Philosophical Society, etc., etc. Second American Edition. 2 vols. 8vo. valuIbleTs'a ^ZnWnT/Vn6 f?m ? V1"!16 ,comPl<*e system of medicine, equally know of no hnnt nf^?^^ ™*°M> and a book of reference to the practitioner » 4» We £ to which ti0,?™'1'1 Wll'?h w,e w9uld more readily P»ace in the hands of a student, ^"-N^X^S^^TSl an7^10ner' ^ a haSly inVeSU^U°n °f a ^ work'fnft?Zrtl^'^^h e*P?rie1Ce b* l"ge or sLll'should De without5,is a^tention.»-mS Lan'oet^ " therC' he Sh°Uld StUdy itS Va™US Parts wilh care and mltvt^tr?™™ °S u 'S W°nkc^, established reputation, is sent out from the press of Sn.,h ^n and Haswell, Philadelphia. No change in the mind of the medical public, fw »,}^gJne,worth of this very celebrated series of medical lectures, has been wrought by ,»iia„J , .V- ter PubllPllons ?n the same subjects. It is just as popular as ever, and we Believe, at this moment, is exerting a far more extensive influence than was ever predicted by the warmest personal friends of the two learned authors."—Boston Med. and Surg. Jour. The following is from the pen of a distinguished Professor in one of the Medical Schools in the West. " We cordially recommend the joint labours of two such distinguished phvsicians as urs. btokes and Bell to the notice of the medical profession. They will be found to em- Dody the principles and practice of medical science down to the present moment."—Louis- ville Journal. MISCELLANEOUS. OUTLINES OF GENERAL PATHOLOGY. By George Freckleton, M.D., Fellow of the Royal College of Physicians. OBSERVATIONS on the PRINCIPAL MEDICAL INSTITUTIONS and PRACTICE of FRANCE, ITALY,and GERMANY: with Notices of the Universities, and Cases from Hospital Practice: With an Appen- dix on ANIMAL MAGNETISM and HOMOEOPATHY. By Edwin Lee, Member of the Royal College of Surgeons, &c. 1 vol.8vo. " Mr. Lee has judiciously selected some clinical cases, illustrating the practice pursued at the different hospitals, and he has wound up the volume with an amusing account of animal magnetism and homoeopathy—those precious effusions of German idealty, for which we refer to the work itself.—Medico-Chirurg. Rev. BOUILLAUD ON ACUTE ARTICULAR RHEUMATISM IN GEN- ERAL. Translated from the French, by James Kitchen, M.D., Philada. MEDICAL AND TOPOGRAPHICAL OBSERVATIONS upon the MEDITERRANEAN and upon PORTUGAL, SPAIN, AND OTHER COUNTRIES. By G. R. B. Horner, M.D., Surgeon U. S. Navy, and Honorary Member of the Philadelphia Medical Society. With En- gravings. 1 vol. 8vo. " An uncommonly interesting book is presented to those who have any disposition to know the things medical in Portugal, Spain, and other countries," and " will doubtless be read, also, with marked satisfaction by all who have a taste for travels.—Bost. Med. and Surg. Jour. AN ESSAY ON DEW, and several Appearances connected with it, by William Charles Wells, M.D., F.R.S., etc. ON DENGUE; ITS HISTORY, PATHOLOGY, AND TREATMENT. By S. Henry Dickson, M.D., Professor of the Institutes and Practice of Medicine in the Medical College of S.C. HINTS ON THE MEDICAL EXAMINATION OF RECRUITS FOR THE ARMY; and on the Discharge of Soldiers from the Service on Surgeon's Certificate : Adapted to the Service of the United States. By Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c, &c. 12 STANDARD MEDICAL WORKS, ETC. MISCELLANEOUS— Continued. MEDICAL NOTES AND REFLECTIONS. By Henry Holland,M.D.; F.R.S., Fellow of the Royal College of Physicians, and Physician Extra- ordinary to the Queen. THE MEDICAL PROPERTIES oTthe NATURAL ORDER RANUN- CULACEiE,&c, &c. By A. Turnbull, M.D. Prof. HORNER'S NECROLOGICAL NOTICE OF DR. P. S. PHYSICK ; Delivered before the American Philosophical Society, May 4, 1838. THE LIFE OF JOHN HUNTER, F.R.S. By Drewry Ottley. 1 small vol. 8vo. "In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equal judgment and candour."—Brit. 8,- For. Med. Rev. ESSAY UPON THE QUESTION, IS MEDICAL SCIENCE FAVOR- ABLE TO SCEPTICISM? By James W. Dale, M.D., of New- castle, Delaware. Pamphlet. METEOROLOGICAL REGISTER for the years 1826-30 ; from Observa- tions made by Surgeons of the Army and others at the Military Posts of the United States. Prepared under the direction of Thomas Lawsox, M.D., Surgeon-General U.S.A. In Press, ARAN'S PRACTICAL MANUAL ON DISEASES of the HEART and GREAT VESSELS. Translated from the French. A TREATISE on BANDAGING and MINOR SURGERY; or, Hints on the Every-dayDuties of the Surgeon. By H. H. Smith, M.D., Lecturer on Minor Surgery, Fellow of the College of Physicians, Member of the Phila- delphia Medical Society. Illustrated by Engravings. PRACTICAL MEDICINE. Illustrated by Cases on the most Important Diseases. Edited by John M. Gait, M.D. B. Sr H. continue to publish THE SELECT MEDICAL LIBRARY AND BULLETIN OF MEDICAL SCIENCE. EDITED BY JOHN BELL, M.D., AT FIVE DOLLARS PER ANNUM, IN ADVANCE. Each No. of the Library will consist of one or more approved works on some branch of Medicine, including, of course, Surgery and Obstetrics. Every work in the Library will be completed in the number in which it is begun, unless the subject naturally admits of division ; and hence the size of the numbers will vary. It will be done up in a strong paper cover, and each work labelled on the back; thus obviating the immediate necessity of binding. Subscribers will receive fourteen hundred pages of closely printed matter of Library in the year. The Bulletin of Medical Science will be published monthly, in num- bers of thirty-six pages. It will be supplied to the subscribers to the Select Medical Library without any additional cost, on their remittingjfoe dollars, the subscrip- tion price of the Library for one year. Those who wish to take the Bulletin alone, will have it sent to their address for $1 per annum. Clubs will be furnished with six copies of the Bulletin for $5. Subscription. — FIVE DOLLARS per annum, in advance; and in no single instance, out of the principal cities, will this rule be departed from. Any person ordering Books to the value of Ten Dollars from the following list, and remitting the amount free of postage, will be entitled to the Bulletin for one year, gratis. LIST OF WORKS SUPPLIED AS SELECT MEDICAL LIBRARY Extras,-by Mail. Subscribers to the Library and Bulletin, and the Medical Faculty in general, are respectfully informed that the Publishers will furnish the following Works as Extras,- for which purpose they are stitched in thick paper covers, with strong elastic backs, similar to the regular numbers; they can be sent by mail at the Periodical charge for Postage, which is per sheet, if under 100 miles, 1J cents, exceeding that distance, 2\ cents. To the name of each work is stated its number of sheets and the selling price; so that any gentleman desirous of having one or more Extras will, by remitting a note, (or order payable in Philadelphia,) be furnished, by return of mail, with whatever he may select, to the amount. The Post Office regulations on Periodicals are such that remittances can be made with little or no expense to Subscribers or Publishers,—the Postmaster enjoying the privilege of franking all such letters. N.B. Those works comprised within brackets are bound in one volume, and must be ordered as one Extra. LEE'S OBSERVATIONS on the PRINCIPAL MEDICAL INSTIO TUTIONS and PRACTICE of FRANCE, ITALY, and GER- * MANY, j J CD I 0 80 r $0 80 PRACTICAL OBSERVATIONS on DISEASES of the HEART, LUNGS, STOMACH, LIVER, &c. By John Marshall, M.D., &c. I | WEATHERHEAD on DISEASES of the LUNGS ; considered especi- } " ally in relation to the particular Tissue affected, illustrating the different ^ | kinds of Cough, J v PRICHARD on INSANITY and other DISEASES affecting the MIND. 14 sheets. • • • • • . 1 25 DAVIDSON and HUDSON'S ESSAYS on the SOURCES and MODE OF ACTION OF FEVER. 8 sheets. .... MACROBIN'S INTRODUCTION to the STUDY of PRACTICAL MEDI- CINE, being an outline of the Leading Facts and Principles of the Science. 6 sheets. ..••••■ SIR JAMES CLARK on the SANATIVE INFLUENCE of CLIMATE. 8 sheets. ..••••• 80 70 80 14 Catalogue of Works supplied by Mail, CHANGES of the BLOOD in DISEASE. Translated from the French of M. Gibert, by John H. Dix, M.D., M.M.S.S. 3 sheets. • • 50 SIR CHARLES BELL'S INSTITUTES OF SURGERY. Arranged in the order of the Lectures delivered in the University of Edinburgh. 19 sheets. $1 50 EPIDEMICS of the MIDDLE AGES, viz. The Black Death and Dancing Mania; translated from the German of Hecker, by Dr. Babington, F.R.S. 7 sheets. ...••• EVANSON and MAUNSELL on the MANAGEMENT and DISEASES of CHILDREN. A new edition in press, shortly to be published. M"3 j jco L THE FOLLOWING ESSAYS ON PHYSIOLOGY AND HY-) GIENE: — Reid's Experimental Investigation into the Functions of the Eighth Pair of Nerves. Ehrenberg's Microscopical Observations on the Brain and Nerves; with numerous Engravings. On the Combination of Motor and Sensitive Nervous Activity; by Prof. Stromeyer, Hanover. Vegetable Physiology. } j§ < Experiments on the Brain, Spinal Marrow, and Nerves. By Prof. Mayer, of Bonn; with wood cuts. Public Hygiene. Progress of the Anatomy and Physiology of the Nervous System, during 1836. By Pro. Muller. Vital Statistics. REID on the FUNCTIONS of the EIGHTH PAIR of NERVES, j 0 60 The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., from November, 1836, to October, 1837. 19 sheets. . • .2 00 PLUMBE on DISEASES of the SKIN; with splendid coloured Engravings. 17 sheets. . . . . • • . 2 25 TURNBULL'S TREATISE on the MEDICAL PROPERTIES of the Natural order RANUNCULACE^E, &c. &c. THE GUMS ; their Structure, Diseases, Sympathies, &c. By George >J! <{ • 0 85 Waite. An ESSAY on DEW, &c. By W. C. Wells, F.R.S. j COLLINS'S PRACTICAL TREATISE on MIDWIFERY. 11 sheets. . 125 EDWARDS on the INFLUENCE of PHYSICAL AGENTS on LIFE : with observations on ELECTRICITY, &c. 10 sheets. . . .100 HORNER'S NECROLOGICALNOTICEOFDR.P. S. PHYSICK.^) . f IS MEDICAL SCIENCE FAVOURABLE TO SCEPTICISM ? | f j By Dr. Dale, of Newcastle, Delaware. > .£ < 0 30 ON DENGUE; its HISTORY, PATHOLOGY, and TREATMENT. ' By Prof. Dickson of S. C. 125 FRECKLETON'S OUTLINES of GENERAL PATHOLOGY. 7 sheets. . 0 75 URINARY DISEASES, and their TREATMENT. By R. Willis, M.D., &c. 10 sheets. . . . . . . . 1 00 MILLINGEN'S CURIOSITIES of MEDICAL EXPERIENCE. 15 sheets. 1 50 in the Select Medical Library,—extra. 15 ANDRAL'S MEDICAL CLINIC: Diseases of the Encephalon, Spinal Cord, &c. &c. 13 sheets. . • • . • . 1 20 The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c, from November 1837, to October, 1838. 21 sheets. . . . . $2 00 LECTURES on the PHYSIOLOGY and DISEASES of the CHEST. By Prof. Williams. With Engravings. 15 sheets. . . . . 1 75 LECTURES on BLOOD-LETTING. By Dr. Clutterbuck. 5 sheets. . 0 65 MEDICAL and TOPOGRAPHICAL OBSERVATIONS upon the MEDI- TERRANEAN, and upon PORTUGAL, ftPAIN, and other countries. By G. R. B. Horner, Surgeon U. S. N., &c. Illustrated with Engravings. 9 sheets. . . . . . . . 1 00 MAGENDIE'S LECTURES on the BLOOD : its Changes during Disease, &c. 12 sheets. . . . . . . . 1 25 The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c, from November, 1838, to October, 1839. 20 sheets. . . . 2 00 HOLLAND'S MEDICAL NOTES and REFLECTIONS. 16 sheets. . 1 60 ARMY METEOROLOGICAL REGISTER for the YEARS 1826,^j ' 1827,1828,1829, and 1830. » HINTS on the MEDICAL EXAMINATION of RECRUITS for the 1 g I Q - ARMY; and on the Discharge of Soldiers from the Service on {-g j Surgeon's Certificate: Adapted to the Service of the United States. By I 0 Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c, &c.J MACARTNEY on INFLAMMATION. 5 sheets. . . .0 50 BURNE on HABITUAL CONSTIPATION—its Causes and Consequences. 7 sheets. • • _.______•_ • • . 0 75 A PRACTICAL TREATISE ou VENEREAL DISORDERS, &c.^ rf f By P. Ricord of the Venereal Hospital, Paris. ttotimp 11 J n tn AMUSSAT'S LECTURES on the RETENTION of URINE, S|^ 0/5 CAUSED by STRICTURES of the URETHRA, and on the Diseases - of the Prostate. Translated from the French by James P. Jervey, M.U. J I ESQUIROL on MENTAL DISEASES. 1|J AN ESSAY ON HYSTERIA. With numerous Illustrative and Curious j-^ < i uu Cases. By Thomas Laycock. J S I CLINICAL REMARKS on some Cases of LIVER ABSCESS pre-^| ( senting externally. By John G. Malcolmson, M.D., Surgeon Hon. L. 1. | C. Service, &c. .r,nrnrmnMa}jS ° 45 THOMSON'S NOTICES of INFLAMMATORY AFFECTIONS M \ of the INTERNAL ORGANS after EXTERNAL INJURIES and « SURGICAL OPERATIONS. J *• The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c, from November, 1839, to October, 1840. 20 sheets. GOOCH'S PRACTICAL COMPENDIUM of MIDWIFERY. 14 sheets. . 1 00 GRAVES'S CLINICAL LECTURES. With Notes and Fifteen additional Lectures, by W. W. Gerhard, M.D., Lecturer on Clinical Medicine to the Uni- versity of Pennsylvania, etc. 23 sheets. 200 2 50 16 Catalogue of Works supplied by Mail— extra. ELEMENTS OF SURGERY, in Three Parts. By Robert Liston,^ f v'f- Fellow of the Royal College of Surgeons in London and Edinburgh, » I V^V < &c Third American, from the Second London Edition, with upwards I S J _ . tV of one hundred and sixty illustrative engravings. Edited by Samuel D. f-g "S 3 ^° G Ross, M.D., Professor of Surgery, Louisville Medical Institute. Author I g? of Elements of Pathological Anatomy, etc.. etc. 1 vol. 8vo. J ^ THE HISTORY, PATHOLOGY, AND TREATMENT.OF PUER^) f PERAL FEVER AND CRURAL PHLEBITIS. By Drs. Gordon, | a I Het, Armstrong, and Lee; with an INTRODUCTORY ESSAY 1 g i A1 ro » by Charles D. Meigs, M.D., Professor of Obstetrics and the Diseases f^,<\ ®l w of Women and Children in the Jefferson Medical College. Philadel- ** I phia. 1 vol. 8vo. . . . , . . J * (_ DERANGEMENTS, PRIMARY A«D REFLEX, OF THE ORGANS OF DIGESTION. By Robert Dick, M.D., author of " A Treatise on Diet and Regimen." ,1 vol. 8vo. 10 sheets. . . . . 1 40 DISEASES OF THE LIVER AND BILIARY PASSAGES, by^ „• f William Thomson, one of the Physicians of the Royal Infirmary of I a> I Edinburgh; and CLINICAL ILLUSTRATIONS OF THE LIVER }£ i 1 60 AND SPLEEN, by William Twining; Surgeon of General Hospital | ^ j of Calcutta, &c, &c, 1 vol. 8vo. . . . . J ■-• ^ A TREATISE ON THE DISEASES OF CHILDREN, WITH^ . ( DIRECTIONS FOR THE MANAGEMENT OF INFANTS; by | f | the late Michael Underwood, M.D. From the "ninth English edition, }£ <; 1 75 with notes by S. Merriman, M.D., and Marshall Hall, M.D., " F.R.S., &c, with notes by John Bell, M.D., &c. Jsl LECTURES ON THE FUNCTIONS AND DISEASES OF THE") ( WOMB; by Charles Waller, M.D., Bartholomew's Hospital. o» I ON DISEASES OF THE UTERUS AND ITS APPENDAGES; {%J by M. Lisfranc, La Pitie Hospital. /-£< 1 10 ON DISEASES OF THE PUERPERAL STATE; by J. T. Ingleby | © | Edinburgh, 1 vol. 8vo. J ^ L APHORISMS ON THE TREATMENT AND MANAGEMENT OF THE INSANE; by J. G. Millingen, M.D. 1 vol. 8vo. 4 sheets. . 0 38 A PRACTICAL DICTIONARY OF MATERIA MEDICA, Includ-1 f ing the Composition, Preparation and Uses of Medicine; and a large I a number of Extemporaneous Formulas: together with important Toxi- ! g J cological Observations; on the Basis of Brande's Dictionary of Materia fHi ] 2 25 Medica and Practical Pharmacy: by John Bell, M.D., Lecturer on I © Materia Medica and Therapeutics, &c.&c. 1 vol. 8vo. j °* { ---------------------4--- J K- OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated from the German of Professor Schill. With copious notes by D. Spillman M.D., A.M., &c, &c. 1 vol. 8vo. 9 sheets. . . . .' 1 00 ARET.EUS ON THE CAUSES AND SIGNS OF ACUTE AND CHRONIC DISEASE. From the Greek, by T. F.Reynolds, M.B.,F.L.S., &c, &c. 1 vol. 8vo. 4 sheets. . . . . .50 LECTURES ON THE MORBID ANATOMY, NATURE, AND! ■ TREATMENT OF ACUTE AND CHRONIC DISEASES. By j § the late John Armstrong, M.D., Author of " Practical Illustrations of yj~< 2 75 Typhous and Scarlet Fever," &c. Edited by Joseph Rix, Member of f m \ the Reyal College of Surgeons. 1 vol. 8vo. J§ I BLUNDELL'S LECTURES ON THE PRINCIPLES AND PRACTICE OF MIDWIFERY. Edited by Charles Severn. lvol.8vo. 19 sheets. . 150 NLM031926352