,v .*^I^'""^- '%*& Surgeon General's Office 5984 ■'ft ■ M^ LECTURES & ON THE THEORY AND PRACTICE PHYSIC. s ux" BY WILLIAM gJOKES, M.D., LECTURER AT THE MEDICAL SCHOOL, PARK STREET, DUBLIN; PHYSICIAN TO THE HEATH HOSPITAL, ETC., ETC. X X" BY JOHN B AND / EfeL, M.B., LECTURER ON MATERIA MEDICA AND THERAPEUTICS J FELLOW OP THE COLLEGE OP PHYSICIANS OF PHILADELPHIA \ CORRESPONDING SECRETARY OP THE PHILADELPHIA MEDICAL COLLEGE ; MEMBER OP THE AMERICAN PHILOSOPHICAL SOCIETY, AND OP THE GEORGOHLI SOCIETY OF FLORENCE, ETC., ETC. SECOND EDITION. IN TWO VOLUMES. VOL. II. Pitlafteljihta: ED. BARRINGTON & GEO. D. HASWELL. NEW YORK —J- & H. G. LANGLEY: CHARLESTON, S. C.-WM. H. BERRETT RICHMOND. VA. — SMITH, DRINKER, AND MORRIS. LOUISVILLE, KY. — JAMES MAXWELL, JR. 1842. [Entered, according to act of Congress, in the year 1842, by Barrington and Haswell, in the clerk's office of the district court for the eastern district of Penn- sylvania.] W8 CONTENTS OF VOL. II. DISEASES OF THE URINARY APPARATUS. LECTURE LI. DR. BELL. Accumulation of knowledge of urinary diseases of late years—Importance of the function of the kidneys—-Their office as depurators—Immediate seat of urinary secretion—Influence of the nerves on this function—Ingredients of human urine—The chief ones noticed—Water—Urea—Lithic or uric acid; its com- binations—Sulphuric and phosphoric acids, and their combinations—Albumen; its tests in urine—Xanthic acid—Cystic oxide—Sugar—Oxalic acid—Bile— Secretion of the prostate gland—Pus—Diseased structure of the kidney— Healthy size and weight—Exploration.—Nephritis—Its species—Hyperemia common to them all in the beginning.—Symptoms; organic and functional; remote or sympathetic—May be confounded with original disease of stomach and bowels—Attention to state of the urine.—Causes ; traumatic and constitu- tional.—Anatomical lesions—Chronic nephritis; its symptoms, lesions, and causes.—Nephralgia.— Treatment of nephritis in general—The acute form re- quires active antiphlogistics—Nephritis in fevers ......page 13 LECTURE LII. DR. BELL. Bright's Disease, or Granular Degeneration of the Kidney.—Renal dropsy— Its organic seat, common accompaniments and constant symptoms.—Symp- toms.—History of the disease—Acute form of the disease; is short, and not often seen—Anasarca soon appears—Acute affection a sequence of scarlatina—Albu- minous urine, how far a characteristic symptom—Properties of the urine in this disease—Tests of albumen in the urine—Blood ; its appearance and composition. —Secondary diseases—Anasarca most common ; next, ascites—Morbid state of the heart—Albuminous urine from diseased heart alone—Phthisis—Diarrhoea very common—Cerebral disease and meningeal inflammation with effusion— Pregnancy developing Bright's disease—Exanthemata?—particularly scarlatina gives origin to it—Anatomical lesions—Summary by different observers—Pre- cise state of the kidney; congestion with inflammation—Mr. Robinson's experi- ments—M. Rayer's opinion—Dr. Burbridge's views.—Causes—Predisposition by particular constitution, and especially intemperance—Exciting causes—cold and dampness....................27 LECTURE LIII. DR. BELL. Treatment of Bright's Disease, or Renal Dropsy.—Origin of dropsies—An- tiphlogistic remedies—Appearance of the blood—After venesection, free purging —Mercurials not inadmissible in all cases—Salivation to be especially avoided —Diaphoretics of great value, and, also, all the aids for securing their effects —Warm bath—Diuretics to be sparingly used—Complication of renal dropsy with bronchitis—Treatment of—Other secondary disorders to be relieved—Em- ployment of tartar emetic—Dr. Osborne's practice in ascites—Measures useful in the more advanced stages of renal dropsy—Alteratives—Great importance of equable temperature of the skin and of regular diet........39 iv CONTENTS. LECTURE LIV. DR. BELL. Suppuration of the KmNEY-Directions taken by the abscess-Most frequent cause, formation of calculi—Not incompatible with even long life.—pyelitis, its varieties, its tendency to end in suppuration and m nephritis—Its ana- tomical lesions.—Treatment.—.Functional Diseases of the Kidneys.—bup- pression of Urine.—Ischuria or Anuria,—an effect rather than a primary disease-Sudden in its attacks—Sympathetic disturbances—Coma—Pyretic ischuria.—Anatomical lesions, not constant—Prognosis is unfavourable— Treatment—Antiphlogistic—Morbid secretions—Circumstances under which they occur.—Excessive diuresis or hydruria—Not always productive of dis- ease—Most troublesome in old persons.— Treatment, dietetic and medicinal— Diabetes insipidus, or anazoturia,—Symptoms— Treatment—Diabetes insi- pidus with azoturia.—Diabetes mellitus, or melituria—Its definition,—quali- ties of the urine, symptoms, terminations, causes, post mortem appearances— Treatment—Diet and regimen of most importance—Various other diatheses of renal secretion, with albumen, lithic acid, or lithuria,—earthy and earthy alkaline phosphates, or ceramuria, cystic oxide, oxalic acid or oxaluria, lactic acid.—Hsematuria.—Diseases of the Bladder—Cystitis, its varieties—The most important is inflammation of mucous coat, or catarrhus vesica—Symp- toms and treatment .................."*7 DISEASES OF THE RESPIRATORY APPARATUS. LECTURE LV. General Principles of -the Diagnosis of Thoracic Disease.—Connexion between symptoms and physical signs—Physical and vital conditions of the thorax—Great assistance to diagnosis of diseases of the chest, furnished by phy- sical signs—Difficulty from symptoms alone—Mutual dependence of signs and symptoms—Sources of physical diagnosis—Insufficiency of signs alone—Re- view of the different signs—Auscultatory phenomena; passive and active . 74 LECTURE LVI. Active Auscultatory Phenomena — Sounds of respiration, of cough, of voice, and sounds of the heart and great vessels—Value of physical signs tested by comparison, on reference to feebleness and strength of respiration, the pheno- mena of voice, detection of foreign bodies in the bronchial tubes—Difficulty of diagnosis, of tubercle in deformed chest from previous disease—Combination of signs, particularly those drawn from percussion and the stethoscope—Signs considered with relation to time—Successive changes—Relation to symptoms —Insufficiency of mere physical diagnosis—Coexistence of morbid action in different tissues of the lungs ; as of bronchitis and pleurisy with pneumonia__ Illustration from tubercular consumption.—The three tissues—•mucous, paren- chymatous, and serous—are more or less affected in many acute, and in most of the chronic pulmonary diseases.........••■•... 88 LECTURE LVII. DR. BELL. Division of diseases of pulmonary organs.—Erythematic Laryngitis__Gene- ral mildness of the disease and simplicity of its treatment—Catarrhal La- ryngitis—chiefly dangerous in infants—Its treatment—Acute CEdematous or Sub-mucous Laryngitis—A most formidable disease—Its symptoms__Re- spiration and deglutition both affected ;"and afterwards the cerebral functions —Duration—OZdema of the glottis not a separate disease—Two varieties of acute laryngitis established by Cruveilhier—Is not of frequent occurrence__ Treatment actively and speedily antiphlogistic—Venesection—General Wash- ington's case—Leeches to the throat, or cups to the nucha—Blisters__Tartar emetic with small doses of opium—Calomel and opium—Early recourse to la- ryngotomy—Mortality from active laryngitis.........103 CONTENTS. V LECTURE LVIII. DR. BELL. Laryngitis Membranacea—Croup.—Anatomical trait characteristic of the dis- ease; lymphatic exudation in a membranous form in laryngeal inflammation— Phlogosis extends to trachea and bronchia; sometimes to the lungs—The chief seat of croup is in the larynx—Proof from dissections and the leading symptoms— Character of the breathing and the voice in croup—Dyspnoea evincing affection of the lungs at the same time.—Causes—referrible to locality, states of atmo- sphere, and age of the patient—Seasons in which it prevails—Mortality from croup in New York, Philadelphia, and Boston—Epidemic croup—Age at which croup is most common—Proportion of the sexes.—Symptoms—Precursory or common ; and imminent and special—First and second stages.—Duration.— Mortality.—Varieties of croup—Spasmodic croup—Dr. Ley's theory—Differen- tial diagnosis—Difference between primary and secondary or consecutive croup—Membranous exudation from air-passages forms in some other diseases.— Treatment—Intentions of cure—First remedy, an emetic—Tartar emetic to be - preferred—Venesection—The warm bath—Leeching or cupping—Calomel with tartar emetic—In approaching collapse, perseverance in the use of calomel and stimulating and antispasmodic expectorants; blisters, epithems, etc. page 112 LECTURE LIX. DR. BELL. True therapeutical action of tartar emetic and of calomel in croup—Practitioners who have employed calomel—Venesection—its advocates—Leeching—Expec- torants ; those of the antiphlogistic kind to be first used—Tartar emetic and opium; calomel and opium—Squills—The alkalies—Polygala senega; its alleged powers and true value—Diaphoresis; is sometimes critical; when use- ful, and how procured—Tartar emetic, as a diaphoretic, to be given in the smallest doses—Warm pediluvia and counter-irritants to the lower extremities —Vapour bath—Warm bath not to be confounded with the hot bath—The arm bath—Antispasmodics; the best antispasmodics, venesection, tartar emetic, calomel, and the warm bath; opium, and afterwards assafcetida, camphor, &c.— Topical remedies; blisters—when and where to be applied—Stimulating liniments—Cauterization of the fauces and pharynx—Tracheotomy.—Laryn- gismus Stridulus; not identical with spasmodic croup as often met with —Description of L. stridulus—With affection of the glottis are associated spasms in other parts—Causes of the disease; the children most liable to it.— Treatment; commonly mild—mixed, hygienic, and medical,—Pre- vention ......................132 LECTURE LX. DR. BELL. Chronic Laryngitis—Itssynonymes—Seat of the disease—Structural changes— Applicableness of the title, laryngeal phthisis.—Large proportion of ulcerations in the epiglottis, larynx, and trachea, in phthisical subjects—Symptoms: sensa- tions, voice, aphonia, cough, breathing—Different species of# chronic laryn- gitis,—a knowledge of, necessary for prognosis and treatment—Examination of the fauces and pharynx—To determine the state of the lungs: auscultation, percussion, and expectorated matter—Duration of the disease—Causes: age, sex, prior disease, vocal strain, atmospherical vicissitudes, habits . . . 148 LECTURE LXI. DR. BELL. Treatment of Chronic Laryngitis.—Rest of the vocal apparatus,—antiphlo- gistics,—counter-irritants,—narcotics, mercurials, iodine, sarsaparilla, balsam of copaiva, blue mass*?ind syrup of sarsaparilla, sulphurous waters__Topical VOL. II.--1 VI CONTENTS. remedies: inhalation of simple and stimulating vapours; caustic to the parts, attention to anginose complication—Syphilitic chronic laryngitis : mercurials, sarsaparilla, iodine—Tracheotomy, when proper—Prevention of the disease- Clergymen,—rules for their guidance—Uniform temperature of air—Jenray s Respirator—Change of climate............PAGE 10/ LECTURE LXII. DR. BELL. Bronchitis. —Its complications with other diseases—Catarrh, a prelude to more serious disease—Importance of early attention to it—Outlines of treatment of catarrh—The dry method of Dr. Williams.—Bronchitis,—its divisions—The kind showing itself in young children—Asthenic variety, or peripneumonia notha—Duration of acute bronchitis—Symptoms,—appearance of the sputum —Physical signs—Percussion, indirectly useful—Touch giving a sense of vibration—Auscultation—Modifications of sound, produced by inflamed and ob- structed bronchia—Division of sounds in respiration, indicating diseases of the lungs—Meaning attached to the terms rhonchus, sibilus, and crepitations— Specification of sound according to the portion of bronchia diseased . . 168 LECTURE LXIII. DR. BELL. Morbid Anatomy of Bronchitis.— Treatment—Venesection, not to be pushed far—Purgatives—Emetics, of doubtful value in acute bronchitis—Tartar emetic, as a counter-stimulant—Rules for its use—Immediate effects various—Case— The warm bath—pediluvium—Blisters and other counter-irritants to the chest —Calomel in bronchitis complicated with abdominal disease; to which are added opium and ipecacuanha—Second stage of bronchitis, with symptoms ofdebility— Stimulating expectorants useful; carbonate of ammonia, wine whey, senega, ace- tate of ammonia—Calomel and a few cups, with stimulants, for congestion of a part of the lung—Diaphoresis without diaphoretics—Diuretics as antiphlogistics sometimes useful—Secondary or Symptomatic Bronchitis—Complication of bronchitis with various diseases, especially eruptive fevers—Treatment by local depletion, counter-irritants, and moderate stimulation—Dr. Copland's plan of external cutaneous revulsion—Emetics—Bronchitis succeeding laryngitis, — Active depletion in.—Hooping-cough—Its connexion with bronchitis—Outlines of treatment—Remittent fever with bronchitis ; in the typhoid stage—Cooling remedies useful—Depletion and stimulation sometimes necessary at once—In- halation of watery vapour—Change of, posture—Quinia and laudanum, for excessive bronchial secretion—Dr. Graves's practice—Sugar of lead . 182 LECTURE LXIV. DR. BELL. Chronic Bronchitis. — Description of—Expectorated matter—pus with hectic fever—Difficulty of diagnosis of chronic bronchitis with purulent expectoration —Ulcerations^ bronchia are rare—Causes,—primary irritation of the lungs,__ and secondary in other diseases—Bronchitis after gastric irritation—Stomachic cough—Its diagnosis—Bronchitis with intestinal irritation,—with other morbid states,—gout, syphilis, &c—Treatment, modified by cause—Venesection not often required—Local bloodletting preferable—Purgatives,—Antimonials__ Calomel or blue mass, with ipecacuanha and hyosciamus—Colchicum and digi- talis—Hydriodate of potassa—Tonics with the balsams—Compound syrup of sarsaparilla with iodine or iodide of iron—Counter-irritants to the chest__In- halation of various vapours—Modification of treatment in complicated chronic bronchitis—Visits to mineral springs—Change of air and climate—Prevention of chronic bronchitis.................19^ CONTEXTS. vii LECTURE LXV. 0 DR. BELL. Narrowing and Obliteration of the Bronchia.—Dilatation of the Bron- chia.—Organic changes in the tubes and air-cells—Thickening, the first change—Symptoms, difficulty of inspiration—Obliteration of the bronchia with shrunken pulmonary tissue—Dilatation of the bronchia may occur very early in life—Causes, prior diseases—Symptoms analogous often to those of phthisis pulmonalis—Differential diagnosis between these two diseases, its great diffi- culty.-— Treatment,—nearly the same as for chronic bronchitis.— Ulcers of the bronchia—Dilatation of the Air-cells.—Pulmonary or Vesicular Emphy- sema.—Dilatation and rupture of the air-cells—Symptoms equivocal—Disease often begins in early life,—constitutes a variety of asthma.—Dry Catarrh— Asthma.—Bronchial congestion, a preferable term—This with pulmonary emphysema constitutes mainly asthma.— Treatment—Mild aperients, alteratives —The alkalies—Regulation of diet...........page 208 LECTURE LXVI. DR. BELL. Hemoptysis or Bronchial Hemorrhage.—May be called bloody secretion— Is idiopathic or secondary; the last variety most common—Causes,—age, in- herited predisposition, certain employments, atmospheric exposures, plethora, compression of the chest—Tubercular diathesis and disease the most frequent cause—Next to this diseases of the heart.—Hemoptysis often vicarious—Apo- plectic congestion of the lungs, an effect rather than a cause—Explanation of its origin—Symptoms—Quantity of blood discharged variable—The physical signs few—Diagnosis, not easy—Prognosis—Organic changes of structure— Treatment—Indications, to arrest the discharge and to prevent its return- Venesection to be freely used at first—Attention to posture—First remedies simple,—cold sponging of the neck and chest—Risk of reaction, unless suitable depletion is practised—Leeches to remote parts,—vulva or anus—Active purg- ing—Peculiarity sometimes following the use of leeches—Sugar of lead— Tartar emetic—Blue mass with laxatives—Astringents—Narcotics and cha- lybeates.....................220 LECTURE LXVII. DR. BELL. Pneumonia.—The transition slight from bronchitis to pneumonia—Peculiarity of seat of pneumonia—Definition—Stages—Symptoms,—local and general,— The three chief diagnostic ones,—Cough, expectoration, characters of the sputa, dyspnoea, pain, decubitus—Percussion—Auscultation—Crepitation—Ap- pearance of inflamed lung—The several stages of inflammation—General symptoms,—disordered circulation and pungent heat of the skin the most com- mon—Precursory symptoms and complications—Pneumonia succeeding bronchitis and other diseases—Typhoid pneumonia—Dr. Williams's and Dr. Stokes's descriptions—Progress—Collapse—Duration.—Disease . . 232 LECTURE LXVIII. DR. BELL. Prognosis and Termination of Pneumonia.—Critical evacuations and critical days—Age modifies results—The old and young most apt to sink under pneu- monia—Part of the lung most liable to inflammation—Which side most affected —Complication with other diseases increases danger—Morbid Anatomy of Pneu- monia—Varieties of pneumonia—Participation of the pleura with the lungs.— Causes—External and internal—Climates and countriesin which pneumonia pre- vails most—la a common disease in southern Europe—Winter and first spring months the chief seasons for pneumonia—Immediate or exciting cause—Particular vm CONTENTS. employments less apt to cause the disease than is supposed-Internal causes, liability of the disease to return in the same person-tuberculous phthisis—Age -young children most liable-Sex-men mu«h more liable than women.- Treatment—Great mortality in pneumonia-Venesection the chief remedy, to be early and freely used-Dr. Stokes's plan of treatment ;-not Sequent venesection ;-local bloodletting preferable ;-wine in conjunction with local bleedino-s in typhoid pneumonia ;-M. Louis's results adverse to bloodlet- tincr.-antimonials and calomel; mode of using tartar emetic, and genera advantages of the practice; combination of calomel and tartar emetic; calomel best in hepatization ; posture to be attended to in these cases; seton in pro- tracted cases with dilated bronchia ............FAGE -**' LECTURE LXIX. DR. BELL. Treatmentof Pneumonia (continued).—Superiority of venesection over all other remedies—Extent of its use and frequency of repetition—Not to be deterred by fear of interfering with critical evacuations—Circumstances which modify bloodletting—Original strength of constitution; complication of pneumonia with other diseases—Purgatives—Revulsives and counter-irritants—Opium and other narcotics—Depression to be met by stimulants and mild tonics—Treatment of complications—bilious pneumonia,—the pneumonia of children—Less deple- tion required in the cases of children—Tartar emetic in their case—Regimen and drinks in pneumonia___Convalescence—Cautions requisite in— Treatment of typhoid pneumonia by Dr. Stokes—Depletion less used, and stimulants more freely ; complications to be attended to ;—remedies for hectic with expectora- tion.—Chronic pneumonia— Physical signs of—Caution against much deple- tion in......................259 LECTURE LXX. DR. BELL. Pleurisy — Pleuritis.— Its forms and complications—Chief symptoms—Fe- ver, pain, difficult breathing, hard and frequent pulse, and decubitus on the back—Even the chief symptoms not always present; and they may be pre- sent without pleurisy—Structure of the pleura—Anatomical lesions—Change in the pleura itself,—in its secretion; immediate effects of this latter—Quality and changes of secreted matters—false membranes,—their characters—tuber- cles and cancerous bodies—Change in the secretion and state of the lung by the effusion—Causes—Identical almost wiih those of pneumonia—Cleg- horn's description of bilious pleurisy—Physical signs ;—altered conformation of the thorax, dulness on percussion,—resonance of voice in auscultation,— cegophony ;—friction sounds.—Dr. Stokes's description of dry pleurisy—Dimi- nished vibration of the parietes of the thorax—General symptoms—Fever, state of pulse, buffy and cupped blood—Progress, duration, and termination of pleurisy— Varieties—Complications—Prognosis— Typhoid Pleuritis 268 LECTURE LXXI. DR. BELL. Treatment of Pleurisy—Bloodletting by venesection the first and chief remedy —In feeble habits and in advanced stages, cupping or leeching—Calomel fol- lowed by saline purgatives—Tartar emetic—Opium in full doses after venesec- tion—Blister to the side—Purging most useful in complicated and epidemic pleurisies—Diuretics; nitre, digitalis, colchicum—Calomel with nitre and a little opium.— Treatment of Sub-acute and Chronic Pleurisy {Dr. Stokes)__ Confinement of the patient to bed—Leeches to the affected side—Small blis- ters—Diuretics—Iodine—Diet at first simple, afterwards more nourishing- Morbid action of the heart; remedies for—Country air—Deformity ; remedies for —Operation for empyema.—Chronic Uncircumscribed Pleurisy with Effusion CONTENTS. IX {Dr. Stokes)—Symptoms—Physical signs of great importance—Decubitus— Effects of changes of position.—Contraction of the Chest—Recovery of natural size sometimes rapid—One of the first signs—Differential Diagnosis.—Pneu- mothorax—Causes, symptoms, and treatment.—Hydrothorax, its causes, symptoms, and treatment..............page 281 LECTURE LXXII. DR. BELL. Phthisis Pulmonalis. — Its causes and special pathology—The disease caused by tubercles in the lungs—Pathological Anatomy of Phthisis—Tubercles— their stages and characters—Granular or crude stage; accompanied by con- solidation—Second stage, or that of elimination and softening—How brought about—Third stage, or that of ulceration—Vomica—Infiltrated tubercle— Order of change in tuberculous lungs—Description of vomicae—Associated lesions of other organs with tuberculous lungs—The mucous surface of the larynx and bronchia and that of the small and large intestine most commonly diseased by inflammation, ulceration, and formation of tubercle in phthisis pul- monalis ......................297 LECTURE LXXIII. DR. BELL. Causes of Phthisis Pulmonalis.—External Causes—Climate—Difference of mortality in different countries—Consumption, a common disease in the Medi- terranean climates,—also in the West Indies, and in the islands of the Indian Ocean—Consumption varies in its rate of mortality in different periods—Close and impure air a common cause—Effects of dust given out in certain trades— Deficient or improper food—Internal causes of consumption—Age—Sex— Hereditary predisposition—Conformation of the chest—Influence of inflamma- tion of the respiratory organs—Tubercle may be formed without inflammation —Conditions for this—Consumption a constitutional disease—Progress, dura- tion, and termination of phthisis.............. 307 LECTURE LXXIV. Pulmonary Tubercle—Combination and enumeration of signs—Signs of bron- chial irritation—depending on their situation and combination—Signs of irri- tation of the parenchyma—Difficulty of diagnosis—Feebleness of respiration an important sign,—interrupted respiration—Signs of irritation of the serous membrane—Friction sound rare—Slight dulness of one clavicle—a difference on the ridges of the scapula—Clavicular dulness and feebleness of respira- tion—Condensation, how detected—General dulness—General acute develop- ment of tubercle—Diagnosis depending on development of tubercle—Tuber- cular dulness....................322 LECTURE LXXV. Tubercle of the Lung {continued).—Signs of ulceration—Gradual transition from crepitating to mueo-crepitatingrhonchus—Cavernous respiration andpec- toriloquism the most important signs—Diagnosis between metallic tinkling of a large cavity and pneumothorax with fistula—Signs from atrophy of the lung —Falling in of the chest without atrophy—Ascertained by measurement of the chest—Signs from the state of the circulating system; few in number—In- creased action of the subclavian—Varieties of phthisis—Acute inflammatory tubercle without suppuration—General principle of diagnosis of this kind of tubercle—Acute suppurative phthisis—Hemoptysical variety .... 333 1* X CONTENTS. LECTURE LXXVI. Tubercle of the Lung {continued).—Chronic progressive tubercle—First stage; symptoms of irritation; expectoration scanty; pain of the side—feigns on per- cussion and auscultation-Second stage; symptoms decided; pulse quick, ema- ciation increases; sweatings more profuse; cough looser; expectoration puri- form, tubercular—Physical signs—Third stage; apyrexia ; perspirations cease, voice lost or hollow ; aphtha? on the tongue—Chronic tuberculous ulceration— Tubercle consequent on chronic bronchitis—Long duration of this variety 01 phthisis—Tuberculisation consequent on absorption—Phthisis complicated witn empyema and pneumothorax; with laryngeal disease—Chronic latent forms-— Cicatrisation of cavities-Inquiries into the state of a patient suspected ot phthisis—Recapitulation of physical diagnosis.—[Fournet's views.] page d4d LECTURE LXXVII. Pulmonary Tubercle {continued).— Treatment of phthisis—To be considered under two heads; the curative and the palliative—The indications in both are to remove irritation of the lung and to improve the general health—Constitutional and accidental phthisis—Tubercle is preceded almost always by irritation—Cir- cumstances to guide the practitioner—Treatment of localised bronchitic variety; of the hemoptysical variety; of the pneumonic variety—Treatment after exca- vation has formed—Incurable consumption—Palliative treatment; of the more distressing symptoms, such as hectic, pain, cough, expectoration, hemoptysis, and diarrhoea....................362 DISEASES OF THE HEART. LECTURE LXXVIII. DR. BELL. Diseases of the Heart.—Position and structure of the heart—its valvular me- chanism—Beat or impulse of the heart; when felt—Percussion—Various tones according to the part of the sternum struck—Auscultation—Two sounds of the heart; the first caused by the systole of its ventricles; the second by the resistance and sudden tightening of the semilunar valves—Different organic affections of the heart—Functional disorders—Simple carditis, a rare disease—Sequences of—Softening—varieties and causes of—Diagnosis not easy—Treatment, similar to that of pericarditis—Perforative ulceration and rupture—Recorded cases of and complications with.—Aneurism, ventri- cular-—Thurman's summary of—Its precise seat and complications.—Aneu- rism ofthe auricles..................377 LECTURE LXXIX. DR. BELL. Hypertrophy of the Heart.—Divisions of hypertrophy—Average dimensions of a healthy heart—Dr. Clendinning's and M. Bizot's measurements—Anato- mical characters and volume of a hypertrophous heart—Exciting causes—Dif- ferent forms and complications of hypertrophy—Connexion between hypertrophy and cerebral disease, particularly apoplexy—Ossification of the cerebral arte- ries—Capillary congestion of the mucous membranes and liver—Serous infil- trations and congestions; disease of the kidneys in hypertrophy of the heart__ Palpitation—Impulse heard through the stethoscope—Hypertrophy with dila- tation—Sounds of the heart and state of the pulse in hypertrophy__Arterial pulse; its cause and characters ; modifications by hypertrophy—'Causes com- monly affecting the pulse—Signs of hypertrophy of the right ventricle.__Treat- ment of hypertrophy—Abstraction of blood short of producinganaemia—Moderate and frequent abstractions to be preferred.—Purgatives and diuretics—Dropsy, its organic causes and consequent pathology—Treatment of—Perseverance in treatment of hypertrophy all important............386 CONTENTS. XI LECTURE LXXX. DR. BELL. Dilatation of the Heart.—Its signs and diagnosis—Treatment, by moderate tonics.—Diseases of the valves and orifices of the heart—Their connection with hypertrophy—Large proportion on the left side—Proportionate size of healthy valves—Indurationrexcrescence, and vegetations of the valves—Endocarditis the most fi^quent cause of valvular disease—General symptoms and effects of an alarming nature—Peculiar and distinctive symptoms—Well-defined pecu- liarities of pulse—Prognosis—Physical signs—Murmurs—Their varieties— Venous or continuous murmur—Venous pulse—Its cause—Purring tremor or thrill.—Pericarditis—Its association with valvular disease and endocarditis— Symptoms—Physical signs—Rheumatic character of pericarditis—Sounds in pericarditis—Anatomical traits of pericarditis—Prognosis.—Endocarditis—Its origin in rheumatism ; a frequent concomitant with pericarditis—Its anatomical characters—Termination in valvular disease—Treatment of pericarditis and endocarditis—Free depletion by venesection, purging, and diuretics ; counter- stimulants ; mercury; hydriodate of potash — Chronic endocarditis; treat- ment of....................page 400 LECTURE LXXXI. DR. BELL. Diseases of the Heart {concluded).—Hydropericardium—Its varieties; their causes and treatment—Adhesions of the pericardium.—Functional Diseases of the Heart—Vagueness of this title—Explanation—Palpitations ; their different origins and different treatment, according to organic and consti- tutional complication.—Syncope—Causes—occasional danger from.—Treat- ment—Precautions in particular cases to avoid syncope.—Neuralgia of the heart and angina pectoris—Symptoms—Causes; not well known—Treat- ment, to vary with complications of disease in other organs.—Asthma . 414 DISEASES OF THE NERVOUS SYSTEM. LECTURE LXXXII. Diseases of the Nervous System—Pathology of, unknown—Molecular change in the nervous centres—Difficulties of distinguishing arachnitis from encepha- litis—General and partial cerebritis—Symptomatology of—Diagnosis of—Pre- servation of intellect in—Production of general symptoms by local lesion . 421 LECTURE LXXXIII. Encephalitis, diagnosis of—Preservation of function with organic disease—Vica- rious actions of parts—Importance of pathology to phrenology—Use of pathology to phrenologists—Arachnitis at the base of the brain—Symptoms of-—Influence of age over the intellectual faculties—Opinions of Bouillaud, Serres, and Foville * —Influence of the optic thalami and corpus striatum on the motions of the extremities—Diagnosis of disease of the cerebellum—Connection with the generative system—Remarkable cases of...........430 LECTURE LXXXIV. Symptoms of Encephalitis — Conclusions as to contraction and paralysis — Remarkable cases of encephalitis — Abscesses in the brain — Sympathetic affec- tions— Enteritis simulating cerebritis—Prognosis in cerebritis — Remote neuralgia a symptom.................447 xu CONTENTS. LECTURE LXXXV. Encephalitis—Treatment of, in the adult—Importance of energetic means—Dan- gerous effects of opening the temporal artery or jugular vein—Copious blood- letting from the arm—Difficulty of producing syncope—Employment of cold— Good effects from purgatives—Encephalitis caused by piles—Treatment—Bene- ficial effects of blisters—Mercury—Dangerous effects of emetics—Dessault's treatment—Use of opium—Violent counter-irritation of coma—Application of boiling water—Treatment of partial encephalitis.....*. page 456 LECTURE LXXXVI. Analysis of Symptoms of Cerebritis—Inconstancy of pain—Arachnitis, pain of —Intermittent pain—Headache—Phenomena of the eye—State of the pupils— Various affections of the functions of vision—Researches of Parent and Martinet —Relief by convulsions—Brain considered as a secreting organ—Dangerous effects of opium; delirium—Phenomena of organic life—Vomiting in hydro- cephalus—Sympathies of the digestive and respiratory systems—Treatment of hydrocephalus—Of internal remedies............468 LECTURE LXXXVII. Apoplexy—Cerebritis and meningitis—Definition of apoplexy—Simple or nervous apoplexy without disorganization—Complicated with Other diseases—Conges- tive or serous^apoplexy—Dr. Abercrombie's opinions—Apoplexy with extra- vasation—Sites of extravasation—Absorption of clot—Apoplexy in children 462 LECTURE LXXXVIII. Apoplectic Effusions—Curative process adopted by nature—Periods of life most subject to apoplexy—Connection of temperaments [and sex] with dispo- sition to apoplexy—Researches of Rochoux—Principles of diagnosis—Varieties of apoplexy—Connection of symptoms with pathological appearances—Rostan's division of—Different symptoms of—Double effusions—Rupture into the ventri- cles—Hemiplegia—Value of the suddenness of paralysis as a diagnostic exa- mined—Symptoms of apoplectic effusions...........491 LECTURE LXXXiX. Apoplexy from ramollissemenl (softening) of the brain—Supervention of apo- plexy on encephalitis—Inflammation round the clot—Variety of paralysis conse- quent on apoplexy—Paralysis croissee—Different forms of paralysis—Origin— Phenomena of face and tongue—Paralysis of the tongue—Treatment of apoplexy —Bloodletting—Purgatives—Lotions, beneficial effects of—Emetics, dangerous effects of—Use of revulsives and stimulants—Treatment of paralysis—Efficacy of strychnine—Its modus operandi—Brucine, its proposed employment . 502 LECTURE XC. Paralysis—Local treatment of—Flesh-brush, shower-bath, &c.—Application of moxa—Cases in which it is useful—Professor M'Namara's plan—Acupuncture with galvanism—Electro-puncturation—Method of applying—Powerful action of small battery—Mr. Hamilton's ohservations—Value of galvanism and electri- city—Use of, in paralysis of the muscles of the face—Paralysis from disease of the arterial system—Case of, by Dr. Graves—Diagnosis of this affection- Pathology of Pott's gangrene—Dupuytren's mode of treatment . . . 512 LECTURE XCI. Paralysis from Arterial Disease—Singular cases of, by Rostan—Diagnosis of paralysis from arterial obstruction—Magnetism, use and action of— Effect of magnetism in disease—Result of trials in the Meath Hospital—Paraplegia— Mechanical hyperemia— Occurrence without disease of the cord or vertebra:— CONTENTS. Xlll Cases by Mr. Stanley—Effects on urine by division of the spinal cord—Ammo- niacal urine—Caries of the vertebra?—Diagnosis of paralysis with disease of the kidney—Prognosis in paraplegia—[Dr. Graves's views and cases of paraplegia —A sequence of fever—Means of prevention and cure—Local injury to a nerve causing partial paralysis] .............page 520 LECTURE XCII. Paralysis, sudden, from abscess of the brain—Curious case of paralysis without effu- sion—Previous symptoms of—Demonstration of the cellular tissue of the brain- Compressibility of the brain—Inaccuracy of the opinions of Drs. Abercrombie and Clutterbuck—Pathological states—Arachnitis without delirium—Trau- ■ matic apoplexy—Case of paralysis of the portio dura—Peculiar appearance of the affected side of the face—Use of the electro-puncturation—Bad effects from—Mechanical support of paralysed parts—Neuroses, active and passive— General pathology of—Principles of diagnosis—Case of neuralgic liver—Neu- rosis from moral causes.................534 LECTURE XCIII. Neuralgic Affections—Principles of treatment of—Connection with organic dis- ease—Neuralgia of the liver—Treatment—Hemicrania—Treatment—Use of iron, quinine, and opium—Endermic method of using opium—Tic douloureux —Opinions of Sir C. Bell—Remarkable case related by—Inflammation of fron- tal sinuses—Violent symptoms—Mr. Crampton's treatment—Affections of the fifth and seventh nerves in cases of cerebral disease—Neuralgia of the side— Researches of Lombard and Brande on the effect of nitrate of silver—Injury to the skin......................545 LECTURE XCIV. DR. BELL. Neuralgia—Appropriateness of the term—This disease may be caused by in- flammation of the nervous sheath—Origin of neuralgia sometimes in the ner- vous centres—Change in the state of the nerves themselves and in their extre- mities—Diagnosis of neuralgia—Nerves and regions chiefly affected with neu- ralgia—the fifth pair and the dorsal and sacral nerves—Varieties of neuralgia specified—Dorso-intercostal neuralgia mistaken for irritation of the spinal cord—Its seat, symptoms, and diagnosis—Lumbar neuralgia—Crural neuralgia —Femoro-popliteal neuralgia, or sciatica—Membranous, ganglionic, and visce- ral neuralgia—Treatment of neuralgia ...... v.....555 LECTURE XCV. DR. BELL. Epilepsy—The true basis for treatment of this disease—Different causes and condi- tions require different treatment—Divisions of epilepsy—Women more subject to it than men—Hereditary predisposition; sometimes dependent on cerebral conformation—Epilepsy may exist with great mental endowments—Occa- sional exciting causes.—Symptoms—No uniform structural lesions.— Treat- ment ; ought to be rational not empirical—Remedies for the plethoric state ; the anaemic—Paramount importance of hygienic means of treatment, espe- cially as regards food and exercise of jnind and body—Bathing and frictions— The chief indications, to abate morbid susceptibility and to withhold all irri- tants to the nervous system—Vegetable diet preferable—Intoxicating drinks and tobacco to be abstained from—Probable morbid irritants—Chief remedies relied on in epilepsy—chalybeates; nitrate of silver ; sulphate and oxide of zinc; sulphate of copper; oil of turpentine ; digitalis—Galvanism . . 570 XIV CONTENTS. FEVE RS LECTURE XCVI. Fever—General considerations on—Erroneous modes of investigation—Import- ance of the labours of French pathologists—complication of fever with local disease—Primary and secondary fevers—Relation of, to local changes—ten- dency to spontaneous termination—Principles of treatment—Errors of Brown and Broussais—Researches of MM. Gaspard and Magendie—Their pathologi- cal conclusions—Importance of the knowledge of secondary lesions—Effect in preventing crisis—Treatment—Humoralism and solidism . . • page 580 LECTURE XCVII. Intermittent Fever— Definition and character of— Phenomena of the paroxysm- Cold stage—Internal congestions—Pathology of—Hot stage—Ague not a simple fever—Affections of various viscera—Theory of Broussais—Effects of bark, quinine, &c.—Modus operandi of.............590 LECTURE XCVIII. DR. BELL. Alleged Cause of Intermittent Fever—Miasm, or malaria, an imaginary cause—More attention due to sensible states of the atmosphere—Slight dif- ference in location modify climate—Direct cause of disease among labourers in the Campagna di Roma—Causes of continued fever.—Phenomena of fever— Periodicity—Ascendancy of the nervous system—Simple intermittent—Bark or sulphate of quinine, sufficient remedy—Opium to ward off a paroxysm— Narcotina as an anti-periodic—Splenic congestion to be removed by quinia— Complication of gastro-enteric disease and congestions with intermittent fever—Routine or a too exclusive practice—The proper eclectic course—Vene- section, when proper, and mercury,*—as preparatives not substitutes for quinia,— Anaemic state requiring iron with quinia—Cold bathing, when proper . 59H LECTURE XCIX. DR. BELL. Intermittent Fever.—Treatment of the cold stage ; in genera] simple—Vene- section sometimes used—Origin in the medulla spinalis of pain in the back and limbs in this fever—Leeching and cupping the spine, and irritants to the same part—Confidence in quinia—Time for using and doses of quinia.—Congestive Fever—Its true nature— Congestion when occurring—Cases—Identity of our congestive fever with malignant or pernicious intermittents of Europe—Writers who describe congestive fever—Baillyand Maillot's experience very valuable— Division of pernicious intermittents ............612 LECTURE C. DR. BELL. Congestive Fever.—Congestion of an organ may disappear with the paroxysm ; is often permanent and becomes inflammation—Nervous coma—Paramount part performed by the nervous system—Inflammation of an organ with the intermit- tent fever—Symptoms deduced from observation of the nervous system—Peri- odical inflammation—Diagnosis— Characteristics of our country fevers—Diffi- culty of ascertaining the presence of inflammation—Hour of the paroxysm__ Morning paroxysms sometimes the most dangerous—Expression of the face— CONTENTS. XV Decubitus—Chief symptoms—Appearance of the tongue; not to be relied on— Pulse varies very much—Temperature of the skin—Gastro-intestinal symp- toms—Suspension of the secretions and excretions—Serous discharges—State of the urine ; sediment in.—Modifications of sensibility—Pains of two kinds.— Prognosis, difficult—Death takes place in the period of reaction of the parox- ysm—Danger estimated by violence of the paroxysm—Cleghorn's prognostics —Case—Different meanings of symptoms according to time—-Duration, and natural or spontaneous termination.—Post-mortem appearances . . page 627 LECTURE CI. DR. BELL. Congestive Fever.—Treatment of the First or Forming Stage—Symptoms— Preventive and curative measures—Different stages—Stage of depression,• to be treated by mild friction, counter-irritants, and evacuants—Avoidance of direct irritants—Opium in the comatose stage or variety—Its use to prevent the paroxysm—Auxiliary remedies—Stage of Reaction—Venesection or topical bloodletting—Advantages of cupping—Reaction after loss of blood—Removal of irritation from the stomach and bowels, by enemata—An emetic sometimes useful—Dry cupping and emetics—Cold affusion and cold drinks—Period of Remission—Early and free use of the sulphate of quinia—Real nature of this medicine—It is not a tonic or a stimulant, but rather a sedative—Dose—Expe- rience in favour of large doses of it in different countries .....642 LECTURE CII. DR. BELL. Remittent Fever.—Resemblance between this fever and intermittent and conges- tive fevers—Causes of remittent fever—Modes of termination—Varieties of— Progress and conversions of one into another—Modifying circumstances—Remit- ting continued or inflammatory fever—Hillary's description of—Treatment.— Bilio-inflammatory remittent—Described by different authors— Treatment.— Congestive remittent—Clark's description of—Treatment analogous to that of congestive intermittent—Nervous variety or complication—Symptoms—Treat- ment—Remittent fever complicated with liver disease and with bronchitis and pneumonia—Organic lesions—Great mortality from remittent fever . . 659 LECTURE CIII. DR. BELL. Divisions of Continued Fever—Synocha—Synochus and Typhus—Sketch of synocha and synochus—Typhous and typhoid fever analysed—Contradictory opinions on the subject—Description of typhoid fever or dothinenteritis—The anatomical lesions in typhoid fever—Causes—Diagnosis—Treatment. . 673 LECTURE CIV. DR. BELL. Typhous Fever.—Symptoms—Apparatus most implicated—Resemblance to typhoid fever—Dr. Stokes and Dr. Tweedie's description of intestinal and bron- chial complications—Causes—Mortality—Treatment; to vary with the condi- tion of the organs—Depletion at first—Cold bath—Stimulants—State of the heart indicating their use—Tartar emetic in typhous fever.....667 XVI CONTENTS. LECTURE CV. DR. BELL. Application of the pathology of congestive fever to that of cholera in its various forms—Phlegmasia; of the skin.—Different genera of— Hyperemia—Exanthe- mata—Erysipelas,—its treatment.—Roseola,—its varieties and treatment.—Ex- anthematous or eruptive fevers proper—Measles, scarlatina, and small-pox— Their precursory fever and first eruption.—Alleged differential diagnosis.— Sequelae of eruptive fevers—Sameness of the organs affected in all of them— first, and chiefly, the air-passages ; then the digestive mucous and the serous membranes and the brain—Skin and pulmonary mucous membrane, the tissues which chiefly suffer—Treatment of the eruptive fevers—Must vary with the changing character of the epidemic visitation—Explanation of different modes of practice—that in the inflammatory scarlatina—Measures required in the con- gested and typhoid variety—Treatment of small-pox—Prophylaxis—Vaccina- tion ; its reputed and real efficacy—Age and selection of matter . . . 703 Index 722 LECTURES ON THE THEORY AND PRACTICE OF PHYSIC. DISEASES OF THE URINARY APPARATUS. LECTURE LI. DR. BELL. Accumulation of knowledge of urinary diseases of late years—Importance of the function of the kidneys—Their office as depurators—Immediate seat of urinary secretion—Influence of the nerves on this function—Ingredients of human urine—The chief ones noticed—Water—Urea—Lithic or uric acid; its com- binations—Sulphuric and phosphoric acids, and their combinations—Albumen; its tests in urine—Xanthic acid—Cystic oxide—Sugar—Oxalic acid—Bile— Secretion of the prostate gland—Pus—Diseased structure of the kidney— Healthy size and weight—Exploration.—Nephritis—Its species—Hyperemia common to them all in the beginning.—Symptoms; organic and functional; remote or sympathetic—May be confounded with original disease of stomach and bowels—Attention to state of the urine.—Causes ; traumatic and constitu- tional.—Anatomical lesions—Chronic nephritis; its symptoms, lesions, and causes.—Nephralgia.— Treatment of nephritis in general—The acute form re- quires active antiphlogistics—Nephritis in fevers. The period is not long beyond which the strictly medical consider- ation of diseases of the urinary apparatus could be easily discussed within narrow limits. Inflammation of the kidneys and bladder, and obstructions, by calculi, of the ureters, were the chief morbid con- ditions of the organs; the passage of calculi, the deposit of gravel and sand, and some obvious deviations from the healthy appearance of this fluid, were the chief external symptoms, in addition to the common rational ones of functional disturbance, indicating disease of this apparatus,—tomake upoursymptomatology. To the organo- logical part was then added an inquiry into nervous irritation, or nephralgia of the kidney, as distinct from inflammation and nephri- tis ; and a mixed condition of the bladder, or neuralgia, with dis- ease of the mucous coat, constituting catarrhus vesicae, or cys- torrhcea, separated from cystitis, or decided inflammation of this organ. Chemistry also came in aid of the observation of the simple physical states and changes in the urine, as marked by its colour, its transparency or turbidness, and deposits of various consistence and hue. Blackall and Wells first, then Cruikshank, Marcet, and Bostock, showed by chemical tests that the urine was modified VOL. II. — 3 14 DISEASES OF THE URINARY APPARATUS. in its composition by various morbid states of the economy, as in dropsy, diabetes, &c. Then appeared the more extended and con- nected researches of Prout; and more recently, or about fifteen years ago, the first observations of Bright, suggesting the connexion between diseased kidney and concomitant disorders of other organs, and a particular condition of the urine. In this road thus opened, have followed Gregory and Christison, Osborne, Willis and Venables, Rayer and Solon, and others ; so that now, whilst grateful for the vast accumulation of positive facts, and an incipient arrangement into a system, setting forth the extended and various diseases of the urinary apparatus, we look with hesitation, not unmixed with dread, at the number of volumes, so intrinsically rich too, before us, when we think of condensing from them a brief yet connected and consistent sketch of the whole subject. For myself, I do not hesitate, at once, to decline such an attempt at this time. The most that I can hope to do, under present restrictions, which, by the way, are partly voluntary and partly compulsory, is to indicate the more important points, which will help you in your own more extended and detailed inquiries hereafter. First, then, I propose to notice, very briefly, the acute and chro- nic inflammations of the renal apparatus, its structural changes, and morbid secretions; and then endeavour to indicate how far these morbid changes are causes, or associated with various im- portant functional derangement in other parts. Perhaps I ought to say, that this will be the scope of my observations in this lecture ; but without, perhaps, rigidly preserving the order of sequence which I propose to myself. The anatomist must have been struck with the large proportion of arterial blood which the kidneys receive from the descending aorta by the renals; nor could the physiologist be slow in infer- ring from this arrangement, and still more from the amount of secretion, and its changes in appearances and quantity, with the several periods of digestion and cycle of other functions, their im- portant role in the animal economy. Still more positive conclu- sions of this nature were drawn from observing the possession of a renal apparatus in animals, even of a low grade of organization. Insects have been found to secrete uric acid through their long Malpighic canals; and which latter have even contained calculi of this acid; and the same substance has been discovered in the saccus calcareus of the Mollusca. The kidneys are among the chief depurators of the economy; being, in this respect, only second to the lungs, and taking precedence of the skin and bowels. If we regard the exclusive function of depuration, or of excretion follow- ing secretion, the renal is without parallel; — all the other organs have absorbent together with secretory function, and the first of these is in them all connected with the wants of assimilation and growth. The kidneys have a secretory function alone; their absorbing power is purely interstitial; or if exercised on their secreted fluid, it is only so in extreme and pathological conditions of the organ. They discharge azote, as the lungs do carbon, and these are the elementary basis of the chief excretions from the living body. The THE URINE AND ITS INGREDIENTS. 15 quantity of solid renal secretion is in strict proportion to the quantity and kind of food taken as aliment ; and by M. Chossat (Journ. de. Physiolog., t. v., 1825), was found to be, in reference to farinaceous, albuminous, and fibrinous aliment, in the ratio of 5.7.9. It would hence appear, that the quantity of azote contained in the food is the principal element determining the amount of solid excre- mentitious urinary matter. M. Chossat found, in fact, that ten- elevenths of all the azote ingested with the food were discharged by the kidney. (Willis—Urinary Diseases and their Treatment : Philadelphia Edition.) The immediate seat of the secretion of urine is the convoluted tubuli of the cortical, and most probably, also, of the medullary substance of the kidney: this fluid is poured out, as we are told by Miiller, from the whole internal surface, and not their extremities only. The influence of the nerves over renal secretion is manifested in the result of experiments, which consisted in a destruction of the renal nerves; and which was followed by an entire suspension of the secretion, although the blood still circulated nearly as before. The Urine and its Ingredients.—Healthy human urine, says Prout, when recently voided and still warm, is a transparent fluid, of a light amber colour. At this time it reddens litmus paper, and its odour is slightly aromatic, and somewhat resembles that of violets ; but the taste is bitter and disagreeable. As it cools, the aromatic odour leaves it, and gradually gives place to another which is pecu- liar, and well known by the name of urinous. In a few days the urinous odour is succeeded by another, which has been compared to sour milk. At length, this also disappears, and is finally suc- ceeded by a fetid alkaline odour. The sensible qualities of the urine, however, as well as the changes it undergoes, are subject to great varieties from many causes; such as different articles of food, different diseases, &c, as will be subsequently shown. The quantity of urine secreted varies with the climate, the season, and temperament, and also the sex, being generally less in women in the better classes of society than in men, owing to the more abstemious habits of the former. In Great Britain from 30 to 40 ounces is estimated to be the average quantity in the twenty- four hours. The specific gravity of urine is from 1-15 to 1-25. Azote has just now been represented to you as the chief ele- ment of renal secretion, or of urine; and I may add, that its two principal forms of combination are urea and uric or lithic acid. But, before proceeding to speak of these substances, it is proper to apprise you of the composition of healthy urine, which, according to Berzelius, consists of the following ingredients, the proportions being to a thousand parts of urine : — £ a fa. Water ..... 933-00 ^ S, b. Urea ..... 30-10 S3 J c- Lithic acid ----- 1-00 b'^« 1 j CFree lactic acid, lactate of ammonia, and i 17>14 .§ g"cL C animal matters not separable from them ) 4j «"3 (^e. Mucus of the bladder - - - 0-32 16 DISEASES OF THE URINARY APPARATUS. (j, ( Sulphate of potash - - ' / |-------of soda - - " |*b ( Phosphate of soda - - S' (-------- of ammonia - - " £~]j , ( Muriate of soda - ■ " *'** S^*" I------of ammonia - - - l"50 ( Earthy phosphates, with a trace of rluate? 1>()0 ) of lime j i Silex - - - - - es 03 1000.00 Besides these ingredients, which appear to be essential to healthy urine, this excretion, in different diseases, has been found to contain the following additional matters : — (Albumen } k. ) Fibrin > of the chyle and blood. ( Red particles ) ( Various acids, colouring matters, &c, formed from, or I. ) accompanying, the lithic acid. ( Nitric acid. m. Xanthic oxide. n. Cystic oxide. ( Sugar. o. < Oxalic acid. ( Carbonic acid. p. Hippuric acid 1 Benzoic acid? q. Prussian blue; cyanurine. Indigo. r. Bile. Cholesterine. s. Secretion of the prostate gland, &c. t. Pus; and perhaps other matters. I cannot follow either Prout or Willis in detailing the properties of all these ingredients, and the circumstances under which they are formed ; but must be satisfied with a few observations on the chief ones. Water, the base of the urine as it is of all the animal fluids, may vary considerably in its proportions compatibly with health : but in some diseases its increase is accompanied by an increase of a natural ingredient, as of urea ; or of unnatural ingredients, as of albumen or sugar. On the other hand, the proportion of water to the urine is not unfrequently very much below the natural standard, as in the various forms of urinary suppression. Urea was long believed to be peculiar to the urine, and of course to be a result of renal secretion; but it is now ascertained, that it may be formed from the constituents of the blood, without the agency of that organ. Urea is transparent and colourless, and without remarkable smell or taste : of course it does not impart to urine either the colour or other properties characteristic of this fluid. Urea is neither sensibly acid nor alkaline. At a high temperature it is converted into am- monia, cyanate of ammonia, and dry, solid, cyanuric acid. It is THE URINE AND ITS INGREDIENTS. 17 soluble in its own weight of cold water, and in every proportion in hot water. Urea combines with several acids, but does not neu- tralise them. Alkalies scarcely affect urea at low temperatures, but when it is assailed by heat, they rapidly convert it (together with water) into the carbonate of ammonia. In certain diseases of the kidney, urea exists in the blood in con- siderable quantities, as ascertained by Dr. Christison and others. There are diseases connected both with an excess and a defi- ciency of urea in the urine. Lithic or uric acid, supposed once to be a product of morbid secretion, is now known to be an invariable ingredient of healthy urine ; and present in solution at all ordinary temperatures. If it exists in the blood at all, it is in very small quantity only. Prout supposes it to be combined with ammonia, and not to be secreted in a free state. It is rendered probable by Liebig and Wiihler, that lithic acid is a compound of urea and a substance itself composed of cyanogen and carbonic oxide. The lateritious and pink sediment were supposed by Proust to constitute a peculiar acid, which he named rosaceous; but these have been found to consist essentially of the liihate of ammonia, and, sometimes, of the lithates of soda and lime, in small proportions. They owe their colouring matter partly to the colouring matter of the urine, and partly to the purpurate of ammonia. The colouring matter of the urine consists of yellow principles, more or less acted on by nitric acid, which Prout supposes to be in some way an ingredient of healthy urine. The next and most important form in which lithic acid appears in the urine, is that of lithic acid gravel, the immediate cause of the precipitation of which is the lactic acid, which is generally at this time secreted in excess, either separately, which is comparatively rare, or in a state of combination with urea, which seems to be the rule. The frequent presence of sugar in urine depositing lithic acid gravel and the frequent appearance of lithic acid gravel in slight forms of diabetic disease, are explained by our learning, that " the lactate of urea and the saccharate of urea are, in fact, but modi- fications of the same substance, and may be considered as the re- presentatives of gelatin; the lactic acid being, as we have said, only a modification of the saccharine principle." The lithic acid is, on the same authority {Prout), a principle of albuminous origin, and may be readily distinguished by the develop- ment of the purpurate of ammonia, by the aid of the action of the nitric acid and heat. The sulphuric and the phosphoric acids appear to exist in healthy urine in union with soda, potassa, and ammonia, and partly with magnesia and lime. The muriates of potassa and soda occur both in the blood and the urine. Muriatic acid exists only, in the urine, in combination with ammonia. I shall not make any remarks on the otherconstituents of healthy urea,but devoteafawwordsto the foreign substances which are occasionally found in it; and one of which, albumen, has of late become an exceedingly important diagnostic test of certain diseases. 18 DISEASES OF THE URINARY APPARATUS. Albuminous urine, on being exposed to a high temperature, under- goes coagulation; and its albumen at first collects on the surface, and then is deposited. Nitric acid added to the urine has the same effect. The chief component parts of calculi merit a passing notice. Of these are the xanthic acid, (the uric or lithic oxide of Liebig,) and the cystic oxide, which last is peculiar to the urine, and sometimes forms whole calculi. Prout, however, regards its presence in the form of calculus to be quite rare; but admits its not uncommon occurrence in certain states of disease. Sugar is not found in the blood in a state of health ; but is generally recognised in the blood of diabetic individuals, where it probably always exists in a greater or less degree: nor is it a natural ingredient of the urine, although found in large quantities in diabetes. Oxalic acid is neither found in the blood nor in the urine in a state of health; but in certain forms of dis- ease probably exists in both fluids. It is usually found in conjunction with lime, forming the oxalate of lime or mulberry concretion. Sometimes it appears as an amorphous sediment: in rare instances as gravel. Bile, in certain diseases, and particularly jaundice, makes its way not only into the blood but into the urine. " Urine containing bile is generally of a deep brownish-red colour, when in consider- able quantity and viewed by a transmitted light. But when con- tained in small quantity, it has sometimes a yellowish-green ap- pearance. A piece of white linen, it is well known, will be stained yellow by bilious urine; and the addition of muriatic acid renders it green. In organic affections of the kidney and liver, Prout has occasionally seen in the urine a crystallized fatty substance, similar to that frequently met with in encysted tumours and various ma- lignant affections, and which has been considered as cholesterine by Caventou, Breschet, Dr. Christison, and others. The secretion of the prostate gland sometimes appears in the urine. In general it may be distinguished from mucus by its albuminous pro- perties, and by its peculiar appearance. Pus occasionally appears in the urine in great abundance, so as to render its presence unequi- vocal. Most generally, it is accompanied by mucus; and be- tween the two there seems to be a close relation. " Pus, when well marked, may be distinguished from mucus by being essen- tially composed of particles. Hence, when diffused through the urine, which it readily may be, pus, after a time, again subsides to the bottom of the vessel, in the form of a pale, greenish-yellow, pulverulent deposit, and the urine assumes its transparent cha- racter. Urine containing pus is almost always invariably albu- minous. Pus may be detected if it and mucus both are present in the urine, by this fluid becoming alkalescent; the ammonia evolved converts the pus into a peculiar glairy substance, which imparts to the urine a ropy consistence. To facilitate a recapitulation of the preceding details, which are derived from Prout, and often given in his own words, I place before you the following table, also found in his work: — ALBUMINOUS URINE AND BILE. 19 TABLE. — Exhibiting a contrasted view of the relations between the prin- ciples of the blood and the principles of the bile and of the urine, formed either mediately or immediately from the blood. £ a a o :—* -a ss « S-a § . a •By c° >■» £ n i- o >-» ^ .s ~ •— ea «-• >- >^« OUSS J-J3 .« -S •« o a O U V a be cs Q..S ts va S » moa «o 3*;=B5;"o23:5"o-Dra_s £q duuifi aqi ui painasa-iday '_______La_________ «■§ ifq »#8" aul UF psinasajdajj _________A. O oi ina|BAinba -5 = o u a 1-12 a a £5 '« 2 2 a 9> Si 1*1 w kj a n to -3 ■ Q.B- a's m a a m .5 § « a -s- -r'S QG .tS a ■s a .s a si .2 « .2 a t. o a '£ O c8 a 2 a -1 55 3>s a 05 a —■ a S m ."o a a.s S 3 20 DISEASES OF THE URINARY APPARATUS. Diseased Structure of the Kidneys.—In order the better to appreciate the extent of the morbid changes in the kidney, we ought to know its standard or healthy appearance. As regards weight, we learn from Rayer that the mean weight in thirty males, from 16 years to 76 years of age, was four ounces three drachms, to four ounces and a half. The density of the organ is variable ; its weight not being always proportionate to its size. Multifarious experiments, at first by M. Comhaire in 1803, and subsequently by M. Rayer and his pupils, demonstrate the little sensibility possessed by the kidney. Hence we are bound to regard with attention any apparent trifling pain or tenderness on pressure in the region of this organ, and to endeavour to ascertain its cause. We also learn from this fact that nephritis may make considerable progress without the patient being apprised of it by pain. As regards injection of the renal tissue evincing disease, M. Rayer assures us that, whenever their anterior is more ingested than their posterior portion, in subjects who have laid as usual, on their back, this condition is to be ascribed to morbid action. He lays stress on this, because the phenomena of hypostatic engorgement of the cadaveric species is of regular occurrence in the kidneys. The assimilation of both substances, medullary and cortical, of the organ to the same colour, by imbibition of blood, when considera- ble, is very frequently mistaken for an effect of disease. When abdominal putrefaction advances with rapidity, the separation of the fibrous capsule is a common phenomenon, and is produced by the softening of the cellular membrane interspersed between the capsule and the substance of the organ. The alterations of colour of the kidneys are often very rapid, so that an artist intent on copying them, is sometimes greatly puzzled to catch the original one. Maceration, although it obscures some morbid states of the kidney, renders others more evident; and of these latter are the granulations observed in Bright's disease. The impregnation of the surrounding cortical substance with water renders it semi- transparent, and so throws out the dull, milky hue of the granula- tions. M. Rayer describes these bodies as more distinctly visible at the anterior part of the right kidney than elsewhere; an appear- ance which he attributes to putrefaction commencing earliest in this portion of the organ. Exploration. — The examination of a patient in whom we sus- pect disease of the urinary organs cannot be conducted with too much care. Manual examination**and percussion will be found important aids. By the former the degree of sensibility of the kidneys, the extent, form, direction, mobility, and resistance of visible enlargements, may be ascertained. Percussion will aid us in making out the origin of tumours in the lumbar regions; but it is to be borne in mind that the dull sound elicited may be due to the enlargement of other solid organs. The examination should be extended to the ureters, bladder, prostate, and urethra. Important aid to diagnosis will be found in the characters of the SYMPTOMS OF NEPHRITIS. 21 urine, as determined by certain chemical tests and experiments. Nor must we stop here, but, as M. Rayer has very wisely pointed out, we ought to inquire into the state of the constitution before we can safely determine the causes of the disease, or the mode of treatment advisable. Nephritis. — A new and, we must needs regard it, improved classification of the inflammatory diseases of the kidneys, is made by M. Rayer. He divides them into three groups,as follows: — I. JVephritis: Inflammation of the cortical or tubular substance; being either—1. Simple. 2. Produced by morbid poisons. 3. Ar- thritic, that is, gouty and rheumatic. 4. Albuminous. II. Pyelitis: Inflammation of the pelvis and calyces; being—1. Simple. 2. Ble- norrhagic. 3. Calculous. 4. Verminous. III. Peri-nephritis: Inflammation of the external cellular tissue and fibrous membranes of the kidneys, or of their investing adipose cellular tissue. IV. Pyelo-nephrilis: A combination of 1. and II. All the four species of the first group, nephritis proper, agree in commencing with partial or general hyperaemia; but they differ in respect to their symptoms and anatomical characters. A deposi- tion of pus is a frequent termination of the simple species; accu- mulation of plastic lymph or lithic acid, in the cortical substance or mammillae, is very often seen in the arthritic species; gangrene, more particularly, characterises the form of the disease produced by infection; whilst the most ordinary appearances in the albu- minous variety are anaemia, consecutive to hyperaemia, increase in size and weight of the affected organ, and milky spots or granula- tions. Induration and discoloration are common to all the species except the third. Symptoms. — Acute nephritis is generally ushered in by a chill and rigors, followed by febrile reaction. Soon there is felt pain, sometimes acute and lancinating ; at others obtuse, dragging, and deep-seated, in the lumbar region. The pain may be superficial or deep-seated; restricted to a small space, or extended over a large sur- face; commonly increased by pressure, but sometimes so obscure as to require forcible alternate pressure on both kidneys for its development. It is increased by motion, especially when the patient is erect; by coughing, sneezing, laughing, and deep inspira- tion ; by the efforts of defecation ; and, in fine, by any strong move- ment communicated to the trunk; also by decubitus on the affected side, and by the heat of the bed. It is remittent, rarely pulsatile, (an ordinary symptom this in peri-nephritis,) and irradiates upwards to the diaphragm, or downwards to the bladder, groin, and testicle, or uterus and broad ligament in the female ; and sometimes to the thigh ; and always on the side of the inflamed kidney, if the disease be limited to one. The bladder is, unexpectedly enough, some- times the principal if not the sole seat of the pain, in cases wherein that viscus is found to be in an almost perfectly healthy state after death, while the kidneys are seen to be profoundly disordered. This is a part of the symptomatology of nephritis worthy of dis- vol. n. — 3 22 DISEASES OF THE URINARY APPARATUS. tinct remembrance; as also the fact that sometimes, without pain in either organ, there is suppression of urine. After various diure- tics have been given in vain, the cathether is introduced, but no urine is found in the bladder; and the patient, if a female, is sup- posed to be nervous. If, on general grounds, or from some suspi- cion of the true renal origin and seat of the complaint, venesec- tion is ordered, or cups to draw blood over the lumbar region, and purgative medicines afterwards given, relief is soon procured. The suppression of urine may, however, as I have seen it within my own observation and practice, return before long, and without febrile action or pain. But the same treatment as before is fol- lowed by the same beneficial results. Among the sympathetic phenomena of nephritis we notice retrac- tion of the testicle, and numbness of the thigh on the same side with the kidney; nausea, vomiting, borborygmus, constriction at the epigastrium, wandering pains of the abdomen, tumefaction of this region, diarrhoea with tenesmus, dryness of the tongue, thirst; a pulse hard and full, sometimes small and intermittent. The skin is dry and burning; but occasionally covered with sweat, which, if there be suppression of urine, is often of an ammoniacal odour. Occasionally, nephritis gives rise to hiccup, laboured respiration, headache, and sleeplessness. The predominance of gastrointes- tinal disorder is such, in some cases of nephritis, that it may some- times impose on us as the chief and primary disease, without a minute attention to the organic derangement of the kidneys them- selves. The pain in nephritis is distinguished from that caused by calculi, in the latter being acute, pungent, and lancinating; in its coming on suddenly, and disappearing in the same way ; in its following the course of the ureter; being lessened in some positions and increased in others. The diagnosis will be still more certain when the urine is suddenly suppressed with the pain, and as suddenly flows with its disappearance ; and especially if small, gravelly par- ticles are seen at the bottom or on the sides of the chamber utensil. In puerperal women nephritis has a marked tendency to terminate in suppuration, and hence the necessity in their case of early re- course to the lancet, even though the pain be not violent. The lumbar pain which the disease induces may naturally be mistaken for labour. The symptomatology of nephritis is incomplete unless careful observation be made of the secretion from the kidneys, — as to its quantity, appearance, and composition. The secretion of urine is always diminished in quantity in this disease, and sometimes it is wholly suspended, — where both kidneys are inflamed. The urine may be excreted rarely, as twice or thrice in the twenty-four hours, or there may be distressing micturition. Its colour is of a deep red, approaching to that of blood and water. The chief changes, in point of composition, are stated by M. Rayer to be caused by impregnation with blood or albumen, by diminished ANATOMICAL LESIONS AND CAUSES OF NEPHRITIS. 23 acidity, neutral reaction or alkalescence, and occasionally by ad- mixture with pus. A white and homogeneous compound is some- times deposited; and in all cases of calculi, there are also deposited small, irregular shaped, gravelly, or sabulous particles. We must receive with some mistrust the assertion that albumen is found not only in the traumatic variety of nephritis, but that it may also occur when the attack proceeds from general causes, or diseases of neighbouring parts. Its appearance is, however, accidental and temporary, and may be completely put a stop to — unless when dependent in part on a coexisting affection of the bladder or urethra — by venesection. In the true albuminous nephritis, (Bright's disease,) the presence of albumen in the urine is a con- stant condition at all periods; and not to be removed by blood- letting. Anatomical Lesions. — General or partial increase of size; the kidney is also red and injected both superficially and deep-seated: induration, red or anaemic, coexisting with increased weight and size; giving, when both kinds of colouration exist, a maculated appearance; collections of pus, especially in the cortical sub- stance; infiltration with the same fluid; ulceration at the mam- milla? ; gangrene, but this is extremely rare. Deposition of disco- loured fibrin instead of pus is seen in the traumatic variety. Causes. — Age has a modifying influence in the occurrence of nephritis, for although it has been seen in every period of life, yet it is more commonly met with in the maturity of adult age, than in old men and children. It is rare to find it in this last class under seven years of age. It is, also, more common in men than in women, and in those of a sanguine temperament than others. Children of gouty or rheumatic parents are liable to nephritis. Its greater frequency in cold and damp climates than in warm ones, is a fact of familiar remark; but in this estimate we must take account of the much larger use of distilled and fermented liquors by the inhabitants of the former than the latter; which alone is a com- mon, perhaps the most common cause, not of a traumatic nature, of renal disease in general. The most direct and the most frequent causes of acute nephritis are contusions and wounds of the kidneys, and the irritation of foreign bodies, such as calculi, worms, or urine unduly retained in the excretory passages, and more particularly in the pelves of the kidney. All morbid states inducing retention are indirect causes of renal inflammation; whether they be inflammation of the ureter, prostate, urethra, and bladder, or displacements and diseases of the uterus, ovaries, rectum, &c. Paralysis induced by cerebro-spinal effusion or compression will, also, give rise to nephritis. Violent movements or shock, by running, leaping, riding on rough roads, are occasional causes of the disease. Various irritants, the operation of which is more particularly directed to the urinary apparatus, are commonly mentioned as often causing nephritis; such are cantharides, oil of turpentine, narcotic acids, &c, but 24 DISEASES OF THE URINARY APPARATUS. their power in this respect is no doubt overrated, and by some (Christison) is entirely denied. Under circumstances of predispo- sition, gouty or rheumatic, a sudden stoppage of perspiration, or a debauch will bring it on ; as will also the irritation of calculi: the sudden disappearance of arthritic gout or rheumatism may be followed by nephritis. . The disease may exist in very different degrees in the two kidneys, even where the cause has been common to both, such as exposure to cold and dampness, the action of canthandes, &c. Inflammation of one kidney caused by topical cause, as a bruise, will produce an evident effect on the other, manifested by a material diminution if not suspension of the urinary secretion. Chronic nephritis is not marked by many diagnostic symptoms. M. Rayer assures us that habitual pain in one or both renal regions, coexisting with diminished acidity, neutral reaction, or more espe- cially alkalescence of the urine, and a sensation of weakness and numbness in the lower extremities, constitute the principal charac- ters of chronic nephritis. But this opinion must be largely qualified when we learn that, in a great number of cases, we can hardly suspect the existence of the disease, unless on the evidence of a most minute examination of the urine. Chronic nephritis is most intimately connected with the generation of phosphatic calculi. " The urinary sediment in chronic nephritis, when the fluid itself is alkaline, is either amorphous, and composed almost wholly of phos- phate of lime, or chiefly constituted by crystals of ammoniaco-phos- phate of magnesia ; or, as most commonly happens, both these salts are held in suspension, together with globules of mucus and a small quantity of lithates. The contents of the bladder are, in ordinary cases, excreted frequently, and in small quantities at a time. Im- pregnation with blood or albumen is rare in the uncomplicated disease, with mucus frequent, and with pus indicative of inflamma- tion of the mucous membrane of the passages." (Brit, and For. Med. Rev., vol. viii.) The diagnosis of this affection is occasionally confirmed by the good effects of local depletion ; as when, after cupping on the loins, the renal pain and the turbidity and alkalinity of the urine not un- frequently disappear altogether. Fever is generally absent, but the disease is attended with progressive marasmus and a general cachectic habit, which M. Rayer believes to favour the development of pulmonary tubercles. The anatomical lesions in chronic nephritis are often not materially variant from those of the acute disease. More commonly, however, we meet with diminished size of the kidney ; but sometimes hyper- trophy with increased weight and hardness of tissue ; granulated, rough, or tuberculated exterior: red injection, but this we may sup- pose to be present as a result of an acute attack just before death : anaemia, partial or general, ordinarily attended with augmented density and in many cases with hyperaemia: a peculiar species of atrophy, of which one of the most remarkable characters consists TREATMENT OF NEPHRITIS. 25 in the appearance of cicatrices on the outer surface of the organ; and, finally, ulceration of, or purulent collections in, the mam- millae. Their investing membranes frequently participate in the in- flammation affecting the organs themselves, — their vessels rarely. The causes of chronic nephritis are the same as those of the acute; but the chief influential ones are irregularity and excesses in food and the free use of alcoholic drinks, which are rendered doubly pernicious by interruption of the cutaneous function through cold and moisture. Treatment of Nephritis.—Acute nephritis requires the antiphlogis- tic treatment to be carried out to its full extent. Venesection to the amount of twenty-four or even thirty-six ounces ought to be practised at once, and in a short period repeated, to the amount required by the violence of the inflammation. In aid of this means, leeches ought to be applied to the lumbar regions, over the kidneys, or cupping practised in the same place, in order to abstract blood to the extent of at least twelve ounces. Laxatives should always be preferred to purgatives; and castor oil, or rhubarb and magnesia, are to be given to the exclusion of saline medicines; and, after all irritating matters are removed from the intestinal canal, enemata will suffice for evacuating the lower bowels. Warm water as an internal fomentation of the colon acting sympathetically on the kidney, and afterwards some preparation of opium, may advan- tageously follow as enemata. Immersion in a warm bath for half an hour at a time, and the administration of mild diaphoretics, of which Dover's powder is the best, are exceedingly useful adjuvants to the evacuating plan. Among the direct reducers of inflammation, calomel and tartar emetic are entitled to a place after general and local bloodletting. Opium may be combined with both of them, in order to aid their sedative effect, and to prevent the nausea which is apt to ensue immediately after the use of tartar emetic, and more remotely after calomel. So long as the renal inflamma- tion is high, both these medicine's will be tolerated in large doses without inconvenience. The probability of ptyalism from the free use of the calomel will be abated by encouraging the peristaltic motion of the bowels, by simple watery or mucilaginous enemata. Counter-irritation will be usefully induced by warm pediluvium, or even the warm hip-bath, and by frictions of the feet and lower ex- tremities generally, and with stimulating liniments. Difference of opinion prevails on the subject of the quantity of drink to be allowed to a patient labouring under nephritis. Some would withhold it alto- gether, or give it in very small quantity, on the plea that the kidney ought to be tasked to as little secretory effort as possible when it is inflamed ; and if possible its function suspended when the ureter is obstructed with calculus. But, on the other hand, it is generally admitted, that the smaller the quantity of urine, the more concen- trated it is, and more abounding in saline and other stimulating ingredients; and hence the advantage of free dilution to obtund, as it were, the acrimony of the urine, and, in fact, to render the task of 3* 26 DISEASES OF THE URINARY APPARATUS. the kidneys themselves easier by increasing the proportion of water in the blood brought to them. . . , . There is scarcely any of the phlegmasia} in which opium in lull and repeated doses is so much relied on as in nephritis. Its use may follow directly venesection, especially if this latter be carried so far as to cause faintness.or it may be given at intervals throughout the whole period of the complaint, in conjunction with the other remedies already mentioned. In nephralgia, the symptoms of which are chiefly measured by pain, unaccompanied by fever, but with greater sympathetic dis- turbance of the bowels, opium is the chief remedy, and more par- ticularly when the pain is kept up by the retention of a calculus in the pelvis, or in the ureter. The treatment of chronic nephritis is not materially different from that demanded in the acute form. Depletion is not required to the same extent, but its repetition is somewhat more called for; and the use of purgatives is not only admissible but decidedly effi- cacious. Narcotic diuretics, such as digitalis and colchicum, with the alkalies, and particularly the liquor potassae, by some recom- mended in the acute form of the disease, are also called for in the chronic. Mineral acids often prescribed in chronic nephritis with alkaline urine are strongly protested against by M. Rayer. Greater reliance, however, is placed on counter-irritation by tartar emetic plaster on the loins, or by caustic or seton to the same part. Blisters are generally objected to; but unless the patient be constitutionally prone to be irritated by them, their use need not be withheld. The diet, which in acute nephritis is of the simplest kind, consist- ing indeed almost wholly of diluent and demulcent drinks, may be more nutritious in the chronic variety. M. Rayer counsels the moderate use of animal food at this time. Attention to the cutaneous function, and preserving an equable temperature of the skin, is of the very last importance for the entire recovery from acute nephritis and the prevention of a relapse. When nephritis occurs as a consequence of the retention of urine, produced either by urinary or cerebral disease, it will be necessary to evacuate the bladder regularly. This is best done by introducing the catheter at proper intervals, instead of allowing it to remain in the bladder; a not uncommon, but a hurtful practice. One of the most troublesome and dangerous forms of nephritis is that occurring after other diseases, and, according to the classification of M. Rave?, the product of animal poisons. The most marked, or perhaps I should say, the most common instance, is nephritis occurring in typhous and typhoid fever, owing, as we are told, to retention of urine. Without denying that this is a contributing cause, I am inclined to believe that the kidneys become affected in the progress of the fever, as the lungs, or the brain, or spleen is known to be, viz., deeply congested, and to a certain extent inflamed; and hence a suspension of their secretory function. BRIGHT'S DISEASE, OR RENAL DROPSY. 27 LECTURE LII. DR. BELL. Bright's Disease, or Granular Degeneration of the Kidney.—Renal dropsy- Its organic seat, common accompaniments and constant symptoms.—Symp- toms.—History of the disease—Acute form of the disease; is short, and not often seen—Anasarca soon appears—Acute affection a sequence of scarlatina—Albu- minous urine, how far a characteristic symptom—Properties of the urine in this disease—Tests of albumen in the urine—Blood ; its appearance and composition. —Secondary diseases—Anasarca most common; next, ascites—Morbid state of the heart—Albuminous urine from diseased heart alone—Phthisis—Diarrhoea very common—Cerebral disease and meningeal inflammation with effusion— Pregnancy developing Bright's disease—Exanthemata—particularly scarlatina gives origin to it—Anatomical lesions—Summary by different observers—Pre- cise state of the kidney; congestion with inflammation—Mr. Robinson experi- ments—Mr. Rayer's opinion—Dr. Burbridge's views.—Causes—Predisposition by particular constitution, and especially intemperance—Exciting causes—cold and dampness. To-day I have to direct your attention to one of the achievements of modern pathology, in its revealing to us, with singular precision, the organic cause of a great number and variety of disorders which have hitherto been regarded as separate or merely functional ones. The discovery is of a peculiar structural alteration of the kidney and accompanying constitutional disorders. The disease was first made known by Dr. Bright; and since farther explained by other distin- guished pathological physicians; but by no one with so much ful- ness and detail, and with the introduction of so large a body of original and collected matter, as by M. Rayer. It has various names, viz., Bright's Disease — Albuminous Nephritis (Rayer); Granular Degeneration of the Kidney (Christison); Albuminuria (Martin Solon — Forget) ; Mottling — White Degeneration — Con- traction — Granulation. The most obvious anatomical lesion of the kidneys in this disease consists in a granulated appearance of the cortical part; the most obvious and most common morbid accompaniment in the system at large is anasarca, or some form of dropsy, and the almost invariable symptom is albuminous urine. If a principal and almost constant symptom, after the old fashion, as that of anasarca, were to justify a name, we should call it renal dropsy. By its dropsieal symptoms, indeed, the disease will, for the most part, first arrest your attention* I cannot give you a better idea of the general and frequently also anomalous features of this disease, than in the very words of Dr. Bright himself (Guy's Hospital Reports, vol. i.). Symptoms.—" The history of this disease, and its symptoms, is nearly as follows : — "A child, or an adult, is affected with scarlatina or some other acute disease; or has indulged in the intemperate use of ardent spirits for a series of months or years : he is exposed to some casual cause or habitual source of suppressed perspiration: he finds the 28 DISEASES OF THE URINARY APPARATUS. secretion of his urine greatlv increased, or he discovers that it is tinged with blood; or, without having made any such observation, he awakes in the morning with his face swollen, or his ankles puffy, or his hands (Edematous. If he happen in this condition to fall under the care of a practitioner who suspects the nature of his disease, it is found that already his urine contains a notable quan- tity of albumen: his pulse is full and hard, his skin dry, he often has headache, and sometimes a sense of weight or pain across the loins. Under treatment more or less active, or sometimes without any treatment, the more obvious and distressing of these symptoms disappear; the swelling, whether casual or constant, is no longer observed ; the urine ceases to evince any admixture of red particles; and, according to the degree of importance which has been attached to these symptoms, they are gradually lost sight of, or are absolutely forgotten. Nevertheless, from time to lime the countenance be- comes bloated; the skin is dry; headaches occur with unusual frequency; or the calls to micturition disturb the night's repose. After a time the healthy colour of the countenance fades ; a sense of weakness or pain in the loins increases ; headaches, often accom- panied by vomiting, add greatly to the general want of comfort; and a sense of lassitude, of weariness, and of depression, gradually steal over the bodily and mental frame. Again the assistance of medicine is sought. If the nature of the disease is suspected, the urine is carefully tested ; and found, in almost every trial, to contain albumen, while the quantity of urea is gradually diminishing. If, in the attempt to give relief to the oppression of the system, blood is drawn, it is often buffed, or the serum is milky and opaque; and nice analysis will frequently detect a great deficiency of albumen, and sometimes manifest indications of the presence of urea. If the disease is not suspected, the liver, the stomach, or the brain divides the care of the practitioner, sometimes drawing him away entirely from the more important seat of disease. The swelling increases and decreases; the mind grows cheerful or is sad ; the secretions of the kidney or the skin are augmented or diminished, sometimes in alternate ratio, sometimes without apparent relation. Again the patient is restored to tolerable health; again he enters on his active duties: or he is perhaps less fortunate; — the swelling increases, the urine becomes scanty, the powers of life seem to yield, the lungs become cedematous, and, in a state of asphyxia or coma, he sinks into the grave; or a sudden effusion of serum into the'glottis closes the passages of the air, and brings on a more sudden dissolution. Should he, however, have resumed the avocations of life, he is usually subject to constant recurrence of his symptoms ; or again, almost dismissing the recollection of his ailment, he is suddenly seized with an acute attack of pericarditis, or with a still more acute attack of peritonitis, which, without any renewed warning, deprives him in eight-and-forty hours of his life. Should he escape this danger likewise, other perils await him ; his headaches have been observed to become more frequent; his stomach more deranged ; BRIGHT'S DISEASE, OR RENAL DROPSY. 29 his vision indistinct; his hearing depraved : he is suddenly seized with a convulsive fit, and becomes blind. He struggles through the attack ; but again and again it returns ; and before a day or a week has elapsed, worn out by convulsions, or overwhelmed by coma, the painful history of his disease is closed." Granular disease of the kidneys, in its acute form, often eludes observation, or rather it is mistaken for simple nephritis, to which its symptoms have a close resemblance; and it is not until it has passed into its sub-acute or chronic state, that it more pointedly fixes the attention of the physician. Even at this time it is referred to some other morbid derangement than that of the kidneys; as may be in- ferred from the preceding description of it by Dr. Bright, who him- self only recognised it, at first, in this state. It is seldom that the lumbar pain or uneasiness, fever,and albuminous and scanty urine are long present before anasarca is formed. Frequently, this affection appears in the course of the first or second day, and it commonly puts on the character of inflammatory dropsy, one external feature being an absence of pitting of the swelling on pressure. Most generally, as Dr. Christison observes, the acute symptoms give place to those of the chronic form of the disease, which runs its own proper course. The only invariable character which he admits of the acute form, is scanty, highly coagulable urine, with more or less fever. More especially is its value evinced in the clear light which it throws on the most common form of dropsy, and on the nature of dropsies in general. These symptoms may prevail alone for a few days, till coma and convulsions suddenly occur, and prove quickly fatal. The acute affection has most frequently been witnessed in children as a sequence of scarlatina, especially, according to M. Rayer, in cer- tain epidemics of this disease; but it also occurs in adults indepen- dently of any exanthematous disorder,and notably in various diseases of the kidney (not granular), and of the bladder. Dr. Christison on this point, as to the indications derived from the presence of albu- men, says: "it appears unquestionable that certain kinds of food may occasion its appearance in the urine of some people; that it may be produced there by certain poisons that act on the kidneys; occasionally by true nephritis, always more or less by pyelitis ; rarely by tubercles; often by carcinoma; often by scurvy and by purpura; seldom during the crisis of acute inflammatory diseases or continued fever. Simply and abstractedly, therefore, it is not a proof of granular disease being present in the kidney; but it is far more frequently produced by granular .disease than by all other causes put together; and no other cause yet ever known occasions so large a proportion in the urine as is generally seen in the early stage, and sometimes, too, in the chronic form of the disorder; so that urine, at least moderately coagulable, according to the definitions given above, probably always indicate granular derangement." (A Sys- tem of Practical Medicine, &c.) The urine in the acute stage is always acid, and voided in small 30 DISEASES OF THE URINARY APPARATUS. quantity: its colour is variable; sometimes of a reddish or deep- brown, depending on the presence of more or less blood ; but more frequently, as the disease advances, it is of a yellowish or greenish- straw colour, like whey, not strained, and in all cases it is more or less turbid (Tissot—Dissertation, 1833). This opaline turbidity, as it has been aptly termed by Christison, is not removable by repose; and arises from modified mucus, in the microscopic scales of the epithelium of the urinary mucous membrane: in rare cases strings of viscid mucus are seen. This turbidness may also proceed from globules of fatty matter being suspended in the urine. Urinary depositions are not common; yet both lithic and phosphatic amor- phous sediments may be occasionally observed. Examined under the microscope, the urine in the first or acute stage of the disease is seen to contain blood-globules in numbers, occasionally mucous globules, and always lamellae of epithelium. The density of the urine is affirmed by M. Rayer to be above the healthy standard, or 1.028, while Dr.' Christison tells us that it is much below or between 1.007 and 1.011, and in a few cases as low as 1.004, rarely above 1.014. But there must be differences in this respect according to the period of the disease at which the examination is made. Al- bumen is commonly present, and in such quantity, according to Dr. Christison, as to occupy, when coagulated and allowed to rest, between a fourth and an eighth of the volume of the liquid. The quantity decreases generally with the advance of the disease, unless an occasional acute attack supervene in the chronic stage. The daily solids of the urine are reduced in quantity; the diminution seeming to affect all the principles of the urine indiscriminately. The calls to urinate are more frequent than in health, and the quantity of urine discharged is at first nearly natural; but as the disease advances, and especially if it approach a fatal termination, it falls far below the common standard ; and in some cases, only one or two ounces are passed daily for many days consecutively. The tests of albumen in the urine have been stated before to be, first, heat alone, and then nitric acid : either causes a curdiness, a coagu- lum, and then precipitation. To these we should add non-precipita- tion by acetic acid. Tissot attaches much importance to physical signs, v.z., a number of bubbles, which remain on the surface of the urine and on the sides of the vessel in which it was received so much longer than those casually made in common urine. Bv star- ring the urine, or better still, by blowing in it through a tube or common reed, a great quantity of these bubbles, like soap bub- bles blown by children in their sports, was developed, if the urine was diseased. In healthy urine the bubbles thus made are smaller and soon disappear. The great importance of the albuminous test of renal disease particularly in connexion with dropsy, renders it desirable that we and ce fain v %Teertain *'! Prese"ce « the urine with reading SnrLS l ? y' ThLmeans for us »o do this have just been men- tioned; but some additional particulars may now be appropriately BRIGHT'S DISEASE, OR RENAL DROPSY. 31 subjoined. In the first place, however, we ought to be aware of the fact, as pointed out by Dr. Wells, that the effects of reagents are not the same on albumen contained in water and in urine. " It must also be remembered that, if alkaline urine be rendered turbid by heat, the loss of transparence is usually due to the precipitation of phosphates, as is proved by its complete restoration on the addition of nitric acid. For this fact we are indebted, we believe, to Mr. Rees. On the other hand, precipitation by nitric acid alone will not prove the matter thrown down to consist of albumen ; such precipitate may be composed of lithic acid, or of lithate of ammo- nia." And an additional source of error is, in attributing the cha- racter of albuminous coagula to a precipitate of lithate of ammonia, which may become soluble in an excess of acid. The examination of the suspected urine should be made repeat- edly, because sometimes the albumen disappears for a time. It is necessary, as Dr. Christison very properly remarks, to attend to the proportion of the albumen, both with a view to the prognosis and the treatment. " For this end, it should be coagulated in a tube, and left at rest for twenty-four hours; upon which the following degrees of coagulability may be noted: gelatinous by heat; very strongly coa- gulable, where a distinct precipitate separates, occupying the whole fluid ; strongly coagulable, where it occupies half the volume of the fluid; moderately coagulable, where it occupies a fourth of the fluid; slightly coagulable, where it occupies an eighth; feebly coagulable, where it occupies less than an eighth; and hazy by heat, where a turbidity is occasioned without visible flakes." The appearance and composition of the blood in granular disease of the kidney, are points of considerable interest; although we must regret that they are not as fully ascertained by the different writers on the subject as we could wish. The frequency of the buffiness of the blood in the first stage of the disease is noticed with con- siderable unanimity. The serum is diminished in its specific gravity owing to the loss of its albumen, and it may fall from 1030, the average healthy standard, to 1022, or even 1019. After venesection, if the urine is rendered thereby less albuminous, the natural state of the urine may return. Sometimes the latter is lactescent from admixture with fatty matters, removable by sul- phuric ether. The quantity of urine is increased, and also that of fibrin, according to Dr. Christison. With the progress of the disease the blood undergoes farther alteration, but the quantity of crassamentum is diminished and that of serum increased: the specific gravity of this latter is also larger, and even may exceed the common standard. The proportion of globules is greatly dimin- ished, and the reduction increases as the morbid change of the kid- ney advances. " Probably," says Dr. Christison, "no other disease except hemorrhage occasions so great an impoverishment of the colouring matter of the blood. The healthy proportion in a stout male being about 1340 grains in 10,000; it has been found reduced 32 DISEASES OF THE URINARY APPARATUS. in granular disease of the kidney, according to its stage, to 1110, 955, 720, 564, and even 427. . . , Secondary Diseases.— Anasarca is an almost invariable attend- ant on granular disease of the kidney; so much so, that it is regarded as a characteristic symptom. But there are instances in which the renal affection lasts for a long time without dropsy. It was this latter, however, which first drew the attention of Dr. Bright to the disease of the kidneys. He found it to prevail in twenty-three out of twenty-four cases of this latter; Rayer, in 16 out of 17. The form it most generally assumes is anasarca, attended with more or less effusion into the great serous sacs, and into the pulmonary cellular tissue. M. Rayer's experience, as repeated by M. Tissot, leads him to believe that ascites is the most common. Most cases of what are called inflammatory dropsies, as well as those following scarlatina, depend on disease of the kidneys. So, too, are most, if not all, cases attended with diuresis, provided the urine be not saccharine. A writer, to whom I have been so largely indebted in my summary of opinions, particularly those of M. Rayer, on all the diseases of the kidneys of which I have hitherto spoken, asserts that anasarca is scarcely a less frequent attendant on the renal lesion now before us than, for example, cough in phthisis (Brit, and For. Med. Rev., vol. x.). Diseases of the bladder, prostate, and urethra, have.in M. Rayer's opinion, little or no influence over 'albuminous nephritis' — granu- lar disease of the kidney; and he has found that the latter rarely induces inflammation in the pelvis and ureters, and still more rarely in the bladder. Diabetes may, he thinks, have some influence in its production. A very frequent accompaniment of Bright's disease is a morbid state of the heart; Dr. Bright having found sixty-seven cases of cardiac affection — hypertrophy with or without valvular lesion—in one hundred of renal degeneration. This gentleman drew a hasty inference, that the latter always preceded and acted as a cause of the former. M. Rayer, on the contrary, believes that the disease of the kidney is very frequently produced by that of the heart, and he has seen slight albuminuria in subjects affected with hypertrophy or valvular lesions, gradually becoming intensely marked, and at- tended with the most distinct evidence of the special renal affection. But it must be added, that there is albuminous urine in cases of disease of the heart or large vessels without renal or Bright's dis- ease; and hence we are assured also of another fact, that this cha- racter of urine is not always the sign of disease in the kidneys. M. Forget, of Strasburg, in the Gazette Medicale de Paris, Sept. 1837, relates a case of a middle-aged woman, who died from disease of the heart, (this organ was hypertrophied, and the mitral valve particularly was ossified and contracted,) but the kidneys were perfectly sound. The most obvious disorders during life were anasarca and ascites, and the passage of albuminous urine. This BRIGHT'S DISEASE, OR RENAL DROPSY. 33 writer gives several cases showing the coexistence of disease of the heart with that of the kidneys and dropsy. Dr. Darwell had before this time pointed out the fact, that the urine of patients labouring under heart disease might have albuminous urine with sound kidneys, or with simple hyperaemia of these organs. Catarrh or bronchitis is noticed by the writers on the present subject, to whom I have chiefly referred, as an extremely frequent secondary disease to that of Bright's. Dr. Osborne (On the Nature and Treatment of Dropsical Diseases), found that bronchitis pre- vailed in eighteen cases out of thirty-six, whose histories he was acquainted with. It is often associated with emphysema, and leads to pulmonary oedema, or, as some allege, lobular pneumonia. "It is occasionally acute, much more frequently chronic. It is often enough cured, yet it is frequently obstinate, and in many instances it is the immediate cause of death. Few survive long if it be ob- stinate, more especially where extensive anasarca concurs, and the primary disease has made some progress." (Christison, op. cit.) There would seem to be an occasional connexion between phthisis and granular disease of the kidney; the latter sometimes occurring as secondary to the former; and at other times pulmo- nary consumption seems to have arisen from the deterioration of the constitution by Bright's disease. Various affections of the stomach may attend the disease; such as dyspepsia and chronic vomiting. Diarrhoea is a very common secondary disorder. M. Rayer saw it in upwards of half his patients; it was remarkable for its intractability, and for its never lessening, no matter how profuse it is, the amount of dropsical effusion. On the contrary, and the observation is not new to those conversant with dropsical diseases, although they may have been ignorant of their organic origin, the effusion seemed to increase with the aggravation of the diarrhoea. Between liver and kidney disease there has been occasionally noted a connexion, but it is not well defined. Cerebral disease, in various forms, is of occasional occurrence in granular kidney. Sometimes an apoplectic attack supervenes suddenly, and proves quickly fatal; but this is far from being a frequent result. In general, the head affection comes on in the insidi- ous form of increased drowsiness, and perhaps some bluntness of the mind and obliteration of the senses; but it must at the same time be borne in mind, that coma is not necessarily connected with the extent or increase of dropsical effusions. Dr. Osborne speaks of arachnitis as a common disease under these circumstances ; and Rayer, of sub-arachnoid serous infiltration as the lesion most com* monly discovered, along with occasional superabundance of fluid in the ventricles. Dr. Barlow has obtained urea from this fluid* Hemorrhages into the substance of the brain, into the ventricles, or the cavity of the arachnoid, have been noted by Dr. Bright; but, after all, M. Rayer thinks them so rare, that he doubts there being any real dependence between the two states of cerebral hemor- rhage and renal lesion. vol. n. -—4 34 DISEASES OF THE URINARY APPARATUS. Several examples of Bright's disease have been observed by M. Raver, as among the apparent effects of pregnancy. ' borne ot these cases were remarkable for the facility with which the disease yielded after delivery to very simple treatment. In certain instances where the disease preceded, or was developed at an early period ot pregnancy, it evidently interfered with the evolution of the ovum, and in cases published both by M. Martin-Solon and himself, led to fatal abortion." The occasional dependence of granular disease of the kidney on the exanthematae, and particularly scarlatina, has„been dwelt on both by Bright and Rayer. Dr. Bright considers scarlatina " as often laying the foundation for the future disease, or as an evidence of the strong tendency existing in the constitution, even when the cure has been apparently complete." At a subsequent date (Re- ports, fyc.) he remarks :— " During the autumn and winter which have just passed (1839—40), we have experienced an almost epidemic prevalence, in London and its neighbourhood, of that anasarca with albuminous urine which has been long known to accompany or follow scarlatina. The attack of the original disease has often been slight; the rash some- times scarcely perceived ; the sore throat often mild ; and the affec- tion of the urine has frequently shown itself while the rash or sore throat has still existed. Haematuria has occasionally occurred during the severity of the attack; but more commonly this symp- tom, with or without anasarca, has followed on the subsidence of the fever, or during the early convalescence. The number who have offered themselves as out-patients, or have been admitted into the wards of Guy's Hospital, under such circumstances, as well as the cases which have occurred in private practice in other parts of London, have been quite unprecedented, within the limits of my experience." Anatomical Lesions in Bright's Disease.— A clear and more connected, and at the same time historical view of the morbid changes in the kidney, altered by albuminous inflammation, or in Bright's disease, will be procured by your having placed before you, as I do now, " the similitudes and differences in the descriptions of the few observers who have made them a subject of special study," displayed " in a condensed form in juxtaposition." Here, again, I must acknowledge my obligations to the able writer in the British and Foreign Medical Review (vol. x.), to whom I have so often referred before. ANATOMICAL LESIONS OF BRIGHT'S DISEASE, ETC. BRIGHT. (1827.) Chronic. 1st Form. The kidney looses its firmness, acquires a yellow or mottled appearance externally; the same yellow colour, slightly tinged with gray, per- vades the cortical substance; the tubu- lar is of lighter colour than natural; the size of the kidney, not materially altered; there is no morbid deposit. 2d Form. The whole cortical part is converted into a granulated texture, with copious morbid interstitial deposit of an opaque white substance; the kid- ney is generally enlarged, sometimes very much so. (The granulations are rendered more apparent by maceration.) 3d Form. The kidney is quite rough, and scabrous to the touch externally, and is seen to rise in numerous projec- tions of about the size of a large pin's head, of yellow red and purplish colour. The form often inclined to be lobulated, the feel hard, the texture of semi-carti- laginous firmness : tubular portions appear drawn near to the surface of the kidney. RAYER. (1837.) Acute. 1st Form. Kidneys enlarged, their weight may reach 12 oz.; firm but not hard; surface of a morbid red colour and studded with small deep red points; Internally, the increased size is found to depend on the cortical substance which presents a great number of simi- lar points, apparently the Malpighian glands injected. Tubular cones of duller red colour, and their striae less distinct than natural; pelvis and calyces injected. 2d Form. The enlargement persists, with slight diminution of consistence; tendency to lobulation is often observed; mottled appearance from red spots on a yellowish-white ground (mixture of hyperemia and anaemia). On division, the cortical substance appears swollen. and of.pale-yellowish tinge, speckled with red ; the tubular of a rather bright brownish-red. Usually Chronic, rarely Acute. 3d Form. Size and weight increased as before; no mottling; cortical sub- stance externally, and on section appears of a pinkish-white and slightly yellow- ish hue, or paler, and like that of eel's flesh. Small vascular arborizations; and sometimes large white granula- tions resulting from deposition of plastic lymph. Ath Form. Size and weight as be- fore ; external surface smooth, of pale yellow colour, speckled or covered with milky-white spots as large as the head of a very small pin ; these are found also in the interior of the cortical sub- stance (which is of the same pale colour as in the two previous forms), and aggregated into flocculent streaks. Chronic. 5th Form. Rarer than the preceding; kidneys as before in point of size and weight; lobules unnaturally distinct; the external surface appears as if a vast number of " grains de semoule" were deposited under the cellular capsule of the organ. 6th Form. The kidney is sometimes larger but often smaller than in health, is hard, and presents inequalities or mamillae on the surface, few or no milky spots (Bright's granulations), but commonly some of these in the in- terior of the cortical substance. Cap- sular membrane almost always thick- ened and very adherent. 36 DISEASES OF THE URINARY APPARATUS. MARTIN-SOLON. (1838.) 1st Degree or variety. Kidney red, hypertrophous, enlarged and heavy — especially cortical substance ; the tubu- lar is also of deep red colour, but not hypertrophous ; the blood combined with these tissues cannot be Temoved by washing; the renal substance is friable and marked with red or blackish stellate points— probably ecchymoses. 2d. Tissue, still hypertrophous, pre- sents a yellowish striated or mottled appearance ; the sulci marking the divisions of the kidney in infancy are sometimes manifest ; the tubular sub- stance is slightly hypersemic. 3d. Kidney almost always hypertro- phous, a state still depending on cortical substance : the external surface, gene- rally smooth, sometimes presents in- equalities. Surface of a pale-yellow hue, something like that of the pan- creas, as likewise is the substance of the kidney internally ; the cortical sub- stance appears to penetrate between the radii of the tubular; and these latter have in some measure disappeared,, or tend to become of pallid colour. The tissue is soft, but to a certain degree friable, though it resists laceration somewhat. 4th. The kidney presents the yellow appearance just described ; and besides white, pultaceous, creamy particles,, ap- parently produced by interstitial exha- lation on the surface and in the sub- stance of the organ (Bright's granula- tions). 5th. Kidney, in addition to the ana- tomical characters of Bright's disease, contains some form of adventitious pro- duct (cyst, tubercles, carcinoma, &c). CHRISTISON. (1839.) 1 Incipient Stage. A minor degree of the second stage,— namely, of the deposition of a grayish-yellow, obscure- ly granulated matter in the cortical structure, with or possibly without some degree of sanguineous congestion. 2. Middle Stage. The deposition of granular or cheese-like matter, the only important and well-established anato- mical character of the morbid formation, seems at first to be, for the most part, chiefly confined to the cortical sub- stance. 3. Advanced Stage. The morbid de- position gradually pervades the tubular substance.* * Dr. Christison also believes that the follow- ing appearances " ought to be distinguished with the view of afterwards tracing their rela- tionship. 1. Congestion of the kidneys with or without some granular deposit in their sub- stance. 2. True granular degeneration of the cortical or tubular structure ; a, finely granular; 6, botryoidal. 3. Degeneration by a smooth, homogeneous, yellowish-gray mass intermediate in consistence between that of the liver and that of the brain. 4. Disseminated tubercles. 5. Induration of semi-cartilaginous hardness. (5. Atrophy with disappearance of the proper renal structure, and with or without one of the previous morbid states. 7. Simple anaemia." " Now, it must be admitted that the gradations of diseases here described seem naturally and closely connected, as far as the fourth; and though it may be difficult to demonstrate the link between the yellowish discolorations, &c, and the deposition of the granular matter,, the fact is no less important that such deposition does not probably occur until the tissue of the kidney has, with greater or less rapidity, passed through the previously described phases. Should a suspicion arise that accuracy has been sacrificed to zeal for systematic arrangement, this may be dismissed with the reflection that each of these forms of disease with its special charac- ters has repeatedly been observed by writers who entertained no particular view respecting the mode of relation of the series. The sixth stage of M. Rayer, acknowledges its connexion with its pre- decessors by the occasional presence of the milky granulations. ANATOMICAL LESIONS IN BRIGHT'S DISEASE, ETC. 37 Such then may, in the present state of knowledge, be fairly admitted to be the mode of progress of this disease under ordinary circum- stances, and when its evolution is regularly accomplished. But it must not be forgot that, in many instances, we are without any direct proof from anatomy, or collateral evidence from symptoms, that the disorder has originated in active congestion : the morbid changes appear indeed to advance so insensibly as almost to exclude the notion of an irritative process having existed in the affected organ." As regards the precise state of the kidney giving rise to albu- minuria or Bright's disease, the probability is, Dr. Christison thinks, that congestion, or even reaction in the kidney, precedes, in the acute stage, a peculiar morbid deposit; but that this last, or the chronic form, is made without any such precursor ; that as the deposit increases, the healthy texture of the kidney begins to be absorbed ; that after a time, although the absorption of the healthy structure goes on, the formation of the morbid deposit often ceases ; and that possibly this deposit is sometimes absorbed in its turn. Mr. Robinson, in a Memoir on the Pathology of Granular Dis- ease of the Kidney, has endeavoured to prove, " that the acute stage of writers is simply acute nephritis, and that all the varieties of morbid appearances occurring in the febrile stage may be con- sidered as resulting from so many different degrees in intensity and duration of chronic inflammation of the kidney." Mr. Robinson, in confirmation of this view, might have referred to the result of M. Rayer's experience, which points to " the striking analogies be- tween simple and albuminous nephritis. The action of cold and damp produces'both diseases. In the acute stage, (with the ex- ception of the deposition of pus, which has either not been observed at all, or at least very seldom, in Bright's disease,) the anatomical characters are identically the same—the injection of the kidneys, their increased size, yellow discoloration, &c, are all appearances common to both maladies. In the most advanced chronic stage, the lesions are so precisely similar, that were it not for several cir- cumstances connected with the progress of these affections, the absence or presence of dropsy, and the constant or only occasional presence of albumen in the urine, it would be impossible to distin- guish them from each other." Mr. Robinson advances another proposition: — " That the pre- sence of albumen in the urine is produced by, and its proportional quantity is in direct ratio to the degree of, congestion of the capilla- ries of the kidney, from whatever cause that congestion may arise." He confirms this view by several experiments on rabbits, in which he tied the emulgent vein of one side, after exposing the kidney; and, after the lapse of a period, varying from ten minutes to an hour, the animal was killed. The urine on being tested by heat and nitric acid was found to contain albumen. " In all these ex- periments the kidneys operated on were more or less congested; their colour darker, and their bulk and weight greater than the remaining organs, which were in every instance perfectly healthy in 3S DISEASES OF THE URINARY APPARATUS, colour, size, and structure." (London Med. Gaz., April, 1842L) Mr. Robinson refers, in confirmation of his own view, to tineey described by Dr. Stokes in the Dublin Journal for March, 1*u, in two of which there was inflammation of the emulgeDt winMnd in all three thickening of the coats and obstruction to the flow ot blood ; and in all albuminous urine had been secreted during lite. Dr. Reginald Bui-bridge, physician to the Taunton and Somerset Hospital, in a communication in the Medical Gazette for the month just quoted, refers to Drs. Elliotson and Darwall, as having long ago pointed out the fact that albuminuria, the presence of albumen in the urine from disturbed function, results from a congestion of the renal capillaries, and is supposed to be proportioned to the extent of it. Dr. Burbridge himself, some years ago, maintained, in his inau- gural essay (at Edinburgh), the congestive origin of the disease. He points out the " one common secondary cause — a protracted dis- turbance in the vicarious action of the kidneys." Reference is made by this writer to the researches of Drs. Abercrombie and Alison, which have sufficiently proved that, in persons of irregular, dissipated habits, and broken constitutions, when the blood is un- usually serous and its motion languid, there is a marked tendency to minute albuminary deposits, taking more or less of the tuber- cular form; and this is much promoted by unusual congestion of blood affecting any organ. Dr. Burbridge has been often struck by the close resemblance which certain of these kidneys, altered by granular disease, seem to bear, in their intermediate or transition state, to the appearance of the gin-liver, or nutmeg-liver of some authors ; an aspect which Mr. Kiernan has proved to arise from mere congestion of blood, and which Mr.. Robinson produced in the kidney by tying the renal vein. The morbid changes in other organs may be readily inferred from what you have learned of the secondary disorders of granular kid- ney. The supra-renal glands are often tuberculated and granular. Dropsical, effusions are seen in the cellular tissue, lungs, peritoneum, pleura, and more rarely in the pericardium. Emphyema and cedema of the lungs ; tuberculated and enlarged liver ; softened spleen ; hy- pertrophied and dilated heart, on one or both sides,, are also among the morbid alterations;, some appearing in one, some in another subject. The mucous coat of the intestines often presents redness, effusion of lymph, enlarged muciparous glands, and ulceration. Among the rarer appearances are, oedema of the glottis, ulceration of the larynx, redness of the mucous membrane of the stomach or bladder, induration of the spleen. Causes.—It is not easy to assign a common cause, or, in a parti- cular case, the specific cause of Bright's disease. As in many other organic degenerations with functional disturbance, the operation of causes is often of long duration, and constitutes a state of pre- disposition, on which any ordinary exciting cause ingrafts the open disease. It is well remarked by Dr. Bright^that there is great reason to suppose that the seeds of this disease are often sown at an early period; and that intervals of apparent health produce a false secu- TREATMENT OF BRIGHT'S DISEASE, ETC. 39 rity in the patient, his friends, and his medical attendants, even when apprehension has been early excited. Intemperance is the most usual predisposing cause, that which deteriorates the blood, over- tasks for a long time the kidney in their functional exercise, and prevents their organic actions. Exposure to cold, or cold and moisture, is the most common exciting cause, or, at any rate, that which developes and aggravates the disease. Warning and moni- tion are conveyed very impressively in the following language of Dr. Bright: " Where intemperance has laid the foundation, the mischief will generally be so deeply rooted before the discovery is made, that, even could we remove the exciting cause, little could be hoped from remedies; but, at the same time, a more impressive warning against the intemperate use of ardent spirits cannot be derived from any other form of disease with which we are ac- quainted ; since, most assuredly, by no other do so many individuals fall victims to this vice." Constitutional circumstances are stated by Dr. Christison to clearly predispose to it. These are the consti- tution of intemperance, the scrofulous habitr and that state of the system which succeeds to scarlatina. Suppressed perspiration was a most conspicuous cause in Dr. Osborne's cases (op. cit.). On his reviewing the causes of the disease (dropsy with albuminous urine), in thirty-six cases, it could be directly referred to suppressed perspi- ration in twenty-two of these. Habitual use of articles of heavy digestion, such as cheese, pastry, smoked meat, &c, may so irritate the kidneys in persons predisposed to the disease as to bring it on. The constitutional, by which he seems to understand the sialogogue action of mercury, is represented by Dr. Christison to be an occa- sional cause. Diuretic medicines taken to excess, have appeared to Dr. Osborne to bring on the disease. Age, sex, and profession, have an indirect influence only. In 74 fatal cases, Dr. Bright found 19 under thirty years of age, 50 under the fiftieth year, 13 above fifty, and 4 above sixty. The early and the latter periods of life are comparatively exempt from the disease. As respects sex, it has been asserted that the proportion of men to women affected is as 3. to 1. LECTURE LJIL DR. BELL. Tre vtment of Bright^ Disease, or Renal Dropsy.—Origin of dropsies—An- tiphlogistic remedies—Appearance of the blood—After venesection, free purging —Mercurials not inadmissible in all cases—Salivation to be especially avoided —Diaphoretics of great value, and, also, all the aids for securing their effects —Warm bath—Diuretics to be sparingly used—Complication of renal dropsy with bronchitis—Treatment o£—Other secondary disorders to be relieved—Em- ployment of tartar emetic—Dr. Osborne's practice in ascites—Measures useful in the more advanced stages of renal dropsy—Alteratives—Great importance of equable temperature of the skin and of regular diet. Treatment. — With the prevalent opinions at this time of the origin of dropsy, in visceral engorgement and chronic inflammation, or in 40 DISEASES OF THE URINARY APPARATUS. membranous irritation and phlogosis, and the condition of circulation induced in consequence, the appearance ot anasarca would prompt the physician, especially the American one, wno de- rives his impressions from the teaching of Rush and his successors, to a correct treatment in the incipient stage of granular disease of the kidney. In this early or acute stage, recourse is had without hesitation to free bloodletting, as we would have in acute nephritis; and its repetition will be governed by the same circumstances as in the treatment of this latter complaint. Nor must we withhold the lancet even after the disease has lasted for some time and has assumed a chronic character, particularly if there be symptoms of oppressed lungs or hypertrophy of the heart. Bloodletting will sometimes give more relief than all our other best devised remedies; and what is also to the point, it will greatly favour the beneficial operation of these. The blood, it has been said, is buffy in a re- markable degree in this disease; and hence we must not rely on this appearance alone as a test of the propriety of fresh blood- letting, so much as on the relief of the renal distress and disorder, and a diminution of the quantity of albumen in the urine. Cupping or leeching over the loins is a useful succedaneum, and in some sub- jects, of excessively broken down constitutions, a substitute for vene- section. A proper caution is enjoined by Dr. Christison, against pushing sanguineous evacuations too far, in the impoverished state of the blood which is so common in this disease, and a rule to guide us on this point. We are required to examine the blood analytically, and to ascertain the proportion of its colouring globules. By the latter we can measure, in degree at least, the advancement of the struc- tural changes in the kidneys ; and either press a continuance of or withhold sanguineous depletion, After bloodletting, purgatives stand foremost in this kidney disease. Amongst these, preference is given by Dr. Bright to elaterium and jalap with bi-tartrate of potassa. Dr. Osborne re- stricts himself to senna mixture, castor oil, or rhubarb and mag- nesia. He refrained from all purgatives which also act often as diuretics. Mercury is not thought well of by Dr. Bright, except in combination with opium and antimony, in the very early stages of the acute renal disease. Dr. Osborne administered large doses of calomel when affections of the head came on; and although he admits their use in rescuing the patient from a state of approaching coma, yet, he adds, they were not followed bv any benefit to the secretions of the skin or of the kidneys. In this restricted view of the operation and effects of calomel, I cannot join. Asa purgative, either alone, and followed by castor oil, or rhubarb and magnesia, or combined with jalap or rhubarb, it is entitled to a preference over most of the class. In the first of these fashions it is particularly useful where diarrhoea is present, a complication contraindicatincr resinous or irritating purgatives. In smaller dose, as of one to two grams, or an equivalent proportion of blue mass, I know of no medi- cine, next to antimony, which acts generallv so well on the skin by TREATMENT OF BRIGHT'S DISEASE, ETC. 41 rendering it soft and moist; certainly, none which acts so kindly on an inflamed or irritated kidney. One of the peculiar advantages of these mercurial preparations is their ready and tranquillising operation on inflamed secretory glands and surfaces. My own experience makes me as confident of the propriety of administering calomel or blue mass after venesection for an excited kidney, whose secretory function is impeded, as I would be of its use in a similar condition of the liver. I know well, indeed, that we cannot so easily insure a continuance of its salutary action, either on the skin or kidneys; but this need not deter from its use in the early stage of the disease, to which it is more especially applicable. In dropsy with hypertrophy or disease of the valves of the heart, Dr. Os- borne, in unison with most practitioners of experience, thinks highly of calomel in combination with squill and digitalis, as a diuretic. Must it not act kindly on the kidneys in these cases? I have found it equally efficacious in the granular disease of the kidney; and where bronchitis is associated in the latter, I know of no adequate substitute for the calomel. In administering mercurial preparations as purgatives, and seda- tive diuretics or diaphoretics, we must continually bear in mind their more than usual tendency to salivate in the cases of Bright's disease; and the injurious effects of such an operation. Certain constitu- tional states, such as of anaemia or chlorosis, or scrofula, will in- duce still farther caution, respecting recourse to mercury. After bloodletting and purging, mild and sustained diaphoresis is entitled to especial favour. Nor must we wait for the effects of the former, before we have our patient put to bed, and his skin brought into a state of moderate excitement by external warmth; and if the extremities be cold, by warm pediluvia, and the cus- tomary adjuncts for quickening the circulation of the lower extre- mities. Amidst many discouraging circumstances in our pro- gnosis of this disease, it is pleasant for us to know, as Dr. Bright assures us, that the most recent cases are often capable of cure by depletion, either by bleeding or purging, according to the acuteness of the attack, or by promoting gentle diaphoresis, both by inter- nal remedies and by strict confinement to bed. It has happened frequently, within Dr. Osborne's experience, that by external heat alone, an improvement, both in the quantity and quality of the urine, and a material subsidence of the oedema, have taken place; and he even goes so far as to assert that, ^whenever general perspi- ration came on, either spontaneously or in consequence of medicine, then the cases always terminated favourably." The diaphoretic remedies are antimonial powders, Dover's powder, liquor ammonia acetatis; and if more stimulating preparations are required, the ammoniated tincture of guaiacum, to which sulphur may be advan- tageously added ; or carbonate of ammonia with camphorated mix- lure — four grains of the former to an ounce of the latter every two hours. In aid of these remedies, and itself an agent of no small activity in the disease before us, is the warm bath, of a tempera- 40 DISEASES OF THE URINARY APPARATUS. ture of 96° F., in which the patient should be immersed for half an hour at a time, twice in the day, until free perspiration is brought on. , , . No little difference of opinion prevails respecting the advantages and even propriety of prescribing diuretics in granular disease ot the kidney. Where hypothesis may be enlisted on either side, we are fain to look to experience for settling the question ; but even here the contrariety of practice is great. Diuretics, entirely proscribed by Osborne, are regarded by Christison as valuable and almost indis- pensable remedies. Bright, whilst objecting to their use in general, gives a qualified assent to the useof them,and particularly of digitalis on certain conditions -r and Rayer reports cases in which they have been the chief means of cure. By conforming to the rules which ought to govern us in the employment of diuretics generally, we shall probably find less difficulty in determining the propriety of their use in the present disease. Before bloodletting, and in the acute stage, they can hardly fail to excite the kidney and aggravate the complaint. At a later period, when phlogosis is abated, certain diuretics, such as the tincture of digitalis and wine of colchicum- seeds, with a solution of the tartrate of potassa, will exert a good effect, more, perhaps, by their sedative and cooling operation on the system at large, than by any special action on the kidneys. After all, the objections against diuretics are overrated; as both jalap and rhubarb, which are so warmly recommended for their purgative powers, are decided stimulants to the kidney at the sa^me time. Tissot tells us, that the favourite diuretics of Rayer are acetate of potassa, and more especially a decoction of the root of the wild horse-radish; which last he prescribes in the proportion of from two drachms to an ounce and a half, in a pint of water. Two cures are reported from using this remedy, in subjects who had not derived relief from any other means. Upon the whole, however, diuretics are entitled to be ranked on a secondary line after diapho- retics. The dose of digitalis when it is employed, as a diuretic, is from one to two grains in powder, or ten to fifteen drops of the tinc- ture three times a day; and of the bi-tartrate of potassa, a drachm or two drachms as frequently, in large dilution. In renal dropsy, complicated with bronchitis, Dr. Osborne has derived much benefit from balsam copaiba in camphor mixture and cinnamon water with gum arabic. He directs 3i. in four ounces of the mixture, of which an ounce is to be taken three times a day. In dry bronchitis the following mixture caused free expec- toration : — R. Gum ammon., Gum arabic, Sacch. alb., singul. dr. ij.; Balsam copaib. dr. ss. Aqua cinnamomi, oz. iv. A tea-spoonful to be taken every hour and. a half. In some in- stances, in which the copaiba produced nausea, it was superseded by TREATMENT OF BRIGHT'S DISEASE, ETC. 43 the tincture of cubebs. Copious expectoration, on the other hand, which oppresses by its quantity without affording relief from the disease, is abated by the administration, in conjunction with the diaphoretic course, of sub-acetate of lead, one grain, and watery extract of opium, a quarter of a grain, four times daily. The application of leeches externally to the larynx, is truly represented by Dr. Osborne to be a most important part of the treatment of bronchitis. The good effects of it are not confined to the larynx, but are apparent also in the unloading of the mucous membrane of the bronchial tubes through their entire extent. In addition, blisters should be applied to the upper part of the sternum and under the axilla. To these Dr. O. generally adds frictions to the back and sides of the chest. When disorder of the stomach or bowels occur, they are met by nearly the same treatment as when they are of primary occurrence. A tendency to dysentery, which is one of the most frequent forms of this complication, was obviated most speedily, in Dr.Osborne's prac- tice, by an enema of four grains of nitrate of silver, followed in three hours after by the starch enema with tincture of opium. The first is retained only a few minutes, but the last generally remains several hours, and the irritation is then at an end. When pericarditis was present, the internal use of tartar emetic, in addition to topical and general bloodletting, produced a great increase of urine with amendment of all the symptoms; while a decrease occurred on two several occasions in which it was for a time superseded by squills. Dr. Barlow ranks tartar emetic among our chief remedies in the acute form of dropsy with renal disease, whether it follow scarlatina in children, or come on without any such precursor, or adults (Guy's Hospital Reports, April, 1840). He regards it as eminently cal- culated to equalise the circulation, subdue the inflammatory action, and restore the functions of the skin. By " its local effects upon the capillaries, when it reaches them through the circulation," it dimi- nishes the inflammation in the superficial capillaries of the lining membrane of the tubuli uriniferi. As regards the dose, it may be given, in the first instance, where the pulse is hard and full, in such quantity as to produce nausea; but in low states of the system he pre- fers small doses frequently repeated, "so as to reach the capillaries without producing depression." He has never found it necessary to give more than half a grain at once to an adult. Doctor Barlow does not recommend the use of the antimony in this disease to the exclusion of other means calculated to aid in fulfilling the same indications; and among the most valuable of these adjuncts should be reckoned moderate local depletion, hydragogue cathartics, the warm bath, or, what is perhaps of equal value when this cannot be procured, the investing of the loins in a large linseed-meal poultice. ff I continue the outline of treatment adapted to the chief compli- cations of disease of other organs with that of the kidneys, it is under a belief that you cannot be as well familiarised in any other way 44 DISEASES OF THE URINARY APPARATUS. with the various symptoms and modifications of one of the most common, and, at the same time, dangerous forms of dropsy. "ence, what I now say on these points, as indeed nearly all that 1 have said in this lecture on Bright's disease, is a contribution of the most valuable kind to the pathology and treatment of dropsy, and is so much in anticipation of anv future observations en projesso on the subject. Dropsy is, in fact, but a symptom, and hence ought to be discussed under the heads of the organic lesions in which it is manifested. Moved by these considerations, I shall introduce some further particulars of renal dropsy as set forth by Dr. Osborne, whose clinical opportunities have been considerable. " In valvular disease of the heart, and, especially, imperfect closure of the aortic valves, the patient, in addition to the diapho- retic treatment, took a mixture of a small quantity of tincture of digitalis, with carbonate of ammonia, camphor, and Hoffman's liquor. This combination was intended to act as a sedative to the heart, and, at the same time, as a stimulant to the circulation through the capillaries. Whether it acted in this way or not, maybe ques- tioned ; but it was certainly followed by warmth of the extremities, diminution of the violent action of the heart, a sense of general relief, and a capability of sleeping with comfort at night. " The measure, however, which appears to me of the highest im- portance in diseased aortic valves, is the establishment of a large issue over the region of the heart. On some future occasion I shall bring forward some faithfully reported cases, which prove that organic disease of the valves is capable of great amendment, if not of complete cure, by this and other counter-irritants, aided by the administration of suitable internal remedies. " General oedema, with coagulable urine, and obstructed perspira- tion, is not unfrequently accompanied by effusion of serum into the peritoneal cavity. This, when not considerable, or of long stand- ing, disappears along with the general swellings. When, however, ascites has formed either in consequence of chronic peritonitis, or induration of the liver, then, although the general swellings have been removed, we have still to deal with a refractory, and often intractable complaint. In addition to the means which are usually adopted, viz., courses of mercury and purgatives, I am enabled, from experience, to suggest some other measures, to the employment of which I must attribute the fact, that within the last four years I can recollect only one case in which tapping was performed in my hos- pital wards, while previously it was a frequent operation. These are the repeated application of leeches to the rectum,* so as to un- * <*I.n lhe Dublin Medical Journal I have described a conveni- S^f ^ducing Heches into the rectum, by securing them z the1 ^z;>altached to the §rooves of an inst— pw TREATMENT OF BRIGHT'S DISEASE, ETC. 45 load the vessels of the vena porta?. The applications of various stimulants to the abdomen, as 1st, an ointment composed of equal parts of iodine, mercurial, and cantharides ointments. 2dly, A paste formed of Spanish soap, spread upon linen, and sprinkled over with muriate of ammonia immediately before being applied; which, by the chemical decomposition which ensues, and the conse- quent gradual extrication of ammonia, produces heat and redness; 3dly, Sinapisms, suffered to remain till the pain becomes urgent. These have the advantage of healing with great rapidity. 4thly, Frictions of six or more drops of croton oil. These are, however, rather uncertain ; in some individuals producing no effect, and in others followed by erysipelas, extending beyond the seat of the application. 5thly, A mixture composed of one part of tincture of digitalis, and two of aquae muriat. calcis; a teaspoonful to be rubbed on the abdomen, morning and evening. This compound appears to excite the absorbents, and increases the discharge from the kid- neys, but does not produce any sensible redness of the skin. The application of these counter-irritants and excitants of the absorbents may be continued, when the administration of mercury and of drastic purgatives has become no longer advantageous, or indeed safe. It is certain that by these latter remedies the distention of the abdomen may frequently be diminished to a certain extent; but beyond this it is extremely difficult to proceed. Whenever the peritoneum has engaged in the process of morbid secretion, and the cavity of the abdomen has remained distended a certain length of time, it obstinately perseveres in retaining a certain quantity of fluid. The urgent and continuous use of the powerful remedies now mentioned, in such cases, is then not only abortive, but sooner or later causes irritation and ulceration of the bowels; and the patient sinks in consequence. It is therefore preferable, in those refractory cases, when the swelling no longer diminishes under the employment of internal medicines, to abstain altogether from their use for a time, and to rely on the application of counter-irritants and bandages, together with regulated courses of diet, and changes of air, until the patient's vital forces are recruited, so as to enable us to make fresh efforts to dislodge the fluid. "■ When noises resembling the ringing of bells in the ears, wake- fulness, delirium, stupor, or headache, come on, then, if there is increased heat of the head, blood must be taken either from the temporal artery, or by means of leeches applied to the temples, or behind the ears. Calomel must be freely given, and followed by brisk purgatives. If those symptoms continue, it will be necessary to apply sinapisms to the nape of the neck, and to persevere in the use of mercurials. These symptoms, which are always of formid- able import in dropsies, and peculiarly so, because usually neglected, and erroneously supposed to belong to the disease merely as symp- toms, may, under this treatment, be very generally averted ; and it would be acknowledged, from an examination of the fatal cases recorded in my table, that, though the patients died immediately vol. 11. — 5 46 DISEASES OF THE URINARY APPARATU from the affection of the brain or its membranes, yet in most, if not all of them, peculiar circumstances existed, which had the ettect 01 disarming the remedies now mentioned of their usual powers, and which, in those particular instances, rendered the disease necessa- rily mortal." , ,. . , , In the advanced and chronic stages of renal disease, particularly where any change may have slowly taken place in the structure of the kidneys, we must be content with a less active treatment than that which has just been detailed. We can seldom promise our patient an entire recovery under these circumstances; but with care on his part, and judicious advice on ours, we may prolong his life for years. " Most of the secondary disorders are obstinate when tftey concur with diseased kidneys. Dyspepsia may be much miti- gated, but is apt to recur. Chronic vomiting, once fairly established, is seldom effectually checked, and may be considered an unfavour- able sign. Diarrhoea is difficult to stop, and apt to return, and therefore must be viewed as unfavourable. Catarrh is often re- movable; but where it resists treatment, the complication is of evil import. Coma is very rarely arrested, and is one of the most unpropitious prognostics among secondary affections. Diseased liver and diseased heart are also unpropitious; being themselves incurable, besides aggravating the effect of renal disorder. The acute inflammations are generally severe, but commonly yield to remedies." (Christison, op. cit.) Among the medicines of the alterative class, and in the use of which the patient must persevere for a length of time, may be mentioned the alkalies, particularly potassa, small doses of antimo- nials, and certain astringents, such as uva ursi, pyrola umbellata, diosma crenata (buchu); and if there be irritability of the kidney and urinary passages, conium, or still better, Dover's powder. The mineral acids are, Dr. Bright thinks, best adapted to the decline of the acute attacks, and are best given conjoined with sedatives. The prohibition of mineral acids by M. Rayer in chronic nephritis, will hardly be revoked on the present occasion. In the alkalies, Dr. Bright has been much disappointed ; and they have even at times seemed to aggravate the disease. " The very careful exhibition of the vinum ferri, the tinct. ferri muriatis, or some other chalybeate preparation, has sometimes appeared to do good for a time, but has not generally been admissible for a continuance." Deserved stress is still laid on purgatives, even when the disease has become per- haps organic. Mercury still has hold of the affections of some to that degree as to induce them to hope for benefit, if not cure, from its absorbent action, and consequent removal of the deposits which take place in the tubuli urmiferi, in the more advanced stages of the disease. Better founded expectations are entertained of the alterative powers of iodine, and particularly of the iodide of potassium (hydriodate of potassae), under these circumstances. On all the means of preserving an equable temperature of the SUPPURATION OF THE KIDNEY. 47 skin, the precautions and pains can scarcely be too great, and must never be suspended. Flannel is to be constantly worn next the skin, and the rest of the clothing, including protection for the feet, correspondingly warm. In the house, the apartments should be kept of a mild and uniform warmth, with as much care as would be deemed necessary for a consumptive patient. To the same effect is the recommendation of Dr. Bright, that a person suffering under renal disease should seek a warm climate for restoration, at any rate relief and suspension of his malady. The exercise should be gentle and sufficient, enough to moderately excite the skin with- out causing much sweating and the danger of subsequent chill,— and to quicken the circulation without giving rise to fatigue. A great deal depends upon diet. Milk, when it agrees, ought to be the preferred article. Light animal food frequently agrees; pastry, fruits, and all badly cooked vegetables are injurious. Fer- mented and distilled liquors, and tea and coffee, should be abstained from. LECTURE LIV. DR. BELL. Suppuration of the Kidney—Directions taken by the abscess—Most frequent cause, formation of calculi—Not incompatible with even long life.—Pyelitis, its varieties, its tendency to end in suppuration and in nephritis—Its ana- tomical lesions.—Treatment.—Functional Diseases of the Kidneys.—Sup- pression of Urine.—Ischuria or Anuria,—an effect rather than a primary disease—Sudden in its attacks—Sympathetic disturbances—Coma—Pyretic ischuria.—Anatomical lesions, not constant—Prognosis is unfavourable— Treatment—Antiphlogistic___Morbid secretions—Circumstances under which they occur.—Excessive diuresis or hydruria—Not always productive of dis- ease—Most troublesome in old persons.—Treatment, dietetic and medicinal— Diabetes insipidus, or anazoturia,—Symptoms—Treatment—Diabetes insi- pidus with azoturia.—Diabetes mellitus, or melituria—lis definition,—quali- ties of the urine, symptoms, terminations, causes, post mortem appearances— Treatment—Diet and regimen of most importance—Various other diatheses of renal secretion, with albumen, lithic acid, or lithuria,—earthy and earthy alkaline phosphates, or ceramuria, cystic oxide, oxalic acid or oxaluria, lactic acid.—Haematuria.—Diseases of the Bladder—Cystitis, its varieties—The most important is inflammation of mucous coat, or catarrhus vesicce—Symp- toms and treatment. Hitherto I have spoken of obvious and admitted organic lesions of the kidneys, as giving rise to and measured by functional dis- orders, either of these organs themselves or of other organs. In next directing your attention to a number of other renal diseases, which depend on, or rather are chiefly manifested by functional disturbances of the kidneys, I would not be understood to deny the presence of accompanying lesions of structure ; but merely to tell you that the connection between the two series of phenomena,— functional disturbances and structural changes,— is not so manifest, 4S DISEASES OF THE URINARY APPARATUS. nor are they in number and distinctness so proportionate to each other as in the diseases which I have already described. But, before attempting this part of my task, I must say a few words on the termination of renal inflammation by suppuration. Were the pus discharged with the urine, the product ot phlogosis of the body of the kidney alone, it ought to have engaged our notice under the head of acute nephritis; one, but happily not usual, termination of which is by suppuration. But, in the first place, I have adduced reasons for believing that pus may be discharged from the kidneys without any affection of their parenchymatous and secreting structure, — the disease being confined to the pelves and calyces ; and, in the second place, pus may be secreted from the kidneys and found in the urine, without any special lesion of the urinary appa- ratus. Hence, the appearance of pus in the urine is not neces- sarily diagnostic of disease of any part of the renal organs, nor of the bladder or urethra ; although it ought properly to give rise to what in a court of justice would be called violent suspicion of such an occurrence. Some curious but at the same time well authenticated cases of purulent, or purulent looking deposits in the urine, in diseases other than renal, and in cases of abscesses in other and remote parts, are given by Dr. Willis in his valuable work already recited; and to which, I am glad to add, you can have ready access, as I have had an American edition of it pub- lished in my Select Medical Library. Burdach regards pus as a secretion intermediate between hemorrhage and secretion; an opinion corroborated by Mr. Gulliver, who has discovered globules of pus in the blood ; not merely in every case in which pus was actually formed in some particular part, but in which there was inflammation and the phenomena precursory to its formation. But although in the blood, pus is foreign to it, and must be dis- charged. This is sometimes done, at random as it were, in the viscera, cavities of the joints, &c.; and in a more favourable manner by the channel of the kidneys. Professor Chelus of Hei- delberg observed the urine of a patient labouring under a puru- lent deposit within the pleura, from a penetrating wound of the chest, to deposit pus which could not be distinguished from that which flowed out of the chest by the wound. When acute nephritis is about to end in suppuration, we see the customary, but in the present case not distinctly morbid signs of rigor and hectic fever; and sometimes, if the enlargement of the kidney has been considerable, a prominence and fluctuation noticed externally. But this last is more common in that variety of the disease which M. Rayer calls peri-nephritis, — agreeably to his division, with which, in a former lecture, I made you" ac- quainted. This eminent pathologist believes pus to be a frequent termination of the simple variety, as contrasted with the arthritic one, of nephritis If it be so, we must receive it in the same light in which Burdach speaks of its occasional occurrence, viz., a modi- fied secretion; a termination and means of relief of inflammation SYMPTOMS OF PYELITIS. 49 of the secreting portion of the kidneys. At other times, a dis- tinctly formed renal abscess may burst suddenly into the cavity of the kidney, and large quantities of pus, occasionally mixed with blood, and also with gravel, if the inflammation have been caused by renal calculi, appear in the urine. It should be mentioned, how- ever, in this place, that the most frequent cause of suppuration and abscess of the kidney is inflammation from calculi. Suppuration sometimes leads to fistulous passages and openings, as in the lumbar muscles, pointing outwardly; or communicating with the liver and giving rise to hepatic abscess; or with the peritoneum, causing acute peritonitis; or with the colon or duodenum, through which the contents of the renal abscess are discharged by the rectum. Life may be protracted for a long time under the existence of considerable disorganization of a kidney, as in the instance men- tioned by Dr. Prout, (op. cit., p. 169,) of a gentleman who, before the age of twenty, laboured under distinct symptoms of an abscess in the kidney; but who, notwithstanding, lived to the age of seventy; and who almost daily, throughout that long period, passed more or less of purulent matter in the urine. " His appearance and state of health were never robust; yet he enjoyed tolerable health and comfort; and only felt greater annoyance than usual when the purulent matter, as it would occasionally do, almost disappeared from the urine. On such occasions the stomach became deranged ; and he had an attack of feverish excitement, which usually termi- nated after a short time, in the sudden discharge of an enormous quantity of pus with the urine; after which he speedily recovered his former state of health. Such attacks were usually brought on by exposure to cold, or by inattention to the state of the bowels, diet, &c, and he finally sank under an unusually severe attack of this kind." Dr. Prout adds in a note: it is remarkable that dropsy rarely appears under this form of disease; the gentleman alluded to, in the text, even to the last, never suffered from cedema. But the phenomena connected with the formation of pus have been placed in a much clearer light by M. Rayer, who shows that this product is by far more common in his second division of renal inflamma- tion, or in pyelitis, than in nephritis proper. A few words now on this disease. Pyelitis, already defined to be inflammation of the pelves and calyces, may be, as was also stated at the time, simple, blennor-* rhagic, calculous, or verminous; varieties, the three last of which express very well its occasional origin. Pyelitis is, also, acute and chronic. The symptoms are nearly the same with those of nephri- tis ; the pain is represented to extend more frequently to the testi- cle, and to be accompanied by retraction of this organ, than in inflammation of the substance of the kidney. It has great tendency to terminate in suppuration; and hence in the properties of the urine we find the best diagnostic symptoms of pyelitis. A frequent ter- mination, ought we not rather to say extension and complication also, is nephritis. The accumulation of matter is sometimes so great 50 DISEASES OF THE URINARY APPARATUS. as to distend the pelvis and calyces, and at length the kidney is stretched out, in a measure, and at the same time loses its healthy organization by atrophy; and, occasionally, an enormous pouch is formed which points and discharges in a manner similar to that just now described, when speaking of abscess of the substance ot the kidney. We can readily believe and understand the fact, that pyelitis seldom exists without being complicated with nephritis; and considering its common origin from the diseases of the lower part of the urinary apparatus and retained calculi, that it should precede this latter in point of time. A frequent complication, and, it may be added,, origin of pyelitis, is inflammation of the mucous membrane, or catarrh of the bladder. The anatomical lesions in acute pyelitis are, vascularity of the mucous membrane of the pelvis and calyces, with red spots and ecchymoses, and occasional extravasation of blood upon its inner surface, and sometimes lymph thrown out in patehes so as to ob- struct, the ureter. Dilatation of the pelvis, where retention of urine was the exciting cause, is frequently met with ; and occasionally we find softening ulceration, or even perforation of the membrane, where calculus was the cause of the disease. The urine contained in the pelves and calyces commonly contains blood and pus, not always discoverable by the naked eye, but visible enough with the help of the microscope. It also contains amorphous sediments of lithate of ammonia, crystallised lithic acid, crystalline phosphate of magnesia and ammonia, and likewise albumen. In chronic pyelitis, the membrane is dull white, its vessels large and varicose, but not reticulated; the external veins on the kidney are large; the pelvis and calyces are distended in many cases, and then the membrane is thickened, without visible vessels., and the ureter much contracted, and sometimes reduced to a mere fibrous cord. Sometimes the inner surface of the membrane is of a reddish- brown tint or mottled ; at other times it exhibits transparent vesicles like sudamina; and occasionally ulcerations are seen: these last corresponding with the pressure made by the edges and points of calculi. The treatment of pyelitis will not differ from that of nephritis; with the addition of those measures obviously called for on a re- moval of the exciting causes, such as of calculi, if possible, and at any rate of phlogosis of the bladder or urethra, as in cystitis and suppressed or aggravated gonorrhoea. A fact, connected both with diagnosis and treatment, is the change which pus undergoes by the action of ammonia and other alkalies, should be known. The ropy and slimy matter resembling mucus detected in the urine, in pyelitis as well as in chronic cystitis, is pus thus modified, either by the ammonia originally in the urine, or by alkaline remedies adminis- tered for the disease. Functional Diseases.-^ shaH now take up that other division of renal diseases, of a more strictly functional nature, at least in the sense explained in the beginning of this lecture, in which the chief morbid manifestations, as far as the kidneys alone are concerned, SUPPRESSION OF URINE, OR ANURIA. 51 consist in some notable change in their secretion, either as regards the deficiency or the excess in quantity, and other great varieties in the properties of the urine. But I can hardly, at this time, promise to give you more than a syllabus of this part of our subject, which, as it presents less novelty, and at the same time is more fully treated of in many works of ready reference, will leave a less sensible defi- ciency than you might otherwise experience. Suppression of Urine — Ischuria renal is of most writers, — the Anuria of Dr. Willis. You must distinguish suppression of uriner that is, a stoppage of the secretion, from retention of urine, or a stoppage of its excretion, — as where it accumulates in the bladder and cannot be discharged. Whether ischuria occurs from organic disease of the kidneys or is symptomatic of other diseases, as of fevers, cerebral affections, &c, it is always seriousrand often fataL Properly considered, it is a symptom more than a disease; since it can hardly be said to acknowledge any one anatomical or physio- logical cause, either primary or secondary. Diminution in the quantity of urine is quite common in nearly all acute febrile and inflammatory diseases. Ischuria is most met with in infants and in old persons. In degree short of this, a disorder manifested by secretion of a very small quantity, which is excreted with great pain and sense of burning, is seen in these persons. They also suffer at the same time from cutaneous eruptions and sores wherever two> surfaces come in contact, as at the axilla, folds of the neck, &c. Complete ischuria, or anuria, makes its attacks generally in the midst of perfect health ; sometimes in gouty subjects, it repre- sents or supplies a paroxysm of the disease. The most notable' symptoms, after those of general uneasiness and anxiety, are nausea followed by vomiting, which continues to be one of the chief, as it is one of the most troublesome symptoms through the whole course of the disease. There is at the same time a singular torpor, both of mind and body. The pulse in general is not much accelerated ;. sometimes it is slower and feebler than natural; the patient scarcely complains, and gradually lapses into a state of drowsiness and in- coherent rambling; the drowsiness increases, and at length termi- nates in complete coma ; in which state, sometimes after repeated attacks of convulsions, the patient expires. It is only after minute inquiry that the practitioner called in to the case ascertains that some lime has elapsed since the patient made water. Examination of the pubic region shows no fulness nor pain: a request that he should make water is so far complied with that he passes, after some delay, a spoonful or two; probably he cannot pass a drop. To give the requisite certainty on the subject, a catheter is now introduced into the bladder, and half an ounce or only a few drops of urine is discharged. In the generality of cases coma occurs aboni the fourth or fifth day from the time when the secretion of urine is totally suspended; and death usually takes place after the lapse of a few days more. Every now and. then,, young women subject to hysteria take a fancy to impose upon, their medical attendants^ by simulating ischuriai 52 DISEASES OF THE URINARY APPARATUS. renalis. Mr. Laycock, in his treatise on the Nervous Diseases of Females, (Philadelphia Edition,) relates some curious instances ot this kind. We read and hear much of vicarious discharges o urine by other organs ; some of the accounts of which are well authen i- cated, but most of them are greatly exaggerated, if not positively untrue. The subjects of most of these cases are hysterical women too, or malingerers in the army or navy, or loiterers about hospitals. Anuria (ischuria) in children, is chiefly of a febrile nature; and, as Dr. Willis justly observes, is connected with derangement of the alimentary canal and nervous centres. The anatomical lesions in those who have died of anuria are, some appearance of inflammation of the kidneys, especially after the disease has followed poisoning; sometimes their substance is much drier than natural. In some cases one kidney has been ob- served to be much enlarged, and the other reduced in size, and of cartilaginous hardness, or very vascular; or these organs are darker, flabbier, more brittle and congested than in health. The bladder is empty and contracted : the blood impregnated with urea. The organic disease of the kidneys most frequently found in connection with ischuria is granular degeneration of the organ. Before undertaking the treatment of ischuria, our prognosis should be announced as unfavourable, since in most cases it is a fatal disease. When the urine is merely much diminished, diuretics, among which digitalis and bitartrate of potassa are preferred by Dr. Christison, will sometimes restore the natural quantity of urine for a time. But when this fluid is reduced to a few drachms in the twenty- four hours, or is altogether suspended, recovery is exceedingly rare. This opinion admits of exceptions, in the case of young and appa- rently well constituted and otherwise healthy persons. In such, as I have found, cupping on the loins and thefreedrinkingof a sweetened solution of the bicarbonate of soda restores the discharge. Active purging with salts and senna, or a large dose of calomel, has had the same effect. In cases of sudden occurrence without apparently pre- vious organic disease, full bloodletting, and anodynes combined with diaphoretics, purgative and terebinthinate injections, and the warm bath, are worthy of some confidence. The recommendation of blisters to the loins and diuretics is of less questionable propriety; but as a means of unloading the congested kidney, they are worthy of trial, after suitable venesection. To these we may add, if the disease should still persist, but in a somewhat mitigated shape, digitalis and colchicum, with blue pill, and the free use5of diluents. Morbid secretions of the kidneys, on which I am now to offer a few brief remarks, are represented by the urine. Its various states under such circumstances are thus described by M. Andral: 1. There are cases in which there is a simple change in the pro- portion of the principles which enter into the composition of healthy urine 1. There are cases in which there is a simple change in the pi rtion of the principles which enter into the composition of healt ine. 2. Other cases, in which the urine contains new principles, as regards it, but which are found in the blood, either in a state of health or disease. EXCESSIVE DIURESIS, OR HYDRURIA. 53 3. There are other cases, again, in which we discover in the urine new principles which are not met with in the blood. Thus, the quantity of water, of urea, and of lithic acid in the urine may be diminished or augmented. We may find, in this fluid, albumen, fibrin, the colouring matter of the blood, or of the bile; also oxalic and hydrocyanic acids, oxides, a black or blue colouring matter, a saccharine matter, a butyraceous or fatty matter, and even hair. The cause of these alterations in urinary composition are to be sought for in the kidneys; sometimes in parts remote from them, in morbid states of innervation, of hematosis, or assimilation, or in external causes, as in the properties of the atmosphere, food, drinks, &c. The alkaline state of the urine has been demonstrated in certain subjects suffering under typhoid fever; while, in other circumstances of frequent occurrence, this fluid is acid to such a degree as to render its emission exceedingly painful. At other times again, the lithic acid concretes, and is deposited in the form of gravel or of calculi. Excessive Diuresis. — Both to morbidly increased quantity of urine as well as to an alteration in its quality in composition, by the addition of sugar, the name of diabetes has been given. The first is called diabetes insipidus, the second diabetes mellitus. But op- site functional states of the kidney are in this way inopportunely included under the same head; for, what analogy can there be in a simple increased secretion of urine, even in enormous quantities, which may be perfectly consistent with heahh, to that peculiarly morbid and so often incurable secretion, in which sugar is formed and prevails to such an extent in the urine. These different states are very properly separated by Dr. Willis, who describes under the title of hydruria simply excessive diuresis or discharge of urine, which is characterised by deficiency of solid matters generally. This writer introduces an account of some remarkable cases of hydruria; the subject of one of which, a Parisian artisan, aged fifty- five, in tolerable health, and of the ordinary strength of persons of his age and small stature, had from the age of five years a constant thirst upon him, and had been affected with diuresis commensurate with his thirst. From the age of sixteen he had not drank less, on an average, than two bucketfuls of water every day, often swallow- ing upwards of two quarts at a draught. His evacuations daily were about thirty-four pounds of urine, and at the most one pound of feces. The urine scarcely exceeded pure water in specific gravity: it had no saccharine matter in its composition, and was quite healthy. A woman, aged 40, and the mother of many children, had suffered from continual thirst and the discharge of a profusion of fetid urine since her childhood. She was in the habit, when a servant, before her marriage, to drink two or three pailfuls of water daily. This woman enjoyed very good general health. The diuresis of old persons comes under the present head ; there is not merely a frequent call to empty the bladder, but, likewise, an augmented flow of urine, often compatible with heahh, until the 54 DISEASES OF THE URINARY APPARATUS. calls are so frequent in the night as to prevent regular sleep, and thus disturb the nervous system. Generally, however, there is asso- ciated some organic disease, either of the kidney or neck of the bladder, or both. As respects causes, Dr. Willis admits the. diffi- culty of telling on what peculiar morbid condition of the system generally, or of the kidney particularly, the elaboration of a large quantity of watery urine depends. It is found to be intimately connected with the nervous temperament. The treatment of hydruria is mixed, or dietetical and medi- cinal. A nice adjustment should be made of the quantity of food and of the fluid drank, to the necessary wants of the economy. The kidneys are to be relieved, also, by an active state of the cuta- neous circulation and secretion, maintained by suitably warm clothing, frictions, moderately active exercise, and the warm bath. Opium is found to diminish very considerably the activity and amount of renal secretion; and in the disease now under considera- tion, it may be beneficially had recourse to. I have found it most useful combined with carbonated magnesia, which latter medicine in small doses, ten grains to a scruple, two or three times a day, has exerted, in my own experience, no small controlling power over the disease. Vegetable astringents, and some of the mineral tonics, such as iron and sulphate of copper, may be given with similar intent. The state of digestion should be carefully watched, and the bowels regulated by nloes and blue mass, or, for more frequent use, rhubarb and magnesia. The next variety of increased secretion of urine is that in which there is a deficiency of urea, anazoturia of Dr. Willis. It is the diabetes insipidus of some writers. The most marked examples of this state of the urine, in the nearly entire absence of urea, is seen in hysteric females during the paroxysm of their disorder, accord- ing to Dr. Prout; but Dr. Willis refers this condition to the head of hydruria. Hysteric urine has often a specific gravity scarcely exceeding that of spring water. It has sometimes a disagreeable odour when passed ; and in almost all instances soon acquires a putrid smell, like that of cabbage-water ; it becomes more or less opaque, and deposits crystals of the triple phosphate of magnesia and ammonia; especially in warm weather. Hysteric urine is not exclusively passed by females; but is occasionally voided by indi- viduals of the other sex. This form of morbid urine Dr. Willis believes to occur frequently among the indifferently tended children of the poor: it is more common in the middle period of life, and occurs equally in both sexes. The leading symptoms of the disease are great thirst, a dry state of the skin, and usually a constipated state of the bowels. In most cases there is an uneasv sensation referrible to the stomach accompanied by a morbid craving for food; at other times nausea' and a perfect indifference to all solid matters, which are almost immediately ejected by vomiting. There are also more or less emaciation, depression of spirits, and great muscular debility, with all their consequences. J DIABETES MELLITUS, OR MELITURIA. 55 The treatmentoi this variety of excessive renal secretion is the same as that laid down in hydruria. No specific treatment can be indicated. Diabetes Mellitus — Melituria. — Great has been the confusion caused by writers affixing the term diabetes to a great variety of diseases, the only common feature of which is excessive diuresis. Could we restrict it, as Dr. Prout does, to a disease in which a saccharine state of the urine is the characteristic symptom, the objec- tion to this nomenclature would disappear; but as there is still a fear that a physician, who has a patient with excessive diuresis, labouring under either anazoturia or azoturia, or a deficiency or excess, respectively, of urea, will report his cases as one of diabetes, it is desirable that the nomenclature of Dr. Willis, in this particular at least, should prevail; and that the disease designated as diabetes mellitus, the only true diabetes, should be called melituria. The peculiarity of melituria, and its difference from simple exces- sive diuresis, was first pointed out by Dr. Thomas Willis, in the reign of Charles II. (1684.) It is fortunately, in this country at least, a rare disease, and is so regarded in England ; although cases every now and then occur there, both in private and hospital prac- tice. Few practitioners could collect, as Dr. Babington of London did for his son, Dr. B. G. Babington, who was engaged in writing an essay on the subject, twenty-three cases of the disease at one time. Symptoms.— A saccharine condition of the urine, tendency to emaciation and suppressed perspiration, are the leading, one might say, characteristic symptoms of melituria; but still we cannot deny that each one may be, is in fact present, in other diseases. Sugar is found in the urine of dyspeptic and gouty persons, as we learn from Prout; and as to the other two symptoms, I need not say that they are common to a great many diseases. Diabetes mellitus makes its approaches very insidiously ; and the first symptom which more particularly attracts the patient's attention, is the frequent eva- cuation of his bladder, both day and night. If he attends to the appearance of the urine, he finds it to be pale, with a diminution of its proper colour, and somewhat turbid on cooling. Soon after, if not at this time, are associated a morbid state of the digestive func- tion, manifested by inordinate appetite and dyspeptic symptoms ; excessive thirst, dryness and hardness of the skin; loss of virility ; and rapid loss of flesh and muscular strength. " Diabetic urine (says Dr. Prout) is almost always transparent, and of a pale-straw or greenish colour. Its smell is commonly faint and peculiar; somewhat resembling sweet hay or milk; and its taste is usually saccharine in a greater or less degree. The specific gravity of diabetic urine has been stated to vary from 1020 to 1050; but I have once or twice seen the specific gravity of saccharine urine as low as 1015; and many times as high as 1055, or even higher. The quantity of urea is sometimes much diminished; though I have never met with a specimen in which this principle was entirely absent; and, in some instances, urea is said to exist in diabetic urine in greater proportion than natural. Lithic acid also is usually found in saccharine urine in greater or less quantity ; and in favour- 56 DISEASES OF THE URINARY APPARATUS. able cases of the disease, the quantity of this acid is often very considerable. The usual saline matters existing in the urine are met with in diabetic urine in nearly the same relative proportions as in health; but the absolute quantity of saline matters, viewed in relation to the quantity of urine passed, is much diminished. Sometimes diabetic urine contains a little blood (Watt on Diabetes, pp. 47, 74); and not unfrequently albuminous matter, analogous to that of chyle. I have seen it also contain a white, milky-like fluid, precisely similar to chyle, which slowly subsided to the bot- tom of the vessel. In this case the vinous fermentative process was induced very rapidly in the urine; the chylous matter appa- rently acting like yeast. TABLE. Specific gravity com-pared with 1000 parts of water at 60 degrees. Quantity of solid extract in a wine pint. Quantity of solid extract j in a wine pint, in grains. oz. dr. scr. grs. 1020 3824 0 6 12 1021 401-6 0 6 2 1 1022 420-8 0 7 0 0 1023 4400 0 7 10 1024 459-2 0 7 1 19 1025 478-4 0 7 2 18 1026 497-6 1 0 0 17 1027 516-8 1 0 1 16 1028 5360 1 0 2 16 1029 555-2 1 1 0 15 j 1030 574-4 1 1 1 14 1031 593-6 1 1 2 13 j 1032 612-8 1 2 0 12 1033 632-0 1 2 1 12 1034 651-2 1 2 2 11 1035 670-4 1 3 0 10 | 1036 689-6 13 19 1037 708-8 13 2 8 1038 728-0 14 0 8 1039 747-2 14 17 1040 766-4 14 2 6 1041 785-6 15 0 5 1042 804-8 15 14 ! 1043 8240 15 2 3 1044 843-2 16 0 3 1045 862-4 16 12 1046 881-6 16 2 1 * 1047 900-8 17 0 0 1048 9200 17 10 1049 939-2 1 7 1 19 | 1050 658-4 1 7 2 18 DIABETES MELLITUS, OR MELITURIA. 57 "The preceding table, constructed by Dr. Henry, shows the quan- tity of solid extract in sixteen ounces of urine of different specific gravities, from 1020 to 1050. In the experiments which furnished the data of this table, the urine was evaporated by a steam heat till it ceased to lose weight: and till it left an extract which became solid on cooling. (Annals of Philosophy, Old Series, vol. i., p. 27.) " This table enables us to ascertain with considerable precision the quantity of solid matter voided by a diabetic patient in a given time. Thus, suppose ten pints (old wine measure) are passed in twenty-four hours, of the average specific gravity of 1-040 ; it appears from the table that this quantity will contain 10x1 oz. 4dr. 2scr. 6grs.=15oz. 7dr. 2 scr.; or upwards of a pound and a quarter of solid extract." Together with saccharine urine, another most striking and almost constant symptom is diuresis in every possible degree. Cases are on record in which thirty pints and upwards have been discharged, in twenty-four hours, for weeks, and even for months together. But still, diuresis is not a necessary part of the disease. The irritation in the stomach, mouth, and fauces, manifested so generally by a red tongue, and a sense of heat at the epigastrium, is present also in the urinary passages ; and the external orifice of the urethrals often red in consequence; and there is sometimes phymo- sis. These symptoms are occasionally among the first that have been noticed in diabetic individuals; while in others they never appear at all. The disease is not confined to spare and feeble habits; Dr. Prout has repeatedly met with it in individuals of a fat and powerful frame. The composition of the urine varies, independently of its saccha- rine ingredients, from that in health. It is denser than natural, both in the actual and relative proportion of its solid contents ; being sometimes as high as 1050, or even 1055. Its quantity has been already mentioned to be excessive, far beyond, indeed, that of fluid drink. An interesting fact is related by Dr. Bardsley, which serves to show that the excess is made up by absorption of moisture from without, rather than always from the component fluids of the body. It is, that the liquid discharged may exceed the alimentary fluids, even when the patient is gaining weight. The difference, how- ever, between the ingesta and the renal excreta is sometimes enor- mous. In a case in Dr. Christison's practice, it was ascertained that, for at least four days, the ingested liquids from all sources amounted to 48 ounces daily, while the urine was no less than 240 ounces. The proportion of solids, instead of being, as in health, between 30 and 68 parts in a thousand, often rises in saccharine diabetes to 90, 100, or 120 ; and even as high, in Dr. Christison's experience, as 136. The actual discharge of solid matter in the urine, as first noticed by Cruickshank, is far beyond what it is in health. The daily discharge of solids, in common, by the urine, seldom exceeds two ounces and a half avoirdupois, in the highest health. But in diabetes it is not uncommon to find the discharge VOL. II. — 6 58 DISEASES OF THE URINARY APPARATUS. of solid matters so great as 22 or even 32 ounces. By the table and formula of Dr. Henry, the quantity thus excreted is easily found; and it ought to be accurately ascertained, as an aid to the study and treatment of a case of saccharine diabetes. 1 he remark of excess of urine over the fluids drank, applies also to the dispropor- tion between the quantity of solids ingested, and that of the excreted solids in the urine ; the latter being more than the solid food taken. Urea was thought, on the authority of Bostock and others, to be wanting in the urine, in melituria; but succeeding experimenters have shown, first, that it was actually present, in a certain proportion ; then, that it was in as large a proportion as in health ; and finally, by Mr. McGrigor, that it was in considerably larger proportion than in health. (London Med. Gaz., vol. xx.) He found that one diabetic patient was passing 1013 grains of urea daily; a second 945 grains; a third 810 grains; and a fourth 512-5; the quantity discharged by a person in health amounting to from 362 to 428-5 grains. None of these patients had undergone any treatment, and the specific gravity of the urine in each, in succession, was 1-040, 1-045, 1-034, and 1-050; the quantity of urine discharged being, in the same order, 38£lbs., 30lbs., 40lbs., and 25lbs. Diabetic (melituric) urine, when allowed to stand in a moderate temperature, generally becomes sour, and smells like turned milk. Sometimes it ferments briskly in the first instance. " The addition of a little yeast, especially if the urine have been previously some- what concentrated by evaporation, always causes it to undergo the vinous fermentation, after which it yields alcohol by distillation; and this, freed from water and weighed, is one of the most certain modes of estimating the quantity of sugar contained in any given measure of the fluid. Reduced by gentle evaporation to the con- sistence of syrup, and suitably treated with animal charcoal, acetate of lead, &c, in the manner generally known to chemists, melituric urine affords a crop of crystals of a sweet substance, which differs in nothing from that obtained from the must of the grape, or from fecula by the action of dilute sulphuric acid. There also remains a considerable quantity of sweet uncrystallizable syrup, analogous in its nature to melasses." (Willis.) The breath and person of those labouring under confirmed melituria*have been observed to exhibit something of a musty, sweetish, haylike smell. As the disease makes further advances the gums frequently become affected, apparently as in scurvy, and then the breath is very offensive. The feces, in this disease, have commonly the dryness and hardness of those of the rodent and ruminating animals— sheep, goats, hares: they are with- out the distinctive fetor. The saliva is sweetish, and the sweat has been represented to be, as in fact the furfuraceous cuticular exfoliation of the legs is, distinctly sweet to the taste. The progress of diabetes mellitus is slow; its most frequent termination is m phthisis pulmonalis. It may, also, end in fatal disease of the liver and jaundice; also apoplexy; a peculiar affec CAUSES OF DIABETES MELLITUS. 59 tion of the stomach brought on by improper food; acute gastritis induced by cold drinks, when the body was heated ; and, finally, inflammatory fever excited by exposure to cold, and rapidly be- coming typhoid. Occasionally it is said to terminate in incurable dropsy. The prognosis in diabetes is generally unfavourable. In sixty cases treated in the Edinburgh Infirmary, during a period of twenty-one years, by Dr. Christison or his colleagues, this gentle- man has not known an instance of a complete cure. Some patients did indeed gain weight considerably, and had the urine reduced to the density of 1030, and to its natural colour, odour, and urinous taste, without any sweetness ; but the final result was a return of the disease and death. Seldom is it in the power of the practi- tioner to report such returns as those of Dr. Bardsley, junior, who states, that out of twenty-nine cases of diabetes under his care, no fewer than eight recovered entirely. The post mortem appearances in subjects dead of diabetes mel- litus are not distinctive enough to elucidate the organic seat or origin of the disease. The kidneys are commonly found larger than in health, more flabby, more gorged with blood, and they present more numerous and larger vessels, and enlargement of the urinifer- ous tubuli. The renal arteries and veins are, also, at times, found enlarged. Sometimes there is an extensive deposition of grayish- yellow, granular matter, invading their cortical and even also their tubular structure. In a few instances the kidneys instead of being enlarged are contracted. Pulmonary tubercles are not uncommon; sometimes they are found softened, and even extensive cavities have been observed. The stomach is sometimes red, and its inner membrane rough and thickened ; but often it is quite healthy. The liver, spleen, and pancreas are usually healthy ; nor do the intestines exhibit unusual appearances in the generality of cases. The inference from the autopsic examinations is merely, that the pathological origin of diabetes is functional, and not essentially an organic derangement. The disease is mainly one of morbid as- similation ; but in what this consists we cannot tell. With the various speculations on the special pathology of diabetes, I shall not entertain you, but pass to a hardly more satisfactory branch of inquiry, that of the causes of the disease. Causes. — A predisposition to diabetes is, in Dr. Prout's opinion, more frequently inherited than acquired. When the latter is the case, it is from a variety of causes, such as residence in a cold and damp situation, particularly if at the same time conjoined with a poor and unwholesome diet, or the too free use of sugar, &c.; also venereal excesses ; the abuse of mercury ; and, in short, any cause tending to derange the assimilating processes. The most frequent exciting causes are, according to Dr. Prout, exposure to cold ; attacks of rheumatism and gout; drinking of cold fluids when heated; mental anxiety or distress; also contusions or other injuries of the back from falls, strains, &c. The writer just referred to has 60 DISEASES OF THE URINARY APPARATUS. seen diabetes follow cutaneous affections. It seldom accompanies these; but it generally, Dr. Prout says, in his own persona expe- rience, always, is associated with carbuncles and malignant Dons, or abscesses allied to carbuncles. . . Treatment. — However they may differ about the relative value of particular remedies, physicians are generally agreed about the practice in diabetes mellitus. The treatment consists mainly in the employment of bloodletting, animal diet, opium, astrin- gents, and the diaphoretic regimen. To be at all successful, it must be conducted on general principles; and in reference to the true light in which the disease is to be regarded, viz., as a simple saccharine condition of the urine, without any increase in its quan- tity ; and as complicated with a preternatural flow of that secre- tion. Diabetes is properly regarded by Dr. Prout as nothing more nor less than a form of dyspepsia ; principally consisting in a diffi- culty of assimilating the saccharine alimentary principle; and like all other forms of dyspepsia, whether it be an inherited or an induced affection, diabetes is liable to be much modified or aggra- vated by concomitant circumstances. The first and chief point to be attended to in the treatment of this disease is diet; under which head are included, of course, both solid and liquid aliments. Dr. Prout does not believe that a diet exclusively animal is required: but of farinaceous matters, the high or the strong, as he terms it, such as the farina of wheat in the shape of bread, &c, seem to be most easily assimilated. The low kinds, reducible to a species of sugar, are, if we except rice, inadmissible; as is strictly every variety of saccharine principle in its crystallisable form. This rule excludes, therefore, at once, all fruits, whether sub-acid or sweet; as well as every compound, natural or artificial, into which sugar enters. Every infringement of this rule retards the cure or endangers a return of all the worst symptoms of diabetes. Thus,Dr. Prout has known the eating of a few saccharine pairs undo, in a few hours, all that he had been labouring for months to accomplish. Quantity is almost if not quite as import- ant as quality. Four to five or six hours is an average period to elapse between the meals; and at the time of taking solid food, and for an hour or two afterwards, all fluids should be abstained from. Generally speaking, mutton or beef, plainly cooked, and particularly mutton-chops or beef-steaks, rarely done, should he taken twice in twenty-four hours; the other meals to consist of any simple article prepared from farinaceous matters, with milk, eggs, &c, only. Fat meats often suit the case, and are taken for some time with a certain degree of relish by the patient. To animal food exclusively, without the slightest deviation, Dr. Bardsley would confine a dia- betic subject, as an indispensable condition for his cure. On the score of drinks great reserve and selection are requisite. Ihe quantity must be very limited. Distilled water is thought well of by Dr. Prout; and large experience is in favour of carbonated lime or magnesia waters, or lime water with milk, for the quench- DIABETES CHYLOSUS, OR CHYLO-SEROUS URINE. 61 ing of the thirst. All the stronger saline waters should be care- fully avoided. With very few exceptions, Dr. Prout has seen more relief from thirst and more support given by sound porter in diabetic cases, than by any other means whatever. Of the strictly medicinal means mentioned as curative of dia- betes, bloodletting is restricted to the young and more robust, and to recent cases. Preference in more advanced stages should be given to topical abstraction of blood by means of leeches applied from time to time over the epigastrium. Stress is laid by some on repeated purgation; but laxatives, to keep up a soluble state of the bowels, are, in general, preferable. As we should readily believe, h priori, much good is derived from the regular use of diaphoretics ; not so much to cause exhausting discharges from the skin as to keep up a moderately excited state of its secreting function. In aid of this class, and as permanently beneficial agents, all the means already recommended for hydruria should be had recourse to here, for maintaining a permanently equable temperature of the skin and activity of its capillary circulation. In confirmation and illustra- tion, at the same time, of the efficacy of cutaneous excitement, I may mention the success which has attended the employment of the vapour bath of a high temperature. Some have gone so far as to attribute the alleged exemption of the Russians from the disease to the use, by all classes, of the vapour bath. Of the sedative remedies, opium claims the first place, and alone, or in combination, as in Dover's powder, it is certainly one of the most useful we possess. The dose of opium is a grain twice or thrice a day, gradually increased so as to keep up a gently hypnotic and soothing action. Astringents are often use- fully combined with opium. Those of the mineral kind, and espe- cially the sulphur of zinc and acetate of lead, are preferred. Among topical applications, after leeches to the epigastrium, cups to the loins, and blisters on the same part and on the stomach, more permanent counter-irritation by means of tartar emetic oint- ment, and secretory derivation by issues or seton, are entitled to some confidence. Diabetes Chylosus. —- Chylo-serous urine of Prout is another mor- bid secretion from the kidneys, with certain associated functional derangements of other organs. Chylo-serous urine is distinguished by its white appearance, and by undergoing,in greater or less degree, spontaneous coagulation. Its specific gravity varies from 1-010 to 1-020 or upwards: it always contains urea, and the saline matters found in healthy urine. The disease occurs in both sexes, before and after puberty ; of the thirteen cases with which Dr. Prout had cognisance, five wore males and eight were females. The consti- tutional disorder is less than might be expected ; two of the females, for instance, while labouring under the affection in a marked de- gree, became pregnant, and brought forth healthy children. Of the thirteen cases, seven occurred either in natives of hot climates, or in individuals who had resided many years in them. Dr. Prout thinks 6* 62 DISEASES OF THE L'RINAKY APPARATUS. this a predisposing cause. M. Rayer says that the disease occurs frequently in Brazil. The disease is not necessarily connected with organic lesion of the kidney. In one of the three fatal cases out of th? thirteen that reached the knowledge of Dr. Prout, the kidney was found to be perfectly healthy. The subject of this case was a young girl, of about fifteen years of age, and the immediate cause of her death was inflammation of the bowels. In one case, in which the urine was examined twice a day, this fluid was found to be perfectly free from albuminous matter. The urine after it has been discharged for a short time, sometimes coagulates into a gelatinous body like blanc-manger, and afterwards gradually separates into a clean, yellowish fluid, and a white clot; at other times, a white, flaky matter is deposited without general coagulation of the mass ; and in other cases, again, a white, homo- genoussubstance is thrown up to the surface like cream. The matter which separates in all these shapes appears to differ somewhat from albumen, to approach to fibrin or casein in its characters, and to contain some oleaginous or fatty matter, which may be easily removed by sulphuric ether (Christison). In a case described by Dr. Graves the coagulable matter was casein. The treatment has not been well defined in this disease. The only ease that I remember to have seen was that of a student of medicine, many years ago, who was a sufferer from dyspepsia to a great degree; undergoing frequent attacks of gastrodynia, and generally suffering from disordered bowels. With him this morbid state of urine was chiefly manifest during the winter, while attend- ing medical lectures in this city. He sat up very late, and took little or no exercise, ate with good appetite and without special restriction. He found that, at any time, he could for a day or two remove or prevent the chylous appearance of the urine by even a small dose of magnesia. On his return to the country in the spring, after his first winter course of lectures, the disease left him, or re- curred but a few times for a short period. The chief if not sole change in his life at this time, was in his taking a good deal of ex- ercise both on foot and on horseback; his habits of study and diet being nearly as before. During the next winter in the city he had the disease again ; but on the approach of spring it disappeared. He went abroad, and was for a time first in a warm and after- wards in a tropical climate, during which period he was exempt from the disease, nor did it ever again recur, except during one winter of close study and restricted exercise in Paris. The chief measures required are those adapted to dyspepsia, viz., the use of plain nourishing food, a regulated state of the bowels, moderate exercise, the warm bath and regular hours; and regular habits inevery particular. Magnesia alone,or magnesia and rhubarb, or some of the alkalies, are among the best immediate palliatives. The morbid renal secretion of serous or albuminous urine has already engaged our attention to an adequate extent under the head of Bright's disease, or renal dropsy, &c. CRYSTALLISED SEDIMENTS, OR RED GRAVEL. 63 The next diathesis connected with morbid secretion from the kidney, is that of the lithic or uric acid, and its various compounds. The acid assumes two distinct general forms in the urine, viz., that of amorphous and impalpable sediment; and that of crystallised and massive concretions. The amorphous and impalpable sedi- ments consist in general of lithic acid in combination with ammonia. The colour, yellow and red, or lateritious, is caused by the yellow colouring matter in the first case, and this same matter tinged with purpurate of ammonia in the second, added to the lithate of am- monia. Urine depositing red sediment is generally more acid than common; and while the quantity is less, the specific gravity isgreater. It is sometimes serous or albuminous. As regards constitutional symptoms and causes, it is observed that the yellow sediments may be called those of healthy or rather those which occur in healthy per- sons who are slightly dyspeptic, or temporarily disordered by atmo- spherical changes and other circumstances. The presence of red sediments generally indicate a feverish or inflammatory state of the constitution, and most commonly are regarded as signs of chronic visceral affections, and particularly of the liver. Crystallised sediments, or red gravel, consist of lithic acid nearly pure. The deposition in this way is not so much an evidence of the excess of lithic acid as of its precipitation by the evolution of other substances in the urine — a process easily imitated artificially by the addition of a few drops of any acid to healthy urine. Amor- phous lithic concretions are generally deposited in the kidneys, and, * perhaps more frequently than any other cause, give occasion to that peculiar train of symptoms constituting a nephritic attack. They are of two kinds, coloured and white. Thepuriform lithic concretions have their nucleus generally formed in the kidney, though, for the most part, the concretion descends into the bladder before it has acquired such a magnitude as to give uneasiness, either in the kidney, or during its passage down the ureter. A remarkable feature attending the formation of this variety of concretions, is the great number in which they are Usually generated,—a circumstance which may be said to be characteristic of them. They vary in size from that of a pin's head to that of a pea or marble. The urine, in this form of concretion, approaches in its properties to the state which deposits the lithic acid gravel; that is to say, usually trans- parent, of a light yellow colour, distinctly acid, rather copious, and of a moderate specific gravity. Children, especially those of dyspeptic and gouty individuals, are exceedingly liable to crystallised lithic deposits in the urine. There is less disposition to form them between the age of puberty and forty years, than at other times. The causes of lithic acid sediments are of two kinds—predisposing and exciting. The first is sometimes inherited, and is sometimes manifested by a strumous and also scorbutic habit. The exciting causes are, errors in diet,exercise, and atmospheric influences. In some persons any acescent food, vegetables, or fruits, will bring on an attack. Potatoes I have seen to be a very decided cause of the 64 DISEASES OF THE URINARY APPARATUS. fine or sandy lithic acid deposit in a person of most *b»^ of living. Writers enter into refined speculatens repec "g ^ kmd of wines that are least hurtful in this disease. The best protection is an abstinence from all. Exercise soon after a meal, or on horse- back, will bring on an attack ; but, on the other hand, hardly any- thing can be more pernicious than bodily mact.vity conjoined with a full or improper diet. . Generally speaking, except a calculus exists already formed in the kidney or bladder, the appearance of lithic acid gravel is not dangerous, as long as it is not deposited while the urine is warm. The treatment of lithic acid deposits, whether of the pulverulent or massive kinds, consists, first and chiefly, of regimen in the large sense, including both diet and exercise, and of the use of suitable me- dicinal substances. I shall not repeat details here, already fully given when treating of dyspepsia, and subsequently of the morbid states of the kidneys, for the regulations of diet, in which both quality and quantity are to be rigidly considered. Milk, useful in some forms of dyspepsia, is injurious in the present case. I have seen exces- sive lithic acid deposits in a young man, whose diet was, at the time, exclusively bread and potatoes with milk. Of the common beverages, weak black tea is the least injurious. Coffee and choca- late should be shunned altogether. Hard waters, such as pump and well, should be avoided ; those from Artesian wells, or from a great depth, containing a little carbonated alkali, and pure river water, are least objectionable. As regards medicinal means, alkalies are long established fa- vourites in this disease. They exert, however, as Dr. Prout re- marks, and I am now merely giving you a brief outline of his views, no curative influence of a permanent kind on lithic acid deposits. To be useful they must counteract acidity at the moment of its development; and their use must be constantly and daily repeated for a long period. The best time is between two and six hours after eating. As regards dose, from ten to twenty grains of the carbonate of potash will, in almost every case, be found amply sufficient to counteract the acid residuum of the meal. Dr. Prout generally prefers potash, on account of the greater solubility of the potash lithates; but soda is more grateful to a few stomachs, while others prefer magnesia. This last article is not regarded with so much favour by Dr. Prout, as by many other writers, except in acidity of the cescum and colon. In almost all instances he asso- ciates the potassa with a few grains of nitre. By giving alkalies with tonics, the good effects of both are often lost; but their sepa- rate use is highly beneficial. Thus, he often gives tonics, even mineral acids, before a meal, and the alkalies after a meal; and with the best effects. Among the secretions from the kidneys of an eminently morbid nature, we rank those of phosphatic salts, and their deposition in the urine. These are the insoluble salts, — the triple phosphate of magnesia and ammonia, and the phosphate of lime. The triple phosphate is usually deposited from the urine in the form of perfectly CRYSTALLISED SEDIMENTS, OR RED GRAVEL. 65 white, shining crystals, and constitutes what is termed white gravel, in contradistinction to the lithic acid crystals, which, from their colour, are termed red gravel. The urine depositing the triple phosphate of magnesia and ammonia is generally pale coloured, and very slightly acescent when passed. For the most part it is abun- dant in quantity, and of moderate or low specific gravity. Exposed to the air for a short time, it gradually becomes alkalescent at the surface, even in some instances before it is cold ; and on such occa- sions an iridescent pellicle is usually formed on the surface, which, on examination, proves to be crystallized, and to consist of the triple phosphatic salt in question. About the same time, also, minute crystals of the salt begin to attach themselves to the sides of the vessel in which the urine has stood for a short time; and this fluid speedily becomes alkaline and putrescent. The constitutional symptoms in well marked instances of the triple phosphate deposit, are characterised by what, for want of a better term, Dr. Prout designates nervous irritability; the manifestations of which are various, and accompanied with more or less debility; a sense of sinking and exhaustion, with fatigue and pain in the back on the slightest exertion. In describing the causes of this disease, we find the delicate and feeble to be its chief subjects. All the causes depressing and en- feebling the system, whether physical or moral, will, in the predis- posed, bring on a deposition of the triple phosphate in the urine. Abuse in food or medicines, particularly of saline and other diure- tics and alkaline remedies, and mercury, will have the same effect. The phosphate of lime is deposited in an impalpable amorphous powder, which is generally white, though occasionally is slightly tinged with the colouring matter of the urine. Often it is so abundant as to be deposited on exposing the urine to heat. The constitutional symptoms are nearly the same as those accompanying the deposition of the triple phosphate. The phosphate of lime is not part of the renal secretion merely; "the mucous membrane lining the bladder, the cavities of the kidney, prostate, &c, often throws off immense quantities of the phosphate and carbonate of lime; and from the mucous membrane of the bladder in particular, much of the phosphate of lime usually found in urinary deposits is derived. The remainder is separated by the mucous membrane lining the cavities of the kidneys, or per- haps by the kidneys themselves." It should be known, however, that, although the triple phosphate of magnesia and ammonia, and the phosphate of lime, are each of them formed separately,and give rise to the constitutional symptoms mentioned, yet, that in by far the greater number of cases, the earthy deposits consist of a mixture of the triple phosphate of mag- nesia and ammonia, and the phosphate of lime, and are by Dr. Prout described under the head of the mixed phosphates. In this last mentioned state of things, when proceeding from constitutional, and not connected with local causes, as disease of the bladder, the urine 66 DISEASES OF THE URINARY APPARATUS. is generally pale-coloured, and on the whole voided in greater quantity than natural. The constitutional disorders are of a mixed nature; deranged digestion and innervation giving rise to all the chief symptoms: the expression of the countenance is haggard, the com- plexion sallow. Diarrhoea alternating with constipation, and black, or, what is more common, clay-coloured and yeasty dejections, are also met with. As an excess of the mixed phosphates in the urine is seldom of common occurrence, the appearance of these salts in any quantity must be regarded as much more frequently signs of and accom-' panied by local diseases of the urinary organs. Hence, a deposi- tion of the phosphates usually accompanies protracted bladder and prostate affections ; and thus superadds, too frequently, the miseries of stone to the other sufferings of the patient. The causes of a predisposing nature of the formation of the mixed phosphates, are the same as of the separate salts; viz., the triple phosphate, and the phosphate of lime. Injuries of the back, by concussions, blows, or other accidents, are exceedingly liable to bring on depositions of the phosphates in the urine; particularly if there have been predisposition in the sufferer to this state of disease. Among the general exciting causes may also be mentioned severe and protracted debilitating passions, excessive fatigue, &c, but the most frequent causes are local irritations affecting for a consider- able time the bladder and urethra ; as, for instance, any foreign substance introduced into the bladder, — all sorts of calculi, the retention of a catheter or bougie in the urethra, strictures of the urethra. Of the diseases connected with the soluble incidental matters, in- cluding soda,potassa, and ammonia, I have not now time to speak, and must therefore refer you to the valuable work of Dr. Prout for the details of these subjects. After a correct diagnosis of the disease connected with the depo- sition of the mixed phosphates, which is reached chiefly by chemical tests, we proceed to the treatment, which, as in all the diseases of the urinary apparatus, even still more than in most other diseases, consists of the dietetical and the medicinal. Were we to be in- fluenced entirely by the alkalescent, and still more ammoniacal condition of the urine, we should recommend a diet as far removed as possible from the azotic, and to consist of a vegetable and acescent nature. But this purely chemical view is not sustained by expe- rience; and Prout very judiciously recommends, when the constitu- tion is deeply involved and much enfeebled, a generous animal diet, consisting principally of solids : fluid aliments, such as soups, should be sparingly used. All causes of exhaustion, either bodily or mental, must be avoided ; and hence a change of air and scene, from the town to the country, produces a double good effect, bv its operation both on body and mind. Of medicines, we select—1, sedatives, of which henbane and camphor are preferred by Prout, but in the severe cases, opium must be employed; 2, tonics, including Pareira brava, CRYSTALLISED SEDIMENTS, OR RED GRAVEL. 67 acidulated infusion of roses, with sulphate of quinia, some prepa- ration of iron, &c, and under this head the mineral acids, as far as they can with safety be used, in order to check and remove the alkalescency of the urine. General languor and debility will be obviated by the shower-bath, tepid or cold, according to circum- stances, of prior habit, or present frame of body; and local, as un- easiness or pain in the back, by various plasters or liniments applied to this part. In severe idiopathic cases opium is almost the only means of present relief or comfort, — in doses of from one grain to five grains, twice or thrice a day. While we are attentive to pro- curing a regular state of the bowels, we must shun active purga- tives, and especially all those of the saline class, even Seidlitz powders, and the common effervescing or saline draught. When the irritation is chiefly restricted to the bladder, and the disease is in its earlier stage, before the constitution has yet suffered, leeches to the perineum, or cups to the sacrum, and purgatives, will be of service, and may often advantageously precede or accompany the use of sedatives ; and these last, instead of being associated with tonics, &c, as in severe cases, may be much more beneficially combined with the citrate or acetate of ammonia. Cystic oxide calculus is a rare disease. It was first described by Dr. Walluston, its discoverer, from one taken from a boy five years old. Since then it has been found and described by Drs. Henry, Marcet, Venables and Bird, and Mr. Brande. The oxalic acid diathesis is sometimes associated with serous urine, and with organic disease of the kidney. Among the symp- toms, which are sometimes very slight, at other times evincing bodily suffering and mental excitement bordering on insanity, hemorrhage from the kidneys is perhaps more frequently produced by oxalate of lime, than by any other form of concretion. For- tunately, however, of the hundreds of individuals in whom the oxalic acid diathesis prevails, a few only suffer from calculus. The formation of a renal calculus of oxalate of lime seems to be generally an accidental circumstance; and, in almost every in- stance, the formation of such concretion depends either on the pre- sence of some foreign body, or some local inflammatory action on the kidney. Among the exciting causes of this diathesis is, in Dr. Prout's opinion, a residence in a damp and malarious district. The influence of diet is very strong. Repeated instances have been seen in which the too free use, or rather abuse, of sugar has given occasion to the oxalic acid form of dyspepsia ; and sooner or later, under favourable circumstances, to the formation of an oxalate of lime calculus. The dietetic part of the treatment of the oxalic acid diathesis is nearly the same as that applicable to diabetes. Fermented drinks should be abstained from. The quality of the water is of the utmost importance. The medical treatment is chiefly analogous to that of diabetes. " The mineral acids, either alone or combined, are usually grateful to the stomach, and may be taken with advantage; 6S DISEASES OF THE URINARY APPARATUS. indeed, generally speaking, (says Dr. Prout,) I have seen more benefit derived from this class* of remedies than from any other. The effects of the mineral acids must be watched; and when they begin to produce a deposition of the lithate of ammonia or of lithic acid, their use must be suspended." The distressing flatulence and irregular action of the heart, so often present in this affection, are relieved by hydrocyanic acid, or infusion of the wild-cherry tree bark. Lactic acid, by some distinguished chemists believed to be merely a modification of acetic acid, is developed both in the pri- mary as well as secondary assimilating processes. In the first, giving rise to dyspepsia, especially heartburn, &c, and unpleasant sensations and derangements of the lower bowels; and in the second, deranging more or less the renal secretion. The remedy for these disorders will be not so much a specific treatment, as the exhibi- tion of alkalies, but an adoption of a suitable regimen by which all the assimilating organs will be rendered fitter for the rhythmical discharge of these functions. After an account of the various states of the urine, evincing morbid secretory action in the kidneys, it would be in order to describe the solid deposits from this fluid, constituting calculi in the cavities of the kidney and in the bladder, or renal calculi and vesical calculi. But I must be content with having directed your attention to the various diathesis and the evidence of morbid con- cretions going on, and the outlines of treatment demanded on these occasions, and leave to yourselves the application of this knowledge to the treatment of the more confirmed stages of the disease. The symptoms of renal concretions, in genera], are not distinctive from those of nephritis and neuralgia, and their real value can only be ascertained by a close attention to all the con- comitant circumstances of the case. The formation and passage of lithic acid concretions are often attended with little or no pain; those of the oxalate of lime produce pain of a more acute cha- racter ; and though principally referred to a particular spot over the region of the kidney, it is often discursive, and shoots in the direction of the ureter, epigastrium, or shoulder. The presence of renal concretions being ascertained, as well by the physiological symptoms as by the chemical tests of their pre- sence in part of similar matters in the urine, means should be taken for their expulsion. These consist, in the case of the lithic acid concretions, of the means to remove the so commonly associated congestions of the abdominal viscera; such as by cupping freely over the loins at the outset; and afterwards by active purgatives, including calomel and colchicum, or henbane if gout be suspected, conjoined with alkaline and diuretic remedies; among which, the tartrate of potassa or tartarised soda is perhaps the most efficient. When congestion is removed, the patient should be put on a plan of treatment adapted to the lithic acid diathesis formerly de- scribed ; and be directed to take simple diluents in conjunction HEMATURIA. 69 with foot or horse exercise. Under this plan of treatment, some- times alternated with the cautious use of diuretics of the terebin- thinate kind, almost incredible quantities of sand and numerous lithic acid concretions, of various magnitudes, have been brought away. If the concretions are presumed to be of the oxalate of lime variety, the same general treatment is useful, including diu- retic purgatives and diuretics, but with the substitution of dilute nitric acid with nitrous ether for the alkalies. Sedatives will be proper in all the cases, as also the warm bath. Concretions of the cystic oxide or of the phosphates will be met by the same general principles of cure. Nor do these differ during the actual descent of the concretions from the kidney. In plethoric subjects thus affected we cup the loins more freely, and give calomel and opium followed by fomentations and the warm bath. Of vesical calculi my notice will be very brief. The symptoms of the presence of calculi in the bladder are detailed in every work on the practice of medicine, as well as of surgery: their precise composition can only be ascertained by an analysis of the gravel or smaller calculi passed with the urine, and of this fluid itself. Guided by this knowledge, we may sometimes, with good effect, prescribe a course of medicine, in which large dilution counts for a great deal, for the relief of the pain and more urgent symptoms, sometimes for a diminution of the size of the calculi, rarely for their solution and entire removal. The means of cure adapted to the indications furnished by the different kinds of calculi are the same as when the principles of which they are composed are secreted from the kidneys and deposited in the urine. The chief reme- dies are the alkaline class, persevered in for a length of time,— months and years, — in such doses as not to distress the stomach or interfere with digestion. The alkalies, in whatever shape exhibited, have an unquestionable and very remarkable influ- ence upon the calculi of the bladder themselves, and upon the symptoms to which they usually give rise. A stone in the bladder, ascertained by sounding, and which caused its possessor torment hardly endurable, has been so far rendered innocuous by the pro- tracted use of Castile soap and lime water, as scarcely to give any inconvenience. On this point refer to Willis, p. 184-190. The value of the alkaline bicarbonates especially, has been placed in a more conspicuous light of late years, by the experiments of Dr. Ch. Petit and M. A. Chevalier. Hematuria, commonly defined to be a discharge of blood from the bladder, is in fact hemorrhage from the urinary organs, without specification of part. Sometimes the blood comes from the kidneys themselves, sometimes from the pelves or ureters, and often from the bladder. It is symptomatic of or caused by some other affection more frequently than it is idiopathic; and hence we meet with it in certain epidemics, as remittent and typhoid fevers; affections of the spleen and liver, and in scurvy. It occurs as an endemial disease in VOL. II. —7 70 DISEASES OF THE URINARY APPARATUS. some countries. In the isle of France, children from their earliest infancy are liable to this complaint, without suffering any pain, or its appearing to prejudice their general health. One of the physi- cians of that island says, that three-fourths of the children are af- fected at one time or another with hematuria. In these cases the bloody urine is generally observed to alternate with that which is chylous or sero-albuminous. The most common cause of haematuria is the presence of some foreign body in the pelvis of the kidney, in the course of the ureter, or in the urinary bladder. The treatment will be modified by a know- ledge of cause ; and commonly will consist of a mild antiphlogistic course, viz., cups to the sacrum or leeches to the perineum; cold cloths to these parts, and on the hypogastric region; cold water enemata; the administration of sub-acetate of lead; or, if the patient have been subject to hemorrhoids, a few leeches to the anus will be of service. Prior constipation or any fulness of habit will require purging, at first with calomel and rhubarb, and after- wards with salines. More formidable cases are treated by injec- tions of cold water, or of alum, in the proportion of forty grains to a pint of water, thrown into the bladder. Revulsives by warmth to the feet, and warm pediluvia, will be serviceable. When hsematuria recurs often, without being caused by the irritation of calculi, and the subject is weakened by the discharge, or his system otherwise debilitated, some preparation of iron is of ser- vice. The muriated tincture has been given with good effect in such cases. When the hemorrhage is from the kidney, it some- times lasts unchecked for weeks together, and then ceases without farther injury. The chief diseases of the bladder are, inflammation or cystitis, and catarrh or cystirrhosa, with their modifications of irritability and spasm. Inflammation of the bladder may appear in one or more of its component tissues; but it seldom fails, except we call rheumatic or neuralgia attacks of the muscular tissue inflammatory, to involve them all. If the mucous coat be the first attacked, we have, besides the common symptoms of inflammation, those of irritable bladder. In the serous coat the symptoms will be those of partial peritonitis. In all these cases the sub-mucous cellular tissue is soon implicated, and then we have the symptoms of acute phlogosis of the bladder. These are, after rigors, acute burning and throbbing pain behind the pubes, and extending to the perineum, with heat and pain at the anus and rectum, and tenesmus, and frequent desire, with difficultyof discharging the urine. To these succeed symptoms of general're- action or fever. The urine is at first scanty, dense, high coloured, and turbid on cooling. If the disease is allowed to go on unchecked, the pain extends upwards through the abdomen generally, which becomes tens.e and tender ; there are then nausea and vomiting, with great prostration, anxiety, and restlessness. Cystitis may be caused by external injuries, by injudicious irri- tation of the bladder in certain operations, or by acrid diuretics; CYSTITIS— CYSTIRRHCEA. 71 metastasis of gout, and the like ; and in females, by difficult and pro- tracted labours, from the long pressure of the head of the child. The treatment of cystitis will be pretty obvious from the symp- toms. Venesection, followed by topical bloodletting from the sacrum, perineum, and anus, as may be deemed most advisable in consider- ation of any prior affection or concomitants of the case; in fine, the same measures may be advantageously adopted as were recom- mended for hematuria. Recourse will be had, more readily than in the latter case, to tartar-emetic, which will take the place of sugar of lead in the early period of the attack, as calomel will that of any tonics towards its close. Depletion having been properly practised, including adequate evacuation of the bowels by castor oil and mild mucilaginous enemata, a blister to the sacrum will do good service. The chronic form of cystitis is often confounded with cystirrhcea, and, in fact, it at times terminates in this latter; and, conversely, cys- tirrhcea may be hurried into cystitis by injudicious treatment or acci- dental irritation. But true cystirrhoza, catarrhus vesicce, is of pri- mary origin, like analogous irritation in all other parts of the mucous system; running through its several stages, from that of irritation bordering on slight inflammation to increase of mucous secretion and solution of the disease. Like other forms of catarrh, it may ori- ginate from exposure to cold and moisture, and its effect, suppressed perspiration. More commonly it is caused by irritation and inflam- mation of the urethra, either from the violence of gonorrhoea, or other sudden stoppage of the discharge ; and in either'case there is an extension of the inflammation of the urethra to the mucous mem- brane of the bladder. But, it has been well said, that idiopathic catarrh of the bladder is just as rare in an acute as it is common in a chronic form. Its advance is insidious, so that it attracts little attention for a length of time. Finally, however, the uneasiness felt about the region of the bladder, the frequent calls to pass urine, and the mucus mixed with this fluid, together with sympathetic disturbances of the digestive canal, are clear indications of a de- veloped and troublesome disease. The nervous system soon partici- pates largely in these disorders, and the irritability, alternating with sadness and depression, and apathy, are great. The urine, when examined, shows a large addition of flocculent mucous matter, which subsides from the general mass of the fluid, collects at the bottom, as in the acute disease, and forms a tena- cious substance that will bear drawing out into ropes a foot and more in length without breaking. As the disease advances, the urine undergoes further changes; its urea suffers decomposition, and it is rendered both acrid and intolerably offensive. The con- tinued irritation of diseased bladder produces hectic and marasmus, which, if not arrested, ultimately prove fatal. Cystirrhcea is described to be, as it is truly, a disease, for the most part, of aged people. 1 have seen it, however, in young subjects: and one of the worst cases which I ever met with was that of a 72 DISEASES OF THE URINARY APPARATUS. young man, about twenty-five years of age, who finally sank under the disease. . , r , The treatment must vary with the constitution and age of the patient, particularly as regards preliminary depletion, which, in some instances, gives great relief. In the case just referred to, J found the sufferings of mv patient, up to the last few months of his life, relieved for a longer period by cupping over the sacrum, orleeches to the perineum, than by opium, or any combination of sedatives that I could devise; even, too, when his general circulation and other or- ganic systems manifested very feeble action. Laxatives and demulcent drinksconstitute an important partof thetreatment. After these opium with small doses of magnesia, which last is preferable to any of the alkalies, injections of laudanum if the pain be great and persistent, or the irritability of the bladder prevent sleep, will be put in requisition. I have found, on some occasions, nothing soothe so much the suffer- ings of the patient as cold water enemata. After the subsidence of inflammation recourse is had to some medicines of the balsamic tribe, of which copaiba is the best. This medicine is highly lauded in this disease, taken by the mouth, and injected into the rectum ; and in many cases undoubtedly deserves its good character. But my own experience is coincident with Mr. Liston's, in leading me to prefer cubebs, in doses of twenty grains twice or three times a day, to which I often add half the quantity of uva ursi and the same proportion of magnesia. I have succeeded in relieving for a time, by this pre- scription, a person whose calls, for years, to pass urine, were almost continual, night and day. Under the use of the cubebs she was so much benefited, that in the course of a fortnight she was able to go out everywhere with freedom; and could retain her water easily for three hours to three hours and a half. In a few weeks, however, the disease returned; the same remedy was prescribed, but its effects were no longer as beneficial as before. The balsam was then used, but without effect; nor was I more successful with a short trial of strychnia. Enemata of oil of turpentine with yolk of egg, blister to the sacrum, injections of warm water, or of a solu- tions of morphia into the bladder, have been generally recom- mended and used. I have tried them all, but without any encou- raging results. Sulphate of quinia and analogous tonics are sometimes serviceable, at other times again seem to aggravate the disease. Much stress is laid by some writers on an3 issue esta- blished in the perineum, as decidedly more remedial in its effects than a similar drain and counter-irritation on the sacrum or spine higher up. Blisters on the inside of the thighs sometimes give partial relief. Even in the chronic form of the disease, after the use, so generally ineffectual or partially successful, of balsams, I have succeeded in giving comparative comfort for weeks to a pa- tient by small doses, two and three times a day, of emetic tartar • and have directed the application of this medicine to the sacrum as an external counter-irritant. The opposite in some respects of cystirrhcea is ischuria vesicalis or retention of urine. In this latter the kidneys, unlike that which PROPORTION OF CASES OF URINARY DISEASE. 73 occurs in ischuria renalis, perform their office as usual, and the urine makes its way into the bladder; but from some cause it can- not be ejected from* that organ. In this case there is more or less pain and uneasiness in the region of the bladder, accompanied, for the most part, in the earliest stages, at least, by an urgent desire to pass off the urine. The distended bladder forms, in most instances, a swelling above the pubes, not only perceptible to the touch, but sometimes, even to the eye; and the drawing off the urine by the catheter, if this can be effected, always gives great and immediate relief to the patient's sufferings. The cause of retention may be inflammation, spasm.ormechanical obstruction at the neck of the bladder or urethra, or a combination of these causes. Retention of urine is also an attendant or conse- quence of hysteria, of paralysis, or of other affections of the bladder, such as a preternatural thickening of its coats, &c. If long con- tinued, it causes suppression of urine, or it may end in rupture, gangrene, &c, of the bladder. According to the cause will be our treatment. If inflammatory symptoms prevail, we have recourse to free venesection and cup- ping over the sacrum and loins, antimony, &c.: if spasm be pre- sent, opium is to be given by the mouth and enema ; also bella- donna, particularly in the form of extract rubbed on the perineum and pubes, or introduced as a suppository into the rectum. The muriated tincture has acquired great reputation in thislast mentioned state. Failing soon to cause the bladder to evacuate itself, we must introduce the catheter and draw off the water; and here I may mention, parenthetically, that the best for one who is not a practised surgeon, is the common-sized silver catheter. If there be symptoms of paralysis or weakness of the spine, moxa, or a small blister is to be applied to this part, and iron and strychnia given internally. When there is associated derangement of digestion, the blue mass, alternating with magnesia and bicarbonate of soda, will answer a good end. The prognosis in retention of urine occurring in old persons is not favourable. We must not be surprised at sudden death, preceded by apoplexy or paralytic seizure. As regards the proportion of cases of urinary diseases in the two sexes, in England at least, we learn that they destroy five times as many males as females—the rate of mortality under this head having been -199 and -087 per thousand. This disparity has been ascribed to mechanical causes; but will a mechanical explanation account for the fact, that sixty-eight males, and only twenty-eight females, died of diabetes? Dr. Yellowly, in a paper published in the Philos. Trans. 1829, estimated that one in one hundred and eight thousand persons was cut annually for stone in England and Wales. It appears from the table, that forty seven in one million males, and five in one million females, die of stone and gravel. The latter, it must be admitted, is a vague term in popular language ; but the mortality from stone is certainly one in one hundred thousand annually." — Registrar's Report, page 105. DISEASES OF THE RESPIRATORY APPARATUS. DISEASES OF THE RESPIRATORY APPARATUS. LECTURE LV. General Principles of the Diagnosis of Thoracic Disease.—Connexion between symptoms and physical signs—Physical and vital conditions of the thorax—Great assistance to diagnosis of diseases of the chest, furnished by phy- sical signs—Difficulty from symptoms alone—Mutual dependence of signs and symptoms—Sources of physical diagnosis—Insufficiency of signs alone—Re- view of the different signs—Auscultatory phenomena; passive and active. It cannot be doubted, that the labours of modern pathologists in the localisation of disease, overrated though they, perhaps, have been by the disciples of certain schools of medicine, have yet done much to remove that great reproach of the art — its uncertainty. The discoveries of the different and numerous seats of morbid action, led, directly, to the study of the symptoms of these lesions, and of those physical phonomena, which resulted from, or accompanied them ; and thus has the science of diagnosis been placed on a sure basis, that time, with its mutations of opinion, can never shake. In the recognition of the seat and nature of disease, it is obvious that a great number of circumstances must be taken into considera- tion, besides the actual signs and symptoms of the affection. Age, sex, habit, exciting cause, and duration of symptoms, all form links in the chain of evidence on which we ground our opinion; but it would appear, that it is in the study of what are termed the signs and symptoms of disease that we have made the greatest advances in modern times. By morbid signs, we mean phenomena, recognisable to the senses, but particularly to those of sight, touch, and hearing, which are evi- dences of physical alterations in the conditions and relations of parts. These alterations may be enumerated : as changes in colour, shape, and volume; changes in resistance; peculiarities of feel; and lastly, the production of particular sounds, under certain circum- stances, perceptible either with or without the assistance of mediate auscultation, and either wholly new or characteristically altered. To the diagnosis founded on the observation of these phenomena we give the name of physical diagnosis, inasmuch as by it, that is to say, by the observation of physical signs, we recognise certain physical alterations of parts, which may be studied without refer- ence to those functional lesions which have preceded, accompany, or follow them. Thus, the feeling of fluctuation reveals the exist- ence of a fluid, but tells us nothing of its cause. The sound of fluctuation shows the coexistence of fluid and air, which may arise from different diseases. The signs of gurgling and cavernous respiration in the lung point out a cavity communicating with the bronchial tubes, and containing some fluid, but the cavities which DIAGNOSIS OF THORACIC DISEASE. 75 produce these phenomena may be of various kinds — gangrenous, phthisical, pneumonic, &c. Dulness of sound of the chest points out an obliteration or displacement of the air-cells, and the substi- tution of a solid or liquid for air, a condition which may arise from various causes. The sensation of friction only points out a rough- ened condition of serous membranes, but reveals nothing as to its cause. The deviations of shape and volume of the great cavities indicate some anormal state; but when we seek for their causes, we must have reference to other sources of information. These illustrations of physical signs might be extended, but enough has been said to explain the true signification of the term. We may consider symptoms as different from signs in this : that while the signs belonging to sight, touch, and hearing, are founded on physical conditions of the organs themselves, symptoms result from changes in the functions of the suffering organs, and in the modifications produced by disease in their vital relations with other parts. And hence we consider symptoms in a threefold manner: 1st. Changes in the functions of the part itself. 2d. Changes in the phenomena of organic life in various parts of the system. 3d. Changes in the phenomena of animal life. Thus, in examining the symptoms of a disease of a particular organ, we investigate the state of its own functions. We then exa- mine the changes caused by disease in all the phenomena of organic life — such as digestion, respiration, circulation, absorption, nutri- tion, exhalation, secretion, and animal heat. From these, we ad- vance to the phenomena of the life of relation, and examine the changes produced in the muscular power or function, the organs of sense, the moral affections, and intellectual manifestations. In a case of acute inflammation of the lung, we observe, in the first place, lesions of its own function, painful and hurried respira- tion, imperfect arterialisation of blood, cough, and expectoration ; these are what may be called local symptoms, but we may have others referrible to the disturbance of organic life in parts distinct from the lung; thus we observe excitement of the heart, fever, and various derangements of the digestive and urinary systems; further, in certain cases there may be signs of a lesion of the phenomena of the life of relation, as, for instance, prostration of strength, and other signs of derangement of the cerebro-spinal system. It must be obvious that, in the detection of the nature and seat of any disease, the more we can combine the observation of physical signs with functional symptoms, the greater will be the accuracy of our diagnosis. Now, if we compare together the diseases of the three great splanchnic cavities, we find that those in which this desirable combination is most attainable, are, first, those of the chest; next, the abdomen; and lastly, the affections of the brain and spinal marrow. Accordingly, if we compare the diseases of these systems with respect to the perfection of diagnosis, we find the order to be, 76 DISEASES OF THE RESPIRATORY APPARATUS. first, the respiratory; next, the abdominal; and last, the cerebro- spinal, or that in which this combination is least applicable. We shall enter on this subject by remarking, that the contents of the chest in the healthy and diseased state are most favourably circumstanced for the multiplication and distinctness of physical signs. And it is obvious, that the great improvement by which the present lime is distinguished in the diagnosis, and, consequently, the treatment, of thoracic disease, is traceable to this circumstance. In confirmation of the former proposition, let us consider — First. That of the different cavities of the body, the chest is that in which the existence of air in quantity is a natural condition. It is wanting in the cranium ; and when occurring in the abdominal cavity, may be generally considered as a morbid production, or an excretion. But the chest is the receptacle of air for the body. Now it is easy to show that, other things being equal, the sound, on percussion, is directly as the quantity of air within the chest; and the applicability of this to diagnosis is at once seen when we consider that the effect of every organic change of the lung is to diminish or to increase the whx>le quantity of air within the thorax, and, of course, to cause a corresponding increase or diminution of the natural sound. Secondly. We must recollect the remarkable separation of the viscera, on either side of the chest. In fact, of all the organs which, in the life of the embryo, and by the law of eccentric development, are formed primitively double on the median line, there is none that preserves its duplicity more completely than the lung. The brain, it is true, is separated into hemispheres, and the liver into a right and left lobe ; but the union of opposite portions of either organ is much more complete than what is found to exist in the lung; and the latter, also, with the exception of the testicle, is the only organ of the body whose original symmetrical halves are covered by separate serous membranes. The importance of all this to physicaldiagnosis is immense, for it is on this circumstance of separation that its true principle, comparison, mainly depends. If this great separation of the lungs did not exist— if, in place of their being merely connected by their vessels and air-tubes at the root, they were fused by continuity of their parenchyma, and covered by the one serous membrane, as the liver or brain —then the diagnosis of the exact seat of disease, which we will see is of the greatest practical importance, could not be attained ; and it would be indeed difficult to discover an empyema, a partial pneu- monia, or an incipient phthisis. Further the division of the lung into lobes, although these portions be not wholly separated, is yet advantageous in the same point of view, as these divisions act more or less in circumscribing diseased action, and of course increase tho applicability of the principle of comparison. Thirdly. The thoracic viscera differ widely from those of the cranium or abdomen in the constant, uniform, and extensive DIAGNOSIS OF THORACIC DISEASE. 77 motions which their functions require. These, whether of the lungs or heart, whether active or automatic, are perceptible by physical signs, and thus we have a standard by which many de- partures from the healthy condition may be easily estimated. It may be said, indeed, that this circumstance of motion is not peculiar to the lung or heart. But, while we admit the existence of the motions of the brain, we must remember that they are slight, and, in the adult, totally concealed by the bony cranium, while those originating in the viscera of the abdomen are irregular, and often imperceptible. Now, on the existence of these motions depends much of the physical diagnosis. If we look to the lungs merely, we find that the act of respiration causes phenomena appreciable by the ear, eye, and touch. The murmur produced during inspira- tion and expiration, and the alternate contractions and expansions of the chest, evident both to sight and feeling, all furnish most im- portant physical signs in cases of disease. Thus, in Laennec's emphysema, when the disease has been carried to a high degree, we find that, on account of the great volume of the lung, the murmur produced is feeble, and the expansion and contraction of the chest is trifling, as compared with the effort of the respiratory muscles. These circumstances may often suffice for the recogni- tion of the disease. Again, in certain cases of empyema, we can easily recognise the absence of motion on one side, and the corres- ponding increase of expansion on the other. Many more examples might be given. Further, the regular motions of the heart, productive as they are of peculiar impulses and sounds, are not only directly available for the detection of cardiac and aortic diseases, but also for those of the lung, as will be abundantly shown in the progress of this work. Fourthly. The thoracic cavity is the only one in the diseases of which the phenomena of the voice can be made available for dia- gnosis. It is true that, of the various physical signs, these are, per- haps, of the lowest value and most liable to mislead; but when combined with other circumstances, they become of important assistance in the detection of pulmonary disease. There is one case of disease of the circulating system, (aneurism of the aorta,) in which we may avail ourselves of the signs drawn from this source. Fifthly. Great assistance is derived in the detection of pulmonary and cardiac disease, from the peculiar modifications of shape which the chest undergoes from a number of causes. If we look to the affections of the head and spinal cavity, we find that, with the exception of some few cases of congenital dropsy, arrest of develop- ment, or chronic effusion, the more frequent diseases of this class do not produce any perceptible alteration or change of shape in the bony cases of the cerebro-spinal mass. In the abdomen, on the other hand, from the very yielding nature of its parietes, changes of volume and shape are common ; but it will be found, that these seldom are available for the detection of the nature of their cause — a circumstance as well attributable to the great yielding of 7S DISEASES OF THE RESPIRATORY APPARATUS. the parietes, as to the fact of the viscera being contained in a single cavity. The chest, however, presents bony, elastic, and fleshy parietes, and its principal viscera occupy three distinct cavities. Although it cannot be maintained that the alterations of shape and volume of the chest will always suffice to point out the nature of their causes, yet we must admit, that, with respect to the diseases of its interior, the modifications of its exterior are more numerous, and of greater diagnostic value in the chest, than in either of the other two cavities. Let us consider the extraordinary convexity of the whole chest, the arching of the sternum, and the appearance of the shoulders, in a case of dilatation of the air-cells; the loss of symmetry in the sides, and the peculiar smooth appearance pro- duced by the pressure of the fluid on the intercostal spaces, in the case of empyema ; the contraction of the side and depression of the shoulder, while the spine remains unbent, in the same case, where absorption of the fluid has taken place ; and the sunken and flat- tened appearance of the antero-superior regions in advanced phthisis. All these are instances of peculiar modifications of shape of the ex- terior walls of the cavity, coinciding with physical changes in the subjacent viscera. It is true, that taken alone they could not lead to a positive diagnosis ; but when combined with other signs and symptoms, their value is highly important; and this, with their number, should make us admit, that, as a means of diagnosis, the modifications of external form, produced by disease, are more valuable, and much more frequently applicable, in thoracic than in the cerebro-spinal or abdominal affections. Sixthly. The thoracic viscera, at least as far as the lungs are concerned, differ most remarkably from the cranial and the abdo- minal, in the facilities furnished by their structure and function for the detection of disease, by the direct recognition of the products of that disease. The conditions on which these facilities are found to depend, are various; but the principal are, separation, mobility, elasticity, and their direct and universal permeability to air, by means of the bronchial ramifications. Of these, the last is the most important. Thus, if we look to the brain with respect to the discovery of effusion, in a case of arachnitis, we find that there is no direct phy- sical sign of such a lesion, and its presence can only be guessed at by the existence of certain symptoms, which modern researches have shown to be extremely fallacious (See Andral,Medical Clinic — Diseases of the Encephalon). We have no physical means of ascertaining its presence or absence. But how different is the case with the lung, in which, by the assistance of percussion, by the ob- servation of changes of position, by the characters of respiration and of the voice, and by the observation of the displacements of the lung itself, the heart, and the abdominal viscera, the detection of a fluid in the serous cavity becomes as easy as it is certain. Ao-ain let us compare the facility of diagnosis of an abscess of the cerebral DIAGNOSIS OF THORACIC DISEASE. 79 with that of the pulmonary substance ; here, also, the existence of the first lesion can only be determined by the study of functional alterations; there is no physical sign, and we must farther admit, even after the researches of a Lallemand, a Serres, a Foville, or an Aberorombie, that he who would make the positive diagnosis of such a lesion, must have a confidence not justified by the present state of the science. But if, in a case of pneumonia, after the recognition of the ordi- nary symptoms and signs of the disease, we discover the pheno- mena of cavernous respiration, gurgling, and pectoriloquism in the affected portion of the lung, we know that there must be a cavity of some kind, and of its nature, our previous observations leave scarcely a doubt. Here, the facility of diagnosis would not exist, if, like the brain, the lung had been a closed organ ; but its permea- bility to air, and the regular and forcible entrance and expulsion of this fluid into and from its cavities, are the conditions which, by enabling us to discover new secretions and organic changes, easily reveal the lesion. The same train of reasoning applies to the diseases of the paren- chymatous organs of the abdomen; the liver, spleen, kidneys, pan- creas, and mesenteric glands. Here, for the same reasons, neither auscultation nor percussion can apply, unless in a case of mere enlargement, when the latter mode of investigation can be some- times employed. Abscess of any of these organs cannot be accom- panied by signs similar to those of abscess of the lung; nor are there any physical means which assist in detecting the earlier stages of inflammation. Nothing is so easy as to detect the suppuration of pulmonary tubercles; but in the case of the abdominal organs, even supposing that tubercles were recognised, who could pronounce upon their actual state 1 Further, in comparing the diseases of the gaslro-intestinal with those of the pulmonary mucous membrane, with respect to the facility of diagnosis, we are at once struck with the difference in favour of the latter. There is no physical sign proper to a gastro- enteritis, and its detection must depend altogether upon vital phe- nomena; but in the case of bronchitis, we have, in addition to the functional lesion, a group of signs resulting from the physical changes of the part, which often enable us to detect the slightest shade of mucous irritation, and to pronounce on the exact locality, extent, and stage of the disease. Lastly. If we consider the chest as to the mechanical nature of its walls, and the mobility of its contained viscera, we see that, in its diseases, a fruitful source of physical signs is contained in the various and remarkable displacements, not only of these viscera, but of those contained in the cavity of the abdomen — a source of diagnosis not applicable to the diseases of the brain, and scarcely to those of the digestive system. Thus, a moderate effusion into the pleura will displace the lung from below upwards, acting but little on the side, on account of its 80 DISEASES OF THE RESPIRATORY APPARATUS. greater resistance. When more extensive, it presses the Jung against the mediastinum, and, in consequence of this septum yield- ing more than the bony wall, it is pushed beyond the median line, of course carrying with it the heart, either to the right or left side, as the case may be. Now, all these displacements of the lung, mediastinum, and heart, are easily appreciable by physical signs. But we observe displacements of the abdominal viscera conse- quent on thoracic disease—a circumstance explicable by consider- ing the nature of the floor of the thorax ; that it is not, as the rest of its parietes, bony or cartilaginous, but formed principally by muscle and some tendinous expansion. Under circumstances of great accumulation of fluid, or of hypertrophy of the lung, this muscular wall yields to pressure; its convex surface becomes flat- tened, or even concave; the viscera of the abdomen, on the side corresponding to the affected lung, are pushed down before it, and, from their displacement, a new and most important source of dia- gnosis is obtained. It is true that the reverse may happen, and the thoracic viscera shall be displaced by abdominal disease ; thus, an enlarged liver or spleen, an abdominal aneurism, or an accumula- tion of air or fluid in the belly, by pressing on the concave side of the diaphragm, may displace the lung or heart; but it is obvious, that when we consider the difference between the abdominal and thoracic walls, and the yielding nature of the latter, such can only occur in very extensive disease. It is plain, too, that the natural action of the diaphragm will tend to diminish these effects, while in the former case it could have no such influence ; and it will be proved in the following pages, that an amount of pressure on the concave side of the diaphragm, carried even so far as to displace the superjacent viscera, does not deprive it of its contractile power. If we take a general view of the cranial, thoracic, and abdominal cavities, it would appear that in none of them is the diagnosis of disease, from symptoms alone, so difficult as in the chest. But further investigations will prove to us, that there is no cavity in the diseases of which (when we combine the study of symptoms, properly so called, with that of physical signs) the determination of the nature, extent, and modificationsof disease, is so easy and certain. In fact, the diagnosis of thoracic disease is founded on the combi- nation of signs and symptoms, and we shall find, that of all the cavities the chest is that in which the physical signs are most numerous, and of most extensive application. The nature of thoracic disease may be occasionally determined by the consideration of signs, or the observation of symptoms ; but it is obvious that the more we combine the two, the more exact will our diagnosis be. In diseases of the thoracic viscera, there is a greater necessity for mechanical diagnosis than in those of the brain or abdomen, for the general resemblance of the symptoms of the different thoracic diseases is much more striking than that of the cranial or abdominal affections. DIAGNOSIS OF THORACIC DISEASE. 81 In the case of the brain, we can often distinguish between arach- nitis and deep-seated local inflammation. In that of the abdomen, it is not difficult to distinguish between a mucous and a serous inflammation ; nay, we are even able to distinguish between the dis- ease of the different portions of the mucous expansion, as between gastritis, duodenitis, ileitis, and inflammation of the large intestine. But in the case of the thorax, this accuracy from symptoms alone is too often inaccessible. Pain, dyspnoea, acceleration of breathing, cough, and expectoration, are the prominent characteristics of a great number of essentially different diseases. It has been asserted, that by studying the varieties in the nature, mode of occurrence, succession, and modification of these symptoms, we can, independently of the information derivable from physical signs, arrive at an accurate diagnosis of thoracic disease. This is the common assertion of those few who are still opposed to the use of mechanical diagnosis. It is not to be denied, that in many in- stances the physician, without the aid of the stethoscope or per- cussion, may arrive at a sufficiently accurate diagnosis, and that, before these modes of ascertaining chest disease were introduced, the nature of many cases was correctly determined; but I feel no hesitation in saying, that for the attainment of such accuracy, the combination of careful observation, uncommon tact, and long expe- rience, is absolutely necessary. In other words, that there must be qualifications which it is next to impossible any young practitioner can possess. And, after all, however painfully and slowly this power of diagnosis has been acquired, it is still imperfect—as asser- tion well borne out by the comparison of the state of our knowledge previous and subsequent to the discoveries of Laennec. The pro- minent symptoms of chest affections which have been enumerated, may occur in the same order and the same manner in many essen- tially different diseases; in bronchitis, pneumonia, tuberculisation of the lung, and pleuritis. Every one who has studied chest affec- tions must have seen examples of all these cases, accompanied by symptoms exhibiting a resemblance which would puzzle the most profound and accurate symptomatologist. Now, supposing that the character and succession of the symptoms were the same, and the diseases of equal frequency, and that we were to fix upon any one disease as the cause of these symptoms, there would be three chances to one against our coming to an accurate conclusion. lam quite aware that many persons will object to this, and main- tain, that although these symptoms occur in the above mentioned diseases, and even in the same order, yet that their nature is dif- ferent. In the characters of expectoration, for instance, sufficient data for ascertaining the nature of its cause may exist; thus, in advanced phthisis it is purulent; in bronchitis, mucous; in pneu- monia, bloody; and so on. All this, though true to a certain de- gree, is yet, when generally applied, far behind the actual state of medicine, which has proved that we may have in each of these principal diseases every variety of expectoration, or no expectora- VOL. II. — 8 82 DISEASES OF THE RESPIRATORY APPARATUS. tion at all; and we may extend the same kind of observation to the cough, dyspnoea, acceleration of breathing, and pain. It may be said, that besides those mentioned there are other symptoms capable of assisting in diagnosis; as, for instance, the mode of decubitus, or the occurrence or non-occurrence of hectic. But both of these are equally fallacious. A patient with the most enormous empyema shall lie on the healthy side, and hectic is often absent, though the lung be full of suppurating cavities, or well marked without a tubercle in the lung. And, with respect to the occurrence of fever in general, it is notorious that every dis- ease of the lung may be apyrexial, or occur with all varieties of fever. Lastly, the advocates of physical examination may well appeal to the frequency of the latent affections of the lung, as showing the necessity of this mode of investigation. The lung may be hepatised without cough, dyspnoea, acceleration of breathing, pain, expecto- ration, or fever. But this change cannot occur without the exist- ence of physical signs sufficient for its detection, and nearly the same remark is applicable to many other instances of pulmonary lesion. It is plain that the study of symptoms alone cannot lead to accu- rate distinction of chest disease; the same remark is applicable to that of physical signs, unconnected with symptoms. Symptoms are insufficient without signs, and signs insufficient without a care- ful comparison of ihese with the symptoms. There is no such thing as a perfectly pathognomonic symptom or sign of any thoracic disease. We must combine the lights drawn from the careful study of symptoms, both past and present, with the observation of physical signs, for by this mode alone can we hope to arrive at an accurate result. Great injury has been done to the cause of physical dia- gnosis by some inexperienced men, who, departing from the princi- ples of its illustrious founder, have neglected too much the study of symptoms. To this subject I shall hereafter recur. Let us now enumerate the sources of physical diagnosis. 1st. Signs purely acoustic, including the results of percussion a«d of auscultation, mediate and immediate. It may be observed here, that of all the signs these are of the most universal applica- tion ; there being no disease of the lung or heart in which they do not occur. 2d. Signs derived from the alterations of shape and volume of the thorax. This source of diagnosis is capable of application to many, though by no means to all the diseases of the lungs, heart, and great vessels. Changes of shape and volume imply either the existence of acute diseases, in which the products of the disease have rapidly accumulated, or, which is the more frequent case, of diseases which have a great degree of chronicity. Under the first head we may reckon rapid liquid effusions into the pleura or peri- cardium, the result of inflammation, and recent pneumothorax, from fistula. Under the second, we have chronic liquid and ae'ri- DIAGNOSIS OF THORACIC DISEASE. 83 form effusions, hypertrophy and atrophy of the lung, both the result of chronic disease, and aneurismal or other organic tumours. 3d. Signs referrible to the sense of touch: these we find to occur in a considerable number of thoracic diseases; as, for instance, in bronchitis, with effusion; in dry pleurisy and pericarditis; in various diseases of the heart and great vessels ; in abscesses of the lung, communicating with the bronchial tubes; in certain cases of liquid effusions into the serous cavities ; and in hepatisation of the lung. 4th. Signs derived from the inspection of the motions of the thorax during respiration : these occur in cases of local or general impermeability of one lung, and in cases where the motions of re- spiration are otherwise impeded or altered. 5th. Signs derived from the inspection of the thorax, with refer- ence to the action of the heart and great vessels. 6th. Signs derived from the existence of an external collateral circulation, as indicative of the existence of obstruction of the great internal venous trunks, such as the cava and innominatae. 7th. Signs derived from the observation of the displacement of the thoracic or abdominal viscera : of these, some may be apprecia- ble by the senses of sight and touch merely, while others must be ascertained principally by that of hearing. The displacement of the heart (perceptible to the eye and touch), and the protrusion of the liver into the abdominal cavity, are examples of the first divi- sion ; while the displacements and compression of the lung, from liquid or aeriform effusions into the serous sacs, furnish examples of the second. Now it is never to be forgotten, that although in these various classes we have a vast number of well-marked and essentially dif- fering physical phenomena, there is not one of them which, taken singly, can be considered as a pathognomonic sign. Nay, we might go farther, and declare that no possible combination of them can be considered absolutely pathognomonic. By some of them, taken singly, or by various possible combinations, we may, indeed, ascertain the existence of certain mechanical conditions of the intra-thoracic viscera—as, for instance, permeability or imper- meability; increase or diminution of the quantity of air; the exist- ence of cavities of various sizes and with various communications; the roughened state of a serous membrane; or the displacement of particular organs : but if we seek to determine by physical signs alone, the cause of all or any of these phenomena, we shall find it to be difficult or impossible. It is only, as we have said before, by the connexion of the accurately ascertained physical signs with the previous history and actual symptoms of the case, that a correct diagnosis can ever be arrived at. In order to establish the proposition that no physical sign, taken singly, can be considered as pathognomonic, let us take a brief view of these different signs, commencing with those least frequently ap- plicable, and proceeding to those of most common occurrence." 84 DISEASES OF THE RESPIRATORY APPARATUS. 1st. Existence of an external collateral venous circulation.--This appearance, which has been described by Reynaud, is indicative of a great amount of obstruction to the internal venous circulation. But of the nature of that obstruction it alone can tell nothing. It may proceed from the pressure of a tumour, aneunsmal, or other- wise, or from disease on the internal surface of the venous trunk itself. This was observed to occur in the vena portse and inferior cava, in a patient whose case is described by the same author, and in whom the superficial veins of the abdomen took on a supplemen- tary action. In obstructions at the right side of the heart, the dilatations of the jugular veins, so long noticed, seems to be the commencement of the same morbid appearance ; and Dr. Graves has shown, that a varicose state of the superficial thoracic veins may occur from can- cerous degeneration of the lung itself. If, for the sake of argument, we assume that these different causes, for the appearance in question, were of equal frequency, and that from it alone we determined on the existence of any one of them, there would be four chances to one against our making a correct diagnosis. 2d. Signs derived from the displacement of the thoracic or abdo- minal viscera.— Of these, those that are most frequently recognised are the displacements of the heart and liver; the first is commonly observed in cases of empyema, the displacement to the right of the median line occurring in empyema of the left side, while that in the opposite direction indicates accumulation in the right pleura. Now, although displacement of the heart to the right side of the sternum constitutes one of the best indications of empyema of the left pleura, yet, taken alone, it is anything but unequivocal. A tumour, or an hypertrophy of the left lung, may produce a pulsation to the right of the sternum; the same may be caused by an hypertrophy and dilatation of the right cavities of the heart. And Dr. Graves and I have shown, that an aneurismal of the aorta may push the heart to the right side. I have also published the particulars of an extra- ordinary case of dislocation of the heart from external violence, in which the organ was driven far to the right of the median line, and in which no sign of empyema of the left pleura had ever occurred. When I come to treat of the affections of the heart, I shall give the particulars of this case. Lastly, well-attested examples of conge- nital displacement of the viscera have been recorded, in which the heart was placed at the right of the median line. On the other hand, displacement of the heart towards the left axillary region is a circumstance, which, from its nature, is commonly overlooked, and which may occur from other causes. I may also remark, that the previous contraction of either side, from a former attack of pleu- risy, should be added to the possible uncertainties of this source of diagnosis, for, in such cases, the heajt seldom resumes its normal situation with respect to the healthy side. As the displacement of the heart, considered alone, and without DIAGNOSIS OF THORACIC DISEASE. 85 reference to any acoustic observation, is reducible, as a sign, to the mere feeling or seeing its pulsations in an abnormal situation ; so, the displacement of the liver is reducible to the observation of a tumour in the right hypochondrium. Now, even supposing that the case was one of displacement of the liver, it will be shown that this might arise from other causes than empyema, to which it is com- monly attributed: intra-thoracic tumours may produce it. I have observed it from Laennec's emphysema ; it may occur from aneu- rism of the abdominal aorta, or from that of the hepatic artery ; and I need scarcely remark, that we may have hepatic tumours, inde- pendent of any disease of the pleura, and conversely, pleural effu- sion without this sign. These observations are sufficient to show, that displacements of the heart or liver cannot alone be looked upon as certain diagnostics of the lesion which has produced them. 3d. Signs derived from the inspection of the motions of the thorax during respiration. — I shall not occupy your time with any commentary upon this class of signs. The respiratory move- ments are so infinitely various in the different diseases of the chest, that we are not warranted in founding any certain diagnosis upon the observation of them alone. 4th. Signs referrible to the sense of touch. — This class presents to us several signs, which, as far as they go, lead to a greater de- gree of certainty than those in the preceding one. Yet, like the other physical signs, they only reveal to us, and that not constantly, mechanical conditions, without leading to the diagnosis of the na- ture of disease, or the pathological-state of the viscera. Thus, the bronchial vibration may occur from any liquid effusion into the tubes, and with various states of the lungs. The feeling of gurgling may proceed from a tuberculous, pneumonic, or gangrenous ab- scess, or from a dilated tube containing muco-puriform matter. The cause of the sensation of friction has not been sufficiently in- vestigated, but we know that the rubbing feel may arise in various states of the serous membranes; while that of non-expansion of parts of the lung will obviously be produced by many different causes. The cases in which the sense of touch leads us to most certainty in diagnosis are those of the diseases of the heart and great vessels; yet every practical man knows, that the most violent im- pulses occur without organic disease of the circulating system, while, on the other hand, extensive hypertrophy of the heart may exist with a natural impulse, and an aneurism of the aorta give no morbid pulsation. 5th. Signs derived from alteration in the shape and volume of the thorax. — In this class of signs we meet with some of considerable value; thus, the convexity of the chest in Laennec's emphysema, when carried to a great degree, is an appearance almost peculiar to the disease; and which, combined with the elevated shoulders and the hypertrophied state of the muscles of the neck, will scarcely mislead. But of the various partial dilatations and contractions there is no one at all pathognomonic : many of them may be con- 86 DISEASES OF THE RESPIRATORY APPARATUS. genital, or the result of former, and of various diseases. Thus, dila- tation of either side may arise from emphysema, pneumothorax, pleural effusions of various kinds, effusions into the pericardium, en- largements of the liver, or aneurisms of the aorta. An apparent dilatation, too, may exist, in consequence of the contraction ot the opposite side; and contraction itself may arise from a variety of morbid causes, or be a congenital conformation. 6th. Signs referrible to acoustics. — These have been hitherto di- vided into those obtained by percussion, and by mediate or immediate auscultation; a division which seems to be unnecessary, as both classes of signs, being appreciable by the ear alone, should be ranged under the general head of auscultatory phenomena. Under this head, therefore, we shall treat of percussion, and auscultation, whether mediate or immediate. Previous, however, to our entering on an investigation of their value as diagnostic means, we shall briefly describe the principles of these modes of diagnosis. It is plain, that we have acoustic phenomena referrible to a passive and an active state of the lung; in other words, to conditions, on the one hand independent of motion or life, and on the other, inseparable from them. The passive phenomena, or those of percussion, which relate merely to the quantity of air within the thorax, may be as well observed in the dead as in the living body ; while the active, or those of respi- ration, the voice, or the phenomena of the heart and arteries, imply motion and life. Hence, we may divide the phenomena of auscul- tation into those of the passive and active conditions. Passive Auscultatory Phenomena. — The great object of per- cussion is to determine the diminution or increase of the quantity of air within the thorax, or in certain portions of that cavity. It has been already observed that of the different cavities in the body, the chest is that in which the existence of air in quantity is a natural condition ; and it need scarcely be repeated, that in the normal state of the cerebro-spinal cavities, air, in a free state, is always wanting. We know, also, that when it occurs in any part of the abdomen, it is either the product of disease, of the fermentation of the ingesta, or of a secretion from the mucous surface, by no means constant in its occurrence or quantity ; but the chest is the great receptacle for air, and, from the first moments of extra-uterine life, contains a vast quantity of it. Upon this peculiarity does the employment of percus- sion depend, because, cceteris paribus, the sound on percussion is di- rectly as the quantity of air contained within the thorax. Now, the result of almost every organic disease of the lung or heart is to diminish or increase the capacity of the thorax for air, and consequently to diminish or increase the sound on percussion; bearing this in mind, we find that the greater number of thoracic affections tend to diminish the quantity of contained air, and con- sequently are accompanied by a proportional decrease of sound, while the smaller (very few in number) have the opposite effect and results. If we consider that the general result of most of the organic diseases is to cause impermeability of the lung, produced either by disposition within, or pressure without the organ, we shall PASSIVE AUSCULTATORY PHENOMENA. 87 see that the principle above stated holds good ; thus, in pneumonia, congestion, oedema, pulmonary apoplexy, tubercle, cancer, and hydatid of the lung, portions of the lung, more or less extensive, which had previously contained air, are now filled by a fluid or solid substance. Even in bronchitis we can have no doubt that the sound on percussion is diminished in proportion to the tumes- cence of the mucous membrane; a fact observed by Avenbruger in the exanthematous diseases. It is true, that the diminution of sound is generally so slight as to escape our means of detection ; yet that it exists even in the first stages cannot be doubted; and when secretion takes place to any degree into the bronchial tubes,, the diminution of the quantity of air can be generally detected by percussion. The same result is observed in all those cases of disease of the pleura or pericardium, in which a liquid effusion occurs. In these cases as in the former, we see a similar effect, though from a dif- ferent cause: namely, the obliteration of air-cells, the diminution of the quantity of air, and the occupation of its situation with reference to the thorax, by a medium giving a dull sound on percussion. The same remarks are applicable to enlargements of the heart, aneu- risms of the aorta, and organic tumours exterior to- the lung. Of those diseases, in which an increase of the quantity of air, and consequently an increase of the sound on percussion, are results, we have but two: namely, dilatation of the air-cells, and pneumo- thorax. It seems possible also, that an extremely anaemic state of the body, by diminishing the amount of the circulating fluid, may produce a morbidly clear sound on percussion, and that in this way we .may explain the extraordinary clearness observed in many phthisical patients, even though the lung contains considerable quan- tities of scattered tubercle. I shall now briefly recapitulate the principal thoracic affections, with reference to the result of percussion. First. Diseases causing a diminution in the sound on percussion. The different forms and stages of pneumonia, serous and san- guineous congestions, pulmonary apoplexy. Tubercle, cancer, melanosis, hydatids. Bronchitis in its first and second stages. All liquid effusions into the pleura and pericardium. Active and passive enlargements of the heart. Aneurisms of the aorta or innominata. Organic tumours of the mediastinum, pleurse, pericardium, or heart. Secondly. Diseases causing an increase of the sound on percus- sion, either partial or general. Dilatation of the air-cells. Hypertrophy of the lung. Pneumothorax, with or without fistula. Pneumopericardium. 88 DISEASES OF THE RESPIRATORY APPARATUS. Now, the great point, as connected with the applicability of per- cussion to diagnosis is, that these diminutions or augmentations oi the quantity of air being almost always partial, give consequently partial phenomena. A circumstance admitting of the application of comparison, which, as we have said before, is so important in physical diagnosis. For example, in the case of solidification of one lung, although, for the sake of argument, we may suppose that the quantity of air within the thorax is diminished by one-half; yet, it does not follow, that the sound on percussion of the whole thorax is proportionally lessened. For the healthy side retains its natural sound, or at all events gives a sound so little diminished as by. no means to inter- fere with the comparison of the healthy with the diseased lung. Again, in a case of incipient phthisis, the upper lobe of the lung is tubercular; yet, this diminution of the quantity of air does not affect the sound of the lower portions; and hence, a comparison between them can be established, and the disease be thus detected. Further, in a case of pneumothorax, or of partial dilatation of the air-cells, the increase of sound is only partially observed, the healthy portions giving less resonance on percussion: so that here, also, comparison can be established. lam aware, that, reasoning upon strictly physical principles, we should expect some diminution or increase of sound in the healthy portions; yet, if this does occur, the alteration is so slight as not to interfere with the facility of diagnosis, unless in extreme cases of disease. It is plain, that if such alteration occur, it will interfere more with the comparison of the parts of the affected lung among one another, than to that of the diseased with the healthy lung. LECTURE LVI. Active Auscultatory Phenomena — Sounds of respiration, of cough, of voice, and sounds of the heart and great vessels—Value of physical signs tested by comparison, on reference to feebleness and strength of respiration, the pheno- mena of voice, detection of foreign bodies in the bronchial tubes—Difficulty of diagnosis, of tubercle in deformed chest from previous disease—Combination of signs, particularly those drawn from percussion and the stethoscope__Signs considered with relation to time—Successive changes—Relation to symptoms —Insufficiency of mere physical diagnosis—Coexistence of morbid action in different tissues of the lungs ; as of bronchitis and pleurisy with pneumonia- illustration from tubercular consumption.—The three tissues—mucous, paren- ehymatous, and serous—are more or less affected in many acute, and in most of the chronic pulmonary diseases. Active Auscultatory Phenomena.— The principle of diagnosis, founded on these signs, is extremely simple. I may give the fol- lowing explanation of this principle: — The manner in which the stethoscope assists us in. detecting the rtate of the thoracic viscera can be explained in a very few words I he air, as it passes through the lungs in the acts of inspiration ACTIVE AUSCULTATORY PHENOMENA. 89 and expiration, the sound of the voice in different parts of the chest, and the impulse and sound of the heart at each pulsation, have all certain characters in the state of health. They present pheno- mena which are to be considered as standards of comparison. Now, every disease of the lungs and heart alters or modifies these cha- racters, according as the case may be; and it is by the knowledge of the morbid phenomena or deviations from the natural state, that we may judge of the state of the thoracic viscera. I need scarcely remark, that I do not maintain, that health im- plies an identity of phenomena in every individual; the signs in a child differ from those in an adult, those of the female from those of the male; and there are other cases of natural modification, but still, taking these circumstances into consideration, the active aus- cultatory phenomena of health have a sufficiently constant charac- ter to deserve the name of standards of comparison, and to be used as such. The active auscultatory phenomena may be classed as follows i. I. Sounds of respiration; — Tracheal. Vesicular. II. Sounds of cough. III. Sounds of voice. IV. Sounds of the heart and great vessels. Now, the effect of disease is twofold: it modifies these pheno- mena, and it gives rise to new and non-analogous signs; so that we have active auscultatory phenomena of health, — next, modifi- cations of these, produced by disease; and, lastly, entirely new active auscultatory signs, whose existence is solely the result of a diseased state: as, for instance, the different rdles; the metallic phenomena ; the rubbing sounds of the serous membranes; and the various murmurs of the heart and great vessels, &c. Having now given a short sketch of the sources of physical diagnosis, I shall announce the great principles that govern their application to the detection of disease ; these may be stated as follows: — First. That the value of most of the preceding signs, or of their combinations, in the determination of the seat, nature, or extent of disease, is to be estimated more by comparison with the phenomena of other portions of the chest, than by their mere existence in a particular situation. Second. That the greater the number of physical signs which can be combined in any particular case, the more accurate will our conclusions be. But of these combinations, the most important and indispensable is that of the passive and active auscultatory phenomena. Third. That the existing physical signs are to be considered in relation to the period of duration of the disease, and the rapidity or slowness of their own changes. Fourth. That in all cases, the value of physical signs must be 90 DISEASES OF THE RESPIRATORY APPARATUS. tested by the existing symptoms and previous history ; whi e, on the other hand, the observation of these physical signs enables us to correct the conclusions to which we would be led by the unaided study of symptoms. I shall first proceed to the elucidation of the principle of com- parison. This principle, which may be said to be the basis of phy- sical diagnosis, has not been sufficiently insisted on, either in the work of Laennec, or of any of the succeeding writers on ausculta- tion. Indeed, Dr. Williams is the only author who alludes to the subject (Rational Exposition of the Physical Signs of the Disease of the Lungs and Pleura). But even this author does not sufficiently insist on its paramount importance, and refers to it principally as connected with the use of percussion. " A person commencing the practice of percussion, will be guided more safely by the compara- tive than by the absolute sounds of different parts of the chest; and although he should lose no opportunity of acquainting himself with the sounds, both of percussion and auscultation, in healthy subjects, he should, in case of disease, more particularly at first, direct his attention to irregularities or want of correspondence of the two sides in the same subject. In instituting this comparison, he should be careful, likewise, to practise percussion on corresponding parts of the two sides, and with such an attention to the manner in which his fingers fall, and, if he uses the digital pleximeter, the manner in which this is placed, that any difference of sound may not arise from these fortuitous circumstances." But the principle of comparison must be applied to all the means of physical diagnosis, and must never be lost sight of, either by the tyro or the most practised investigator of disease; for, as will be shown, it is the only mode of avoiding error. We have already seen how beautifully the anatomical structure of the thorax favours the application of this principle; the organs in this cavity being more remarkably and completely separated than those of the cranium or abdomen. From this circumstance two important consequences are derived: first, the facility of compa- rison of the different portions, and next, the circumscription of disease. Let us now take some examples of the value of comparison. Feebleness of respiration occurs in many diseases of the lung. Now, suppose we are called to examine a patient with symptoms of incipient phthisis, we may find the vesicular murmur under the clavicle exceedingly feeble, a character of common occurrence in cases of tubercular disease; yet, if from this alone we were to con- clude that tthe case was really phthisis, we might be altogether wrong, for many persons have a naturally feeble respiration over the whole chest. In such a case, the sign of feebleness of respira- tion under the clavicle might be of no value, for it would be only the natural character of the respiratory murmur. But suppose that, in another case, we found the same feebleness of respiration m the same place, and, not content with this superficial examina- COMPARISON OF AUSCULTATORY PHENOMENA. tion, we explored the opposite side, and found the respiration there unusually loud, then, indeed, the feebleness of respiration would become a sign of positive value ; because, under such circum- stances, experience tells us that, in most cases, it is actually pro- duced by tubercular development. Thus, in this instance, the sign derives its whole value from comparison. Let us now take the opposite case : there is a character of re- spiration termed puerile, from its resemblance to that of children, and which commonly occurs in cases where some other portion of the lung has been disorganised. But the mere circumstance of hearing puerile respiration in one portion of the lung, is by no means a conclusive proof of the existence of disease in some other part, for, in certain cases, the respiration is universally puerile, independent of any disease; it is only the coexistence of puerility in one portion, and feebleness in another, that gives any value to the sign; in other words, it is by the test of comparison that its value must be estimated. The same observations apply to the phenomena of the voice. An increased resonance of the voice is a common sign of solidity of the lung, but one of no value, except by comparison, for many persons present a natural bronchophony over a large portion of both lungs. But, where the resonance is loud and distinct in one lung, and either wanting, or much less intense, in the corresponding portion of the opposite one, it then becomes a sign of decided value. I might also extend this to the sign of pectoriloquism, about which such a quantity of error is extant. Some persons are naturally pectoriloquous in the upper portions of the lungs; and it is plain that, in such cases, the discovery of the phenomenon under the clavicle, er over the shoulder of one side, might lead to great error unless tested by comparison. The following is an important and common illustration of the value of comparison. A patient presents the symptoms of cough, muco-purulent expectoration, accelerated breathing and pulse, emaciation, and hectic. Under these circumstances, we detect a mucous rattle in the subclavicular region ; a sign which, when properly estimated and corrected, may lead to an almost positive diagnosis of phthisis, with softening of the tubercles. Now, if, in a patient labouring under the above symptoms, we were to con- clude, from the mere existence of this sign in this situation, that the case was really phthisis, we might fall into error, for a compa- rative examination of the different portions of the chest might show that the rdle was universal; a discovery which would greatly diminish its value as a sign of phthisis, and leave a probability that the case was one of bronchitis, with copious effusion into the smaller tubes. In such a case, the value of comparison is obvious. On the other hand, the existence of rdle, either under one or both clavicles, while the inferior portions remained free, would, when occurring with the symptoms described, be a most important diagnostic of phthisis. 92 DISEASES OF THE RESPIRATORY APPARATUS. Comparison must be used in determining the value of the modi- fications of the original active phenomena, as well as that ot the new or non-analogous signs. A good example of this is seen in the detection of foreign bodies in the bronchial tubes; for it is prin- cipally by the comparison of the respiratory sounds in both lungs, that the diagnosis of a foreign body can be arrived at. I may also observe that, in certain cases of aneurism of the aorta or innomi- nata, it is by a comparison of the respiratory murmur, in either lung, that the existence of the tumour at an early period can be detected. We get a good idea of the value of comparison by reflecting that the cases in which diagnosis is most difficult are those in which the phenomena are the same over the entire chest. There are two cases of phthisis in which physical diagnosis is extremely difficult; the one an acute, the other a chronic case ; yet, in both of which, the tubercle is equally and universally developed in both lungs, and, consequently, similar phenomena being given by all parts of the chest, the diagnosis, by comparison founded on the localisation of disease, becomes inapplicable. The same remarks apply to the case of double empyema, in which we lose the advantages that the comparison of the differences between the physical phenomena of either side gives us in single pleurisy ; and also to that of double and equal dilatation of the air-cells, the detection of which must depend on the direct signs, and history of the case. One of the most striking instances of the difficulties which arise when the application of comparison is fallacious, is that of the development of tubercle in a patient whose chest has been deformed from previous disease. Patients who have recovered from em- pyema with a contracted side, are liable to tubercular development, and the stethoscopist may be called to determine the question as to whether tubercle exist or not. I have been more than once in this situation, and believe that a more difficult case for diagnosis can hardly be met with. The symptoms will seldom afford any assist- ance, as they may proceed either from incipient phthisis, or be those commonly present during the convalesence from empyema. And, in consequence of the previous disease of one pleura, and the contraction of the chest, we are deprived of the advantages of com- parison of the phenomena of both lungs, by the stethoscope and percussion. Thus, if we find the side originally affected to be duller than the other on percussion, this may be explained either by the diminished volume of the lung, or by the development of tubercles. The same difficulty exists in the observation of respira- tion, and the phenomena of the voice. But if the opposite lung be the seat of tuberculous disease, we may detect the affection in its early periods; yet, in a remarkable case that I lately saw, and in which, after a comparatively rapid recovery from empyema of the left side, tuberculous disease set in; all the stethoscopic signs indi- cated disease in the left lung, and not in the right; and yet, on dissection, the right lung was found full of miliary and granular COMPARISON OF AUSCULTATORY PHENOMENA. 93 tubercles, while the left contained scarcely any. Of this, the pre- ceding considerations afford an easy explanation. The left lung was dull on percussion, from its diminished volume; for the same reason its vesicular murmur was feeble, while, in the right, the disease had not become sufficiently extensive to cause a greater dulness, or even an equality of sound. It is plain that, under these circumstances, a greater amount of disease in the right lung would be required to lead to its detection than in a case where the opposite lung had not been previously affected by empyema. Independent of the importance of the principle of comparison, its practice in all cases is of the greatest utility, by leading to the discovery of lesions which would otherwise escape us. I remember being called to see a patient, who had received an injury of the side, and who was labouring under fever, cough, expectoration, and dyspnoea. His attendants had examined him repeatedly with the stethoscope, and discovered nothing but bronchitis. I had him stripped, and found the phenomena of empyema and pneumothorax in the lower part of the right lung ; his attendants had examined the upper part of the chest carefully, but had neglected the lower, and thus the true nature of the disease had escaped them. With respect to the heart, it is evident that the diagnosis, by comparison of signs with one another, is not so applicable as in the lungs. We are forced, in many cases, to depend upon the charac- ters of isolated phenomena ; and hence the difficulty which attends the detection of diseases of the heart may be in part explained. If we consider the heart as a single organ, it is plain that we have no standard for comparison, and the same observation applies if we take it as a double organ ; for the arterial and pulmonary hearts have original differences, whether anatomically or physiologically considered. Yet, comparison is not wholly inapplicable in cases of diseases of the heart. By it, we may often determine the seat of disease, if not its nature; we also find it applicable in the diagnosis of certain cases of aneurism of the great vessels. We now proceed to consider the next principle of physical dia- gnosis ; namely, the combination of signs, and, in particular, those drawn from percussion and the stethoscope. For example: a patient is affected with stridulous breathing, and by percussion we discover that one clavicle is decidedly dull. This proves that there is in that situation a diminution of the normal quantity of air — a condition generally produced by either pulmonary solidity, or by displacement of the lung from an aneurismal tumour. Here, to determine the important question as to whether the case be disease of the lung or aneurism, the em- ployment of. the stethoscope becomes absolutely necessary. We must correct the passive by the active signs. Again : suppose that we detect feeble respiration in any portion of the lung, we have a character which may be produced by essen- vol. 11. — 9 94 DISEASES OF THE RESPIRATORY APPARATUS. tially opposite states of the pulmonary tissue ; in other words, b> an increased or a diminished quantity of air. Percussion must be used to correct the stethoscopic observation. The active signs are to be corrected by the passive. . A patient has presented, for some time, decided dulness of the upper portion of one lung, and we find, subsequently, that this por- tion regains its sound. Now, this circumstance may be produced either bv the formation of a cavity, or by the return of the lung to its healthy state. Here the observation of the active signs is neces- sary to determine the value of the passive. A patient has presented the sign of friction, or the rubbing sound produced by the inflamed state of the serous membrane; and, after a time, this active phenomenon is observed to disappear, which may result either from the cure of the disease, or the separation of the layers of the pleura or pericardium, by a liquid effusion. To deter- mine the point, we must have recourse to the observation of the passive phenomena. If it be the former case, percussion will give a clear, if the latter, a dull sound. In the case of a foreign body in the trachea, or the pressure of an aneurismal tumour on one bronchus, we may observe either complete absence or great diminution of the respiratory murmur in either lung. This modification of the active auscultatory phenomena, for its value in the diagnosis of aneurism, depends entirely on the result of percussion, as we shall see hereafter. It is only by the combination of these two classes of signs, that we are able to arrive at the diagnosis of a rare, but most important disease, namely, acute general development of tubercles, with bron- chial irritation. In many of these cases, stethoscopic observation can only detect intense bronchitis; and, without the aid of percus- sion, no other diagnosis could be arrived at. Now, acute bron- chitis may exist with apparent clearness of sound ; but if, in such a case, we observe an increasing and decided dulness of the chest, the diagnosis of a general development of tubercle may be often safely arrived at. Many more instances, illustrative of the necessity of this and other combinations, might be given. I may, however, add one more common example. A patient has been attacked with symp- toms of inflammation of the lung, and at an advanced period we find the affected side completely dull on percussion. This may arise either from a pleural effusion or a solidification of the lung, and the observation of the active phenomena will be necessary to determine the question. Thus, the passive and active auscultatory signs mutually correct each other; yet even their combination with all other classes of signs will be insufficient, if the history and symptoms of the case be not accurately considered and compared with them. In other words, it is not enough to compare one set of signs with another, but all the signs, whether acoustic or not, with the history and symptoms. Let us next consider the physical signs in reference to the DURATION OF PHYSICAL SIGNS. 95 duration of the disease, and the rapidity or slowness of their own changes. A patient, previously healthy, is attacked with inflammatory symptoms and pain in the side. Now if, in the course of twenty- four hours, we find the affected side dull on percussion, a strong probability exists that the case is one of effusion into the pleura, rather than hepatisation of the lung. Let us, on the other hand, suppose that the symptoms have continued for a week or ten days, and that, at the end of that time, we find the sound clear on per- cussion, then, at all events, we may conclude, that the case is not pleurisy with effusion, or hepatisation of the lung. It may be dry pleuritis, pleurodyne, or bronchitis. We discover the signs of a cavity in any portion of the chest. Now, the determination of the nature of that cavity will depend much on the history of the patient. If he has been in good health, and free from pulmonary symptoms, up to within a week or fort- night of the time when we have first examined him, the great pro- bability is, that the cavity is not tuberculous. It may be a pneu- monic or a gangrenous abscess. On the other hand, if the case has been chronic, in the ordinary acceptation of the word, the chances are, that the cavity is tuberculous. Let us suppose that we discover an extensive gurgling over the upper portion of one side, and that the question arises, as to whe- ther this is caused by an anfractuous phthisical cavity, or by dilated tubes. Here, along with other sources, the period of the continu- ance of the symptoms is a most important element in settling the question. If the patient has had similar symptoms for five, ten, or fifteen years, the chances are, that the case is one of dilated tubes; but if his symptoms have continued only for three or six months, then it would be almost certain that the signs proceeded from a multilocular phthisical abscess. It would be easy to show, that many other diagnosis are founded on the connection of the actually existing physical signs with refer- ence to the period of continuance of symptoms. I may enumerate a few of these : — Foreign bodies in the trachea. Acute general development of tubercle. Laennec's emphysema of the lung. Certain cases of empyema and pneumothorax. Hydrothorax. Nervous palpitation of the heart, as distinguished from organic disease. Pericarditis with effusion. Rupture of an hepatic abscess into the lung. Sympathetic cough. — This example, perhaps, requires some explanation. We may find, in a case where violent cough has existed, either that there is no physical sign of disease, active or passive; or that, if there be, the signs are insufficient to account Q6 DISEASES OF THE RESPD1ATORY APPARATUS. for the symptoms. Now, these circumstances may arise either from incipient organic disease, or from mere functional lesion. If the symptoms have continued for a considerable length of time, the great probabilities are, that the case is one of original, or symp- tomatic neurosis of the lung. The above instances are sufficient to show the application of the principle of combination of the history of the case, quoad the period of duration of symptoms, with the actually existing physical signs. But we must go farther, and consider these signs with reference to the rapidity and slowness of their own changes. Perhaps the most interesting source of physical diagnosis is drawn from considering the signs, with reference to their permanence for certain periods, and the mode and order of their successive mani- festations. One of the best examples of this is seen in the case of dilated tubes. It may be often difficult to pronounce whether the signs of an excavation proceed from a phthisical cavity, or from dilated tubes. Now, as a general rule, it may be stated, that the extension of the cavity is much more rapid in the former than in the latter case; and from this we derive the following rule; that if, in any instance, we can recognise a rapid extension of a cavity, the case is not one of dilated tubes. If, in the course of a fortnight, or a month, the stethoscope indicates a decided increase in the size of the excavation, we recognise an ulcerative extension, rather than that almost imperceptibly slow process by which the bronchial tubes become dilated so as to simulate abscess of the lung. Again, we may experience difficulty in determining whether a patient labours under an enlargement and valvular disease of the heart, or an aneurism of the ascending aorta. I have seen several of such cases, in which I at first suspected an aneurism ; as much, if not more, from the history and symptoms as from the signs; but in which my suspicions were converted into certainty, from observ- ing that the extension of the signs of dulness, pulsation, and the accompanying murmurs occurred much too rapidly to permit the supposition that they proceeded from a-further enlargement of the heart itself. In the case of a foreign body lodging in the right bronchus, we have another excellent example of this source of diagnosis: the sudden suspensions and reappearances of the respiratory murmur in the affected lung, while the sound on percussion remains clear, point out sudden alterations of the conditions of permeability and impermeability in the corresponding bronchus. And it is scarcely necessary to observe, that these are circumstances only explicable on the supposition of a moveable foreign body existing in the tube. Indeed, in the mode of succession of the various signs in°the different thoracic diseases, we have a source of diagnosis of such importance, that it seems not impossible but that future investigation will show that it is in this department we are to seek for the perfection of phy- sical diagnosis. For in many instances we find, that in different SYMPTOMS WITH PHYSICAL SIGNS. 97 diseases the characters of the signs are identical, but their modes of succession are constantly and characteristically different. For example, oedema of the lung presents a crepitating rdle, often undistinguishable from that of pneumonia, as far as its phy- sical characters are concerned ; but successive observations may determine the point. In oedema, the dropsy of the lung causes no further organic change, and the crepitus consequently persists, with little or no change, for a length of time, the sound on percus- sion remaining the same. On the other hand, there exists in pneu- monia a cause which produces successive and important modifi- cations in the structure of the lung; and, accordingly, we find corresponding changes in the physical signs. The crepitating rdle by degrees masks the vesicular murmur, and, as the congestion advances, gradually disappears, until impermeability of the cells and finer tubes is produced. We have then dulness of sound and bronchial respiration. But the changes do not stop here, for the lung may pass into suppuration, or return to health; in either of which cases, important changes in physical signs take place. In these successive changes, then, is founded the physical dia- gnosis between pneumonia and oedema. I may here remark, as illustrative of the importance of studying the mode of succession of signs, that although there is no single sign in pneumonia which is pathognomonic, the possibility existing of every one of them arising from other causes; yet we know of no other disease which presents, in its progress or resolution, the same mode of succession of phenomena. I have already stated, that no possible combina- tion of signs can be considered as absolutely pathognomonic. The observations just now made are by no means contradictory of this, as they apply not to any existing combination, but to the successive developments of physical phenomena. I might adduce many other instances of this mode of investiga- tion, but enough has been stated to explain the principles. The preceding observations strongly illustrate one of the most important principles connected with the science of thoracic disease, namely, that it is not enough to be able to recognise, nicely distinguish, and remember signs, but that we must know how to reason upon them. Here we see the fusion of the mechanical and the patho- logical parts of the science, learn their mutual dependence, and find why it is that the mere auscultator, or the mere symptomatologist, can never excel in the diagnosis of diseases of the chest, I sluill now, in conclusion, briefly allude to the absolute necessity of studying the symptoms in relation to the physical signs. It is true that the mere observation of certain physical signs may, under particular circumstances, lead us to conclusions probably correct, but the object of medicine is certainty. The existence of gurgling and cavernous respiration under the clavicle, tells of a cavity communicating with the bronchial tubes, and containing air and liquid ; -in other words, of an abnormal physical chano-e : so far 9* JJS DISEASES OF THE RESPIRATORY APPARATUS. we have certainty. For the relative frequency of its causes, we might say that the cavity was probably phthisical, but the possi- bility would exist of its being a dilated tube, a pneumonic, or a gangrenous abscess. . Again, the occurrence of metallic tinkling, and amphoric reso- nance, points out the presence of a vast cavity communicating with the bronchial tubes, and containing air and liquid ; and in like manner, from the comparative frequency of its. cause, we might conclude that the case was probably an example of empyema, pneumothorax, and fistula; but on the other hand, these pheno- mena may occur from an essentially different pathological condition of the lung; nay, further, we shall find, that some of the metallic phenomena may arise from sources altogether external to the thorax. Let us take a few more examples, illustrative of the insufficiency of mere physical diagnosis. It is commonly held by those who are but partially acquainted with auscultation, that the crepitating rdle is a sign of pneumonia ; that it is so is true, but in some of its forms it may occur in other affections. Let us suppose that we are called to a patient whom we have never before seen, and, with the history of whose case, or his present symptoms, we are ignorant, and that on applying the stethoscope to the postero-inferior portion of the right lung, we discover a crepitating rdle, we have then a phenomenon which may be produced by many essentially different causes ; and were we to make the diagnosis of pneumonia, our opinion would rank nothing better than a mere guess. Among its various causes, the phenomenon might be produced by the follow- ing : acute pneumonia in the first, the suppurative, or the resolu- tive stage ; chronic pneumonia, congestion, cedema, mucous catarrh, tubercle, hepatic abscess opening into the lung, pulmonary apo- plexy. Now, supposing that these were all the possible causes of the phenomenon, and that their occurrence was of equal frequency, and that, without an accurate investigation into the history and symptoms of the case, we concluded that its cause was an acute pneumonia in the first stage, there would be nine chances to one against our guessing right. But if this crepitating rdle was ob- served in a patient who had been but twenty-four or forty-eight hours ill, and had previously no symptoms of"pulmonary disease; if he had inflammatory fever, pain of the side, cough, acceleration of breathing, and viscid expectoration, we might safely conclude that its cause was an acute pneumonia in the early stage. Again, if it occurred in a patient who had been attacked some days before with the constitutional symptoms of pneumonia, which had sub- sided after judicious treatment, and in whom there had been pain of the side which had disappeared; bloody and viscid expectora- tion, which had been succeeded by a clear or concocted mucus; dulness of sound and bronchial respiration, which had subsided or was diminishing; we might safely conclude, that the rdle was an example of Laennec's crepitus of resolution. Lastly, if it occurred AUSCULTATION NOT EXCLUDING SYMPTOMS. QQ in a patient in the advanced stages o( pneumonia, in whom the powers of life were sinking, who had the prune-juice sputa, or was expectorating a yellow purulent matter, and in whom the affected portion of the chest sounded absolutely dull and with distinct bron- chial respiration, we might safely declare that the lung was in the third or suppurative stage. It is true, that differences in the character of the sign in these different stages may exist, and be ap- preciable ; but my experience leads me to the firm belief.that in test- ing the value of any sign we are to look more to the history of the case, and the accompanying physical and vital phenomena, than to its absolute character. Here, I am anxious not to be understood as depreciating the importance of studying the actual characters of physical signs. On the contrary, I am convinced that the more the ear is accustomed to appreciate minute differences of sound, the greater will be our accuracy in detecting the nature of disease. But while I do not deny the possibility of training the sense of hearing to such a pitch of accuracy as that from the character of sounds we may yet, in certain cases, infer the vital cause of phe- nomena, I feel that this perfection is not easily attainable, and, at best, can be enjoyed only by the few. And it must never be for- gotten, that disease occurs under infinitely numerous modifications, so that the result being the same, the physical phenomena may not be absolutely similar. Again, we meet, under the same circumstances, a patient with feebleness of respiration, and dull sound on percussion in the same situation : this may depend on inflammatory, tubercular, or can- cerous solidification of the lung, pulmonary apoplexy, empyema, hydrothorax, contraction of the chest from a former attack of pleuritis, enlargement of the liver, pushing up the diaphragm, ascites, and aneurism of the aorta. Here the same observations as in the former case evidently apply. The same train of argument is applicable to most of the other classes of physical signs, as will be abundantly shown when I come to speak of the diseases in particular. It has been objected to the advocates for the stethoscope, that they discard the consideration of symptoms, and that, throwing overboard all the knowledge we possessed previously to the intro- duction of auscultation, they pretend to ascertain the existence of all diseases of the chest by the sole observation of physical signs. There is only one answer to be made to this objection— namely, that it is wholly groundless; indeed, those who make it only betray their ignorance of the subject. Laennec never taught that auscul- tation could supersede the mode of examination by symptoms ; on the contrary, he devotes a considerable portion of his work to their history and analysis, and, in many places, especially insists on the necessity of their careful study. He gives instances where the physical signs having been accurately observed, the history and symptoms of the case were alone to determine the nature of the disease: thus, in describing a case of dilatation of the bronchial 100 DISEASES OF THE RESPIRATORY APPARATUS. tubes, he states that the physical signs allowed of two suppositions — either that of an extensive dilatation of the bronchial tubes, or of a multilocular phthisical excavation ; — " I determined, however, on the first diagnosis," says Laennec, " from the general state of the patient and the history of the disease." Andral, who is the second writer on auscultation, devotes a large portion of his work to the examination of symptoms ; so do Louis, Bertin, Forbes, Duncan, Elliotson, Hope, Williams, and all other writers of any authority on the subject. It is true, that combinations of physical phenomena may some- times arise, which would lead to a great degree of probability, indeed almost a certainty in diagnosis. A patient with a dilated side, giving morbid clearness on percussion, with the sound of fluc- tuation on succession, and in whom also the stethoscope detected the metallic tinkling, &c, might be said, with almost positive cer- tainty, to labour under empyema, pneumothorax, and pulmonary fistula;.but such cases, or those analogous to them, are compara- tively rare; and, even in the case in question, the cause of the fistula would be undetermined. In the cases we are every day called to treat, the value of physical signs must be tested by the history and symptoms, and these in their turn must be corrected by the physical signs. Whoever neglects either source or informa- tion will fall into the most fatal errors. We must have recourse to the assistance of each and every one of these means ; and even still, with all this combined knowledge, we shall meet with cases, the real nature of which is involved in the greatest obscurity. Indeed, when we reflect on the infinite complications of disease, modified by circumstances infinitely numerous, it would be strange if such did not arise ; and there can be no doubt, that if our means of diagnosis were extended one hundredfold beyond their present state, the same circumstances would still occur. Physical signs form an addition, constitute an assistance to diagnosis, but nothing more; yet of their value every impartial mind must be convinced, who compares the state of our knowledge previous and subsequent to their discovery. It is on the discovery, explanation, and con- nection of these signs with organic changes, and with the symp- toms and history of the case, that Laennec's imperishable fame is founded. Time has shown that his principles of diagnosis were not the bagatelle of a day, or the brain-born fancy of an enthusiast, the use of which, like the universal medicine, was to be soon for- gotten, or remembered only to be ridiculed ; it has shown that the introduction of auscultation, and its subsidiary physical signs, has been one of the greatest boons ever conferred by the genius of man on the world. A new era in medicine has been marked by a new science, depending on the immutable laws of physical phenomena, and, like other discoveries, founded on such a basis, simple in its application and easily understood. A gift of science to a favoured son: not, as was formerly supposed, a means of merely formino- a useless diagnosis in incurable disease, but one by which the ear is MORBID ACTION IN DIFFERENT TISSUES. 101 converted into the eye; the hidden recesses of visceral disease opened to the view ; a new guide in the treatment, and a new help in the early detection, prevention, and cure, of the most widely spread diseases which afflict mankind. In conclusion, I would refer to one of the most essential points as bearing on the diagnosis of chest disease — namely,the coex- istence of morbid action in the different tissues or structures of the lung. In a practical point of view, the lung may be considered as consisting of three different parts or tissues. We have, in the first place, an extensive mucous expansion, forming the internal or lining membrane of the lung, and which may be described as com- mencing at the rima glottidis and terminating in the air-cells. We have next these air-cells, and their connecting cellular tissue, form- ing, with their bloodvessels, what is called the parenchyma of the lung; and, lastly, we have its external serous covering, the pleura. From this division authors have arranged pulmonary affections into those of the mucous membrane, those which involve the air- cells and intervesicular cellular tissue, and, lastly, those affecting the serous covering. Under the first, they class the different varie- ties of laryngeal,tracheal, and bronchial disease ; under the second, such affections as pneumonia, tubercle, pulmonary apoplexy, &c, &c.; and under the third, we have the different forms of pleuritic inflammations, and the various effusions into the cavity of the pleura. This division, though convenient in the writing of systems, and to a certain degree applicable in the practice of medicine, is found to fail when we accurately consider the symptoms and pathology of thoracic disease. In many cases, indeed, do we find it impos- sible to draw the line of distinction between the affections of these different elements, for not unfrequently the diseased action extends more or less to them all. We have bronchitis combined with pneu- monia, pneumonia complicated with pleuritis, and very frequently the three lesions coexist: an observation which applies both to the acute and the chronic diseases of the lung. In the treatment of pulmonary affections it is of the utmost importance to bear this principle always in view. For example, in almost every instance of acute pneumonia there is bronchitis also,a circumstance never to be forgotten in the treat- ment and progress of the case. For in many instances, after the relief of the pneumonia, properly so called, we have to contend with an extensive and severe bronchial inflammation, which, if un- relieved, may cause the death of the patient. And the importance of this is further shown, if we recollect that the mode of treatment of the two cases is not the same, and the source of danger and the effects on the economy totally different. But the complication with bronchitis is not the only one to which such a case is subject — for disease of the pleura is perhaps as fre- quent, from whence the term pleuro-pneumonia, one applicable to the great majority of cases. It is true, that the pleuritic inflamma- 102 DISEASES OF THE RESPIRATORY APPARATUS. tion is generally of the dry kind, and hence of less importance; but the reverse may occur, and a purulent effusion, or a serous collec- tion, form in the cavities of the pleura; so that in certain cases the practitioner, ignorant of these facts, might suppose that he was contending with hepatisation of the lung, when in truth his patient was labouring under empyema or hydrothorax. Again, let us consider the ordinary case of tubercular consump- tion. Were we to confine our ideas of this affection to the mere growth and suppuration of tubercles, we would have indeed a most limited and erroneous view of the disease. For in this affection we have not only tubercle in every stage and form, but also the extension of disease to all the tissue's of the lung. Many varieties of pneumonia may occur—and the disease in the abstract is a com- mon complication, producing the most important modifications in the symptoms and progress of the case. If we consider the mucous membrane, we shall find the same remarks to apply ; many cases appear to commence by bronchitis, and in their progress the state of the mucous membranes comes to be of the utmost importance. Every form of disease may, and commonly does occur, and bron- chial secretion is frequently the chief source of the wasting expec- toration. If we now examine the serous membrane, we find evidence of extensive disease. In the great majority of cases, adhesions — sometimes so complete as to obliterate the whole sac—thickenings, effusions, or even ulceration with a fistulous communication pass- ing inwards, are common occurrences. This frequent complication of pleuritis in consumption, as we shall find hereafter, may be con- sidered as a great good, for, in many cases, it may be looked on as one of the processes of nature towards bringing about a cure. It may be laid down as a general principle, that in many acute, and in almost all chronic affections'of the lung, we find these three tissues more or less engaged. In one case the disease predominates in the bronchial mucous membrane; in another, in the parenchyma ; in a third, in the pleura ; yet still the principle will be found very generally true, and its practical application is sufficiently obvious. But as, in the present state of our pathological knowledge, we must admit that cases are to be met with in which disease seems to be confined to a single tissue—and further, that, even in the compli- cated cases, disease may be traced as commencing in one tissue and then extending to another—it becomes convenient to study the affections separately ; and experience shows that the principles of treatment should vary according to the isolation or predominance of irritation in any of these three essential elements. Now, the knowledge of these facts is of the utmost importance to the student of physical diagnosis, and will remove many diffi- culties which must otherwise occur in the course of his investiga- tions. Thus, in a case of bronchitis, he will be prepared to meet with dulness of sound on percussion, resulting from an accom- panying congestion of the vesicular structure, or the sound of ERYTHEMATIC LARYNGITIS. 103 frottement from the deposition of lymph on the pleura, or even aegophony from a slight liquid effusion. Nor will he be surprised or puzzled, if, in a similar case, the signs of a pneumonia or a hydrothorax should supervene. In a case of partial pneumonia, the existence of a sonorous or sonoro-mucous rattle in the other portions of the lung will not embarrass him. He gives to the first case the denomination of bronchitis, because he finds that irritation predominates in the mucous membrane; and although there may be signs of sanguineous congestion, or even of pleurisy, yet these seem of comparatively little importance, and their treatment may often be merged in that of the prominent inflammation. On the other hand, these may become sources of danger, and for this he is prepared. So also in the case of pneumonia — the extent and cha- racter of its proper signs enable him to recognise the disease, even although more or less of bronchitis or pleurisy may coexist. The same observations will apply to the diseases of empyema and phthisis; in the first of which the signs of bronchitis so commonly occur, and iiUhe second, where there is scarcely a physical sign of • pulmonary disease that may not arise. LECTURE LVII. DR. BELL. Division of diseases of pulmonary organs.—Erythematic Laryngitis—Gene- ral mildness of the disease and simplicity of its treatment—Catarrhal La- ryngitis—chiefly dangerous in infants—Its treatment—Acute (Edematous or Sub-mucous Laryngitis—A most formidable disease—Its symptoms—Re- spiration and deglutition both affected ; and afterwards the cerebral functions —Duration—(Edema of the glottis not a separate disease—Two varieties of acute laryngitis established by Cruveilhier—Is not of frequent occurrence— Treatment actively and speedily antiphlogistic—Venesection—General Wash- ington's case—Leeches to the throat, or cups to the nucha—Blisters—Tartar emetic with small doses of opium—Calomel and opium—Early recourse to la- ryngotomy—Mortality from active laryngitis. I shall follow the division of the diseases of the pulmonary organs laid down by Andral, viz., into, 1, those which are seated in and primarily and chiefly affect the air-passages; and 2, those of the vascular and parenchymatous structure in which hematosis takes place. In the first section we have the diseases of the larynx, both acute and chronic ; which, again, may be inflammatory or nervous ; and, if the former, may be accompanied by an erythema or a tumefac- tion of the mucous membrane of the part, or by the secretion of mucus or of pus, or the formation of false membranes. Simple erythematic laryngitis is the mildest of all the forms of inflammations of this organ. Its causes are external and internal. The former are sudden variations of temperature; breathing air in 104 DISEASES OF THE RESPIRATORY APPARATUS. which irritating molecules are suspended ; throwing open the neck, which had been habitually covered, to a cold air. Of the internal causes we find enumerated fatigue of the larynx in protracted and loud singing and speaking. Sometimes it supervenes on the dis- eases of other organs, and by simple continuity of tissue, as we see in inflammation of the pharynx or of the bronchia, or sympathy as in gaslro-enteritis. It is sympathetic, as in measles, in which the same inflammatory congestion is present in the conjunctiva and the bronchia. It also shows itself in small-pox and in erysipelas. Erythematic laryngitis is sometimes preceded by a feeling of general discomfort; sometimes by fever: and again it makes its attack suddenly, and manifests itself by a pain in the larynx, which may be slight, or of a more acute nature, augmented when the patient speaks or coughs, or when the larynx is pressed on. The voice looses its force, is changed in character, and hoarse. Deglu- tition is painful, and the cough is harassing by its frequency and dry- ness. After a while some mucus tinged with blood, and more fre- quently opaque, is excreted. When the inflammation is slight, it is not accompanied by any notable symptom; but when it is intense, the innervation may be so profoundly disturbed as to mask the evidences of the local disease. This last is an occurrence common in nearly all the anginose affections, and should be borne in mind by the physician when he is called upon for his prognosis. The patient when questioned will often reply that he feels no pain: he is dis- inclined to speak, and dozes much. The treatment of the milder cases of this form of laryngitis is very simple; consisting in tepid mucilaginous drinks, a mild purge, followed by warm pediluvium. But if the inflammation be more acute, blood should be drawn from the arm; and if relief does not soon follow, leeches must be applied to each side of the larynx, from oppo- site the os hyoideus to the thyroid cartilage. There will be risk of the inflammatory afflux being increased, unless the leeches are in sufficient number to act decidedly on the injected mucous mem- brane, by the abstraction, from its minute and capillary vessels, of a sufficient quantity of blood. Mild counter-irritation will follow, if necessary, and a mercurial purge. Sometimes, though rarely, this disease may be converted into bronchitis, or into another kind of laryngitis, or become chronic, and give rise to laryngeal phthisis: hence, though it is never to be neglected, it demands more especial attention in those who have had laryngitis before in any form, or who are predisposed to phthisis. The expression — < it is only a slight cold or sore throat,' is a foolish, and has been often a destructive remark, by lulling suspicion of danger, and preventing the requisite remedial means from being adapted. Catarrhal laryngitis, little different from the preceding, is caused more directly by atmospherical changes, sometimes of an epidemic nature, and suppressed perspiration. Its treatment is the same as that of the erythematic variety, with the difference that more benefit is obtained by the administration of an emetic. This ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 105 remedy is the more necessary in the catarrhal laryngitis of infants who are unable to throw off the accumulated mucosities in the wind- pipe, and are in imminent danger of suffocation in consequence. Here is an instance of the importance of removing an effect which may be more perilous than the cause, or inflammation of the mucous membrane itself. Derivation by purgatives is also advisable in this case ; and if the principle be admitted, we should select those which most excite to increased secretion the mucous follicles of the intesti- nal canal. Calomel, therefore, with aloes or rhubarb, will be pre- ferable to the saline purgatives, which often excite excessively with- out their exerting a good effect on the laryngeal disease. The common cough mixtures are of very doubtful efficacy in laryngitis, since they contribute to increase the»secretion of mucus without a corresponding augmentation of ability to throw it off. Free expec- toration, by which the bronchia are cleared, will not suffice for the laryngeal tube without additional efforts of a voluntary nature, which children cannot make, or rather will not, because they do not understand the necessity and use of the measure. Counter- irritation, by stimulating liniment rubbed on the neck, or even a small blister over the part, is at times called for, in cases of con- tinued and excessive secretion of mucus in the larynx. Acute (Edematous or Sub-mucous Laryngitis. — A more for- midable variety of laryngitis is that called cedematous, which should be regarded as an aggravated degree of the erythematic. (Edematous ought not in propriety to designate this more violent stage of inflammation of the larynx—the effusion in the sub-mu- cous cellular tissue being only an effect of the inflammation. Acute laryngitis in this degree is one of the most alarming and intractable diseases which we are called upon to combat. It is more frequent in adults than in children. Sometimes it begins with the symptoms of cynanche tonsillaris. Soon, however, its diagnosis is rendered evident by difficult and even laborious inspiration, accompanied with stridor and hissing sounds, whilst the expiration is free; pain and feeling of constriction at the larynx, greatly increased by pres- sure on the thyroid cartilage, flushed face, lustrous eye, great thirst, full and frequent pulse. The cough is very troublesome, harsh and more stridulous than in croup, and accompanied by constant and voluntary hawking, as if to clear the passage by expectoration. The voice, at first acute and piping, gradually becomes thick, then hoarse and whispering, and at last is completely suppressed. There is sometimes great difficulty in swallowing, owing to the epiglottis ceasing to perform its valvular office; whence it happens that, when the patient begins to drink, a portion of the fluid escapes into the larynx, and produces a fit of coughing, which seems to threaten instant suffocation. The pain from ineffectual trials to drink pro- duces in some a real hydrophobia; the sight of the fluid recalling so vividly former sufferings. An examination of the fauces shows them, in most instances, to be inflamed, and very often, by pressing VOL. II. — 10 106 DISEASES OF THE RESPIRATORY APPARATUS. the tongue as much as possible downwards and forwards, the epiglottis can be seen erect, thickened, and of a deep red colour. Laborious respiration and an inadequate supply of air affect the appearance of the patient, as manifested in his pallid counte- nance, anxious expression, livid lips, protruding and watery eyes; pulse quick, feeble, and irregular; with a colder surface of the body. The patient is restless and apprehensive ; he seldom sleeps for many minutes at a time : when he begins to doze, he starts up in a state of the utmost agitation gasping for breath, every muscle being brought into action which can assist respiration, now a con- vulsive struggle. He is quite enfeebled, becomes delirious, drowsy, at last comatose, the circulation being more and more languid ; and he dies on the fourth or fifth, day of the disease, or even earlier. Instances, says Dr. Cheyne, (Cyclopaedia of Practical Medicine,) have come to our knowledge, in which the disease has terminated fatally within twelve hours (one of Dr. Armstrong's patients died in eight hours and another in seven); and, therefore, continues Dr. C, if a person dies suddenly in the night, who had complained on the foregoing day of sore throat, laryngitis may be suspected as the cause of death. Contrasted with these are other cases in which the disease has lasted three or four weeks. By some an oedema of the glottis has been regarded as a different disease from that now under consideration ; but without good cause. The term is misleading : it ought to be oedema rima glot- tidis. The only difference between this and the acute sub-mucous laryngitis just described, is in the extent to which the cellular tissue is inflamed. Sometimes there is simple effusion; at other times pus is met with. Cruveilhier (Dictionnaire de Medecine et de Chirurgie Pratiques) makes a division of laryngitis into super-g\ot- teal and sw6-glotteal. The former coincides more with that form described above, and depends on the anatomical lesions in the mucous folds which extend from the epiglottis to the arytenoid cartilages, (aryteno-epiglotteal ligaments,) and which become by inflammation so enlarged and tumid as to be felt by the finger on examination. The epiglottis itself is sometimes the chief seat of the lesions observed. The sub-glotteal variety consists also in an inflammation of the cellular tissue, but of that portion below the rima, and extending to the cricoid cartilage, which is necrosed. The symptoms are the same as those of the first variety, except that they are somewhat less violent; as owing to the greater density of the cellular tissue below the folds of the glottis, there is less infiltration than when these latter are inflamed. Hence, also, the disease is not so speedily fatal in the sub-glotteal variety, which we should, therefore, regard as that with which those persons are affected, who, as has been already stated, have lived for weeks under an attack of acute oedematous laryngitis. The causes of acute laryngitis are not very obvious. Sometimes they are atmospherical vicissitudes. At times the disease super- ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 107 venes on convalescence from fevers,and,again,on chronic laryngitis- It has been observed in connection with erysipelas. Happily this formidable disease is not of frequent occurrence. I have already said that it is confined almost entirely to adults; there being very few cases on record in which it has attacked chil- dren, or persons under the age of twenty. Authors describe, among the accompanying phenomena, in some cases, swelling of the integuments which surround the larynx, especially on the fore- part of the neck. I have had one case of this kind under charge, in which the tumefaction was so rapid that it could hardly be exaggeration to say that its progress was almost visible. The subject was a child between^wo and three years of age. Venesec- tion and purging seemed to have little effect in controlling the dis- ease, which was obviously arrested, however, by leeches applied to the neck. Calomel was given at the same time, and seemed to be useful in completing the cure. But I am anticipating what is to be said on the treatment of acute cedematous laryngitis. The weight of experience is in favour of free bloodletting, which, to be serviceable, must be early resorted to. At the same time, it must be admitted that we cannot hope by this means to remove the cedema and the consequent obstruction to respiration, which constitutes so much of the character as well as gives danger to the disease. But if the physician should be fortunate enough to be present at its inception, and aware of its symptoms, he may, by the use of the lancet, arrest the inflammatory action which causes the cedema; or if the first critical period have passed, the farther swelling may still be prevented and absorption facilitated by this means. It is not often that a French writer can be quoted. whose directions, of a therapeutical character, so nearly correspond with our practice, on this side of the Atlantic, as those of M. Andral (Cours de Pathologie Interne). He says: In this dreaded malady we act promptly and energetically. The first indication to be fulfilled is, to detract blood largely by venesection, which will be quickly followed by a vomit or a purge. Leeches are to be applied round the neck in large numbers; in a short time the intestinal canal is again to be acted on, and sinapisms are to be applied to the lower extremities: in a word, we should adopt a treatment eminently perturbating. On this main outline of practice we must offer some remarks. The use of the lancet will be more serviceable in a case in which the patient is yet in the prime and vigour of life, than when he is farther advanced and his constitution impaired. It promises more, also, if the complexion is good, that is, if it indicate arterialization of the blood; as when the face is flushed, and even turgid, and eyes bloodshot. But when the face and lips, especially the latter, become livid, the expression anxious, and the eyes protruded and watery, we can no longer hope for a removal of the swelling and stricture of the glottis by general bloodletting, which has thedisadvantage atthis time of weakening the action of the heart and of the respiratory muscles, 108 DISEASES OF THE RESPIRATORY APPARATUS. and thus of disabling the patient from bearing up yet awhile against the depressing influence of the disease. But even in this latter stage it may be justifiable to open a vein, and to watch whether any relief follows the discharge of blood, an effect manifested by a somewhat less laboured inspiration, and an amended colour of the face and lips. If such a change take place, we shall be encouraged to let the blood flow until the main indication be fulfilled. Otherwise we promptly close the orifice, and prevent farther loss of the circulating fluid. When we have them at our disposal, leeches applied in the manner already advised exert a more evidently controlling influence over the inflammation of the laryngeal membrane than venesection. Both in the case of the child before mentioned, and in that of an adult, a married female, about thirty years of age, patients of mine, leeching arrested the dis- ease, after copious venesection had failed to do so. But, in both, the amount of blood drawn in this way was large. From the adult nearly twenty ounces were taken, under my own eye, after venesec- tion had been used to procure a smaller quantity in the early part of the day. Tartar emetic was also freely administered, both as an enietic and counter-stimulus. Dr. Francis of New York, about seventeen years ago, was attacked with acute laryngitis, for which he was bled to the extent of a hundred and fifty-two ounces in six days: and three or four days after, as he was still thought to be in a precarious state, he was bled again. (See a paper on Laryngitis by Dr. Beck, in his Journal, No. 12.) Dr. Cheyne (op. cit.) gives a still more marked case of the value of venesection, because the general appearance and the habits of the patient would not seem to bear such heroic treatment. It was of a young woman, who earned a pittance by gathering cockles on the strand at ebb tide, and afterwards by hawking them through the streets of Dublin. This person presented herself July 13th, 1813, on the second day of laryngitis, pale, scarcely able to articulate or swallow, the effort producing a convulsion, as when a crumb enters the windpipe, the voice sounding as if she were throttled, inspiration being slower than natural, and sibilous. The successful treatment consisted in bleeding her at noon, ad deliquium, which, by the way, says Dr. Cheyne, had nearly proved fatal. The venesection was repeated twice in the course of the evening. On the following day respiration was rendered difficult by the least exertion. Hitherto she was unable to swallow. She was again bled, and a purgative enema and blister were prescribed. Next day she began to expec- torate yellow mucus, and could swallow fluids. On the 16lh July, convalescence was begun. Of the inefficacy of bloodletting on other occasions, a remarkable instance was presented in the practice of Dr. Armstrong. The loss of one hundred and sixty ounces of blood within six "hours gave temporary respite to the difficulty of breathing, but yet it was so far from arresting the inflammation that death took place within twenty-four hours. The first accurately reported case of acute ACUTE CEDEMATOUS OR SUB-MUCOUS LARYNGITIS. 109 laryngitis, and one which will ever have deserved historical import- ance attached to it, was that which proved fatal to Washington. " The disease," says Drs. Craik and Dick, his physicians, "com- menced with a violent ague, accompanied with some pain in the upper and fore-part of the throat, a sense of stricture in the same part, a cough, and a difficult rather than painful deglutition, which were soon succeeded by fever, and a quick and laborious respira- tion." The General had himself bled in the night of Friday, 10th Dec, 1799, that of his seizure, to the amount of twelve or fourteen ounces. On the following morning " were employed two pretty copious bleedings, a blister was applied to the part affected, two moderate doses of calomel were given, and an injection was ad- ministered, which operated on the lower intestines, but all without any perceptible advantage, the respiration becoming still more difficult and distressing. Upon the arrival of the first of the con- sulting physicians, at half-past three in the afternoon, it was agreed, as there was yet no signs of accumulation in the bronchial vessels of the lungs, to try the result of another bleeding, when about thirty- two ounces of blood were drawn without the smallest apparent alleviation of the disease. Vapours of vinegar and water were frequently inhaled; ten grains of calomel were given, succeeded by repeated doses of emetic tartar, amounting in all to five or six grains, with no other effect than a copious discharge from the bowels. The powers of life seemed now manifestly yielding to the force of the disorder; blisters were applied to the extremities, together with a cataplasm of bran and vinegar to the throat. Speaking, which was painful from the beginning, now became almost impracticable; respiration grew more and more contracted arid imperfect, till half- after eleven, on Saturday night, retaining the full possession of his intellect, when he expired without a struggle." Harsh strictures were made at the time by English writers on the treatment of the illustrious patient by his physicians; particularly on the score of such large sanguineous evacuations. The disease was, in fact, at that time unknown — at least as laryngitis; and it was not until the year 1806, according to Dr. Cheyne (op. cit.), that a case was dul)' recorded as such. Dr. Monro, who was called into consultation, announced, as his opinion, that the symptoms arose from inflammation and thickening of the wind wipe; and after- wards recommended, in case suffocation should be imminent, to perforate the larynx between the thyroid and cricoid cartilages. Laryngotomy was performed, but only after stertorous respiration had come on, and the countenance was changed from the purple of imperfect respiration to cadaveric paleness: the patient died two hours afterwards. The most approved method of treatment recommended at this day will be found to vary little in its general features from that pursued in the case of General Washington. One very important means was not used by his physicians — the application of leeches. Objections have been made on valid grounds to vomiting the patient, 10* 110 DISEASES OF THE RESPIRATORY APPARATUS. whose epiglottis in this disease remains stiffened and erect, and of course leaves the glottis open to the introduction into the larynx of fluids ejected from the stomach, or, at any rate, to the irritation of the rima glottidis in their passage from the esophagus into the mouth. But whilst we deprecate vomiting, we are notforbidden the use, in relatively large doses, of tartar emetic, which, in this form of laryngitis, as well as in croup, is tolerated to a great extent. By toleration, I mean its not causing either vomiting or purging; at the same time that it tends to abate arterial action. The medicine may be administered in quarter and half grain doses every hour, or even half hour, according to the intensity of the disease. A very minute fraction of opium combined with it will enable the stomach to retain it more readily, without diminishing its sedative or contra- stimulant effects. If we are deprived of the use of leeches, cups to the nucha should be applied, after venesection, so as to detract as much blood as can possibly be spared from the laryngeal region. The two means of bloodletting may even be had recourse to in very severe cases almost conjointly, or in quick succession. Tartar emetic failing to produce the desired reducing effect on the system, without vomiting, or even after its beneficial but incomplete sedative operation, calomel, con- joined with minute doses of opium, should be given every hour, or at most two. If want of confidence be felt in the tartar emetic alone, or fears entertained by certain physicians that it must ne- cessarily vomit in this as it is known to do in various other states of disease, the medicine may be advantageously combined with calomel and opium, and continued until relief be procured. After venesection and leching, a blister over the upper part of the sternum may be of service, or preferably on the nucha; and, if there be much, as often there is, spasm of the glottis and larynx, it may be dressed w'th morphia or belladonna ointment. For the relief of this symptom, while we are removing its cause — inflammation — assafcetida in mixture, with a few drops, in each dose, of the tincture of belladonna, will be of service. Gentle frictions, with the bella- donna tincture, or liniment over the larynx and trachea, will con- tribute to the same end. Mr. Crampton and others recommend the application of leeches to the inflamed palate and tonsils: the objection is not in any danger or subsequent inconvenience, but in the difficulty of the operation. The leech must be directed to the required spot by its being inclosed in a tube, the introduction and application of which is itself not a little irritating at anytime; but in laryngitis must be productive of great distress. Remembering, also, the temporary tumefaction of the part to which leeches have been applied, we reasonably fear even a slight increase of this condition of the glottis, although it would be of short duration. On one point in the treatment of acute oedematous laryngitis, there is unanimity of opinion. It is, to have recourse to laryngotomy so soon as symptoms of suffocation are exhibited, and the remedies ACUTE (EDEMATOUS OR SUB-MUCOUS LARYNGITIS. m which have been employed do not exert a marked ameliorating effect. The designation by Dr. Baillie of the period of thirty hours of treatment, by bleeding and opiates, without relief, after which bronchotomy should be performed, is entirely too arbitrary. Dr. Cheyne very properly remarks, that "thirty-hours may be too long to wait, or it may be too short. If the circumstances of the patient, especially the condition of the circulating fluid, be such as to con- traindicate bleeding, and to show that asphyxia is imminent, it may be improper to put off the operation for thirty, minutes. If the com- plexion is good, if asphyxia is not threatened, the operation may be delayed for thirty days." Seldom, indeed, has the operation been performed soon enough to afford well grounded expectations of relief; for, as Mr. Ryland justly observes, (Diseases and Inju- ries of the Larynx and Trachea,) when the disease has continued some time, the lungs become gorged with venous blood, serum is effused into their reticular texture, and emphysema is likewise induced in them. The brain suffers, probably from the nature of the blood circulated through its vessels, and gradually loses its functions. The consequence is, such an exhaustion of the vital powers that reaction and recovery cannot take place even when the respiration is rendered free by means of laryngotomy. But whilst stress is laid upon an early recourse to the operation, we must still not deprive the patient of the chance of recovery by omitting it even in the last and apparently hopeless stage. Mr. Goodeve relates the case of a patient of his who was quite insen- sible when the operation was performed; no pulse could be found at the wrist; his face was suffused with blood, and his lips livid ; and it was hard to say whether he breathed or not, and yet he recovered. The spot to be selected for laryngotomy is the triangular space between the thyroid and cricoid cartilages, over the crico-thyroid membrane. An incision of an inch in length is made through the integuments along the central line of the neck, just over the crico-thyroid space; the edges of the wound are then separated, and the incision is continued down to the membrane, which, upon being exposed, may either be punctured with a trocar, or divided in a transverse direction with the scalpel. If the disease, for the relief of which the operation has been done, requires that the artificial opening be maintained for some time, it will be neces- sary to introduce a canula through the wound, and confine it there by bandages, as the irritation produced by it will cause strong ex- pulsive efforts on the part of the patient; but if the disease is of a temporary nature, it will suffice to cut away a portion of the crico- thyroid membrane. Laryngotomy is more suited to adult males than to any other class of persons, because the larynx is lower in the neck, and its dimensions larger, and consequently the crico- thyroid space more ample (Ryland). The canula has been worn by different persons for a length of time without inconvenience; the periods varying from six months to fifteen years. The mortality is great in acute laryngitis. Of twenty-eight 112 DISEASES OF THE RESPIRATORY APPARATUS. cases collected by Mr. Ryland, eighteen proved fatal; and even this is under the average, in his opinion. (Edema of the larynx, which I have described in its acute stage, does, however, occasionally present itself in a sub-acute, if not chronic form, as part of general dropsy; or supervening gradu- ally on phlogosis of another organ, with but little premonition of its approach. It constitutes the serous infiltration of Bayle. It is not less dangerous in this than in the acute form. Hydrogogue cathartics and diuretics, among which digitalis must not be forgotten, and vesication of the fore-part of the neck, will be the chief reme- dies. It is in this form that we may anticipate most from laryn- gotomy. LECTURE LVIII. DR. BELL. Laryngitis Memeranacea—Croup.—Anatomical trait characteristic of the dis- ease; lymphatic exudation in a membranous form in laryngeal inflammation— Phlogosis extends to trachea and bronchia; sometimes to the lungs—The chief seat of croup is in the larynx—Proof from dissections and the leading symptoms— Character of the breathing and the voice in croup—Dyspnoea evincing affection of the lungs at the same time.—Causes—referrible to locality, states of atmo- sphere, and age of the patient—Seasons in which it prevails—Mortality from croup in New York, Philadelphia, and Boston—Epidemic croup—Age at which croup is most common—Proportion of the sexes.—Symptoms—Precursory or common ; and imminent and special—First and second stages.—Duration.— Mortality.—Varieties of croup—Spasmodic croup—Dr. Ley's theory—Differen- tial diagnosis—Difference between primary and secondary or consecutive croups-Membranous exudation from air-passages forms in some other diseases.— Treatment—Intentions of cure—First remedy, an emetic—Tartar emetic to be preferred—Venesection—The warm bath—Leeching or cupping—Calomel with tartar emetic—In approaching collapse, perseverance in the use of calomel and stimulating and antispasmodic expectorants; blisters, epithems, etc. LaryngitisMembranacea—Croup.— Croup has received a variety of names: Cynanche Trachealis, C. Laryngea, C. Stridula, Angina Palyposa, Suffocatio Stridula, Morbus Strangulalorius; Bronchitis, by Young; and Empresma Bronchilemmitis, by Good. The attempt to designate this disease by a symptom, whether of a sound in breath- ing, or of a sense of imminentsuffocation, must be misleading, because not exclusively belonging to it: and a term which implies its primary fixation in any other part than in the larynx is erroneous. Croup is now adopted, both by continental as well as English writers, and is a title which cannot mislead by its connexion with any hypothesis of cause or nature. In the United States the disease is known, among the people, commonly by the term Hives. The anatomical trait which distinguishes croup from other va- rieties of laryngitis is the production primarilyin the larynx of a false membrane. This production is secreted from the mucous or lining membrane of the larynx; it consists of albumen with a propor- LARYNGITIS MEMBRANACEA —CROUP. 113 tion of phosphate of lime and carbonate of soda; and occasionally fibrin. It is corrugated and hardened by diluted sulphuric, nitric, and hydrochloric acids; and, on the other hand, rendered softer and diffluent by concentrated acetic acid, liquid ammonia, alkaline solutions, and a strong solution of the nitrate of potassa. Regarding this false membrane or lymphatic exudation as a product of inflam- mation, we should naturally expect to see the surface from which it is given out evince this morbid state. Accordingly the mucous membrane itself is often found to be rough, red and thickened ; but at other times one is not a little surprised to find it unchanged in these particulars. It is no forced supposition, however, that the inflamma- tion may be so far relieved by this pseudo-membranous secretion that there would be diminished redness, which, as in many other cases of greatly increased vascularity during life, disappears en- tirely by death. The same explanation will apply to those cases in which there is neither false membrane nor increased redness observable after death, although there had been unequivocal symp- toms of croup before this termination. Even when we speak of this new product as the anatomical character of the croup, we must at the same time admit that it is not always present: it should rather be regarded as one of the chief proofs of an inflammation of the mucous membrane of the larynx, which may still be checked early, and thus the lymph will not be given out with sufficient freedom to form the membrane. Sometimes, in place of 'this latter lining entirely the cavity of the larynx, we find patches and shreds, and at times merely thickened mucus. But farther observation shows, that the morbid action, in croup, is not long confined to, although it commonly begins at, the mucous membrane of the larynx. The trachea and bronchia are soon interested, and to such a degree as to be lined with this mem- branous exudation continuous with that of the larynx ; and the bronchia are filled with a tenacious mucus. Evidences of inflam- mation may generally be discovered over the whole of the mucous membrane of the lungs: their cavity is always full of fluid; the interstitial cells are sometimes filled with serum. Nay, we have known, says Dr. Cheyne (Cyclopcedia of Practical Medicine), parts of the lung hepatised, and inflammation to extend not merely to the parenchyma, but to the serous membrane, in consequence of which we have seen fluid effused into the cavity of the pleura. In many dissections the lungs have a solid feel, do not recede when the thorax is opened, and cannot be compressed. Some have divided croup into varieties according to the extent of the region of mucous surface affected ; hence we have laryngeal, laryngeo-tra- cheal, and laryngeo-bronchial. We may not be able, nor is it very desirable for practical purposes, to designate in advance these varieties ; but it is exceedingly important that we should be fully aware of the coincidence of tracheitis and of bronchitis, also, and at times even of pneumonia with croup, or the laryngitis of chil- dren. For the most part, the first lesions are felt and seen in the 114 DISEASES OF THE RESPIRATORY APPARATUS. mucous membrane of the fauces and larynx, and subsequently extend to the tracheo-bronchial portion. At other times the irrita- tion begins at the bronchial terminations, is manifested in cough, and then suddenly and violently fixes itself in the larynx. Dr. Stokes, in treating of the primary inflammatory croup of children, lays down, as one of the most important considerations, the complication with inflammation in the remaining portions of the respiratory appa- ratus. In a considerable number of cases, he assures us, that the laryngitis is preceded by some inflammatory affection of the lung, which continues during its progress, but which is overlooked in consequence of the prominence of the croupy symptoms. " I have little doubt," continues the author, "that many children that die with symptoms of croup are carried off as much by disease of the lungs as by that of the larynx and trachea ; for I have seen many in- stances in which, during life, the stethoscope indicated unequivocally the existence of intense bronchitis or pneumonia, and have inva- riably found that the diagnosis was confirmed by dissection." We cannot doubt the correctness of the opinion of a frequent conjunc- tion of croup with bronchitis and pneumonia. In the few fatal cases of the disease, or at least of a pulmonary disease beginning with croup, which I have seen, this conjunction or complication was undoubted ; the patient having recovered from the laryngitis, but sank under the pulmonary lesion. But it would be generalising too much were we to say, that in the majority of cases of croup, in its first stage and in its first attack, that pneumonia existed either antecedently to laryngitis, or even came on contemporaneously with the latter. The absence of the diagnostic signs, and the prompt and entire relief afforded, in many instances, by the very first remedy, an emetic, forbid such a supposition to the extent advocated by Dr. Stokes. In reasoning on the order in which the pulmonary complications show themselves, we cannot be unmindful of the effects of the mechanical impediments to respiration by the encroach- ment on the calibre of the larynx and the almost occluded glottis. The breathing will be laboured and hurried, the blood is imper- fectly changed in the lungs; there is effusion of serum in their parenchyma, and accumulated mucus in the bronchial cells. Special Pathology of Croup. — The seat of the inflammation of croup has been already stated to be the mucous membrane which lines the air-passages, and, in a more particular manner, the larynx and the trachea. The membranous exudation varies in thickness, consistence, and extent of surface over which it is spread: it is more commonly found in the larynx and upper third of the trachea than in any other situation (Ryland). Bretonneau gives three instances in which the false membrane extended from the epiglottis, without breach of continuity, to the extremities of the bronchial ramifications. In reply to the remark of Laennec, that this false membrane is generally found in the larynx, but that it very rarely extends above the glottis, we may cite the experience of Dr. Thomas Davis, who, in his published lectures, remarks, that of six prepara- LARYNGITIS MEMBRANACEA — CROUP. 115 tions then upon the table before him, nearly every one presents the false membrane also in the inner surface of the epiglottis. We must even go farther, and admit that in a great many cases, especially those in which croup proper has been preceded by fever and an- ginose symptoms, that a lymphatic exudation forms on the tonsils and pharynx. M. Guersent estimates at nineteen out of twenty the number of cases of croup in the child originating in this way. This proportion is doubtless too large to represent croup in general. In twenty-six fatal cases of croup in the Children's Hospital at Paris, between*1831 and 1839, there were but thirteen with inflammation other than of the air-passages; in nine there was an accompanying membranous exudation of the tonsils, pharynx, and isthmus of the fauces. As many English writers, and most of our own, persist in calling croup cynanche trachealis, and one of the former even takes credit to his countrymen for having established beyond doubt its tracheal seat, I shall adduce additional, I would call it conclusive evidence, in favour of the disease being more especially laryngeal than tracheal. Desruelles, in his Traiti Theorique et Pratique du Croup, d'apres les Principles de la Doctrine Physiologique, 2me ed., Paris, 1824, quotes, or refers to the following writers respecting the seat of croup:—It is probable, says Vieusseux,that croup, which is suddenly fatal, is that in which the larynx is the part first affected. Royer Collard holds the same opinion. Bard has seen a whitish coat on the fauces, epiglottis inflamed, and covered with mucosities extending to the larynx. MM. Beauchene, Sedillot, Carron d'An- necy, Leveque Lasource, Lechevrel, Latour, Valentin, Dejaer, Mercier, Carus, Regnaud de Lormes, have published cases in the Journal General de Med&cine, in which a lesion of the larynx was manifest. Albers, after an inspection of the cadaveric phenomena, believes that most frequently inflammation arises in the larynx and upper part of the trachea. Boisseau {Diction. Abrege des Scien. Med.) says, the larynx is always affected in croup; it is also the only part. The bronchia are frequently intact, and are never alone inflamed. The trachea is never affected without the larynx being in a similar condition. Simple croup, in the opinion of Desruelles himself, has its seat in the mucous membrane of the larynx ; but the false membrane is often thicker in the trachea, and the traces of inflammation greater in it. From these appearances, Dr. Jackson, of the University of Pennsylvania (Amer. Jour. Med. Scien., vol. iv.), has drawn an inference that the exudation begins lower down, as in the bronchial ramifications, and, ascending to the trachea, ulti- mately reaches the larynx; an opinion coincident with that of Dr. Stokes already detailed. In two fatal cases, the symptoms of which and the post mortem appearances are described by Dr. Jack- son, the membrane was continuous from the superior margin of the glottis down and into the bronchia, or the lungs. It became thicker in its progress downwards. The mucous membrane of the larynx, trachea, and bronchia, beneath this lining, was highly injected with blood and inflamed ; presenting an appearance rather rougher 116 DISEASES OF THE RESPmATORY APPARATUS. than common. Blaud (Nouvelles Recherches su la Laryngeo- Trachiite—Connue sous le nom de Croup) details twelve fatal cases, in all of which there was a membranous exudation lining the upper part of the air-passages; and in almostevery case, when regions are specified, the larynx is shown to be affected, and thence mostly down to the middle of the trachea: in one instance thefalse membrane is stated to extend from the trachea to the bronchia and their rami- fications. In the case of a child three years old, whfch terminated in six hours, false membrane formed, and was found after death, in the whole of the larynx and greater part of the trachea, adherent, and coming off in strips. The character of the voice and breathing in croup, which arises from a spasmodic contraction of the constrictor muscles of the larynx, is further evidence of its laryngeal seat. The glottis can be voluntarily narrowed by some persons, so as to produce or imi- tate the sonorous hissing of croupal breathing. Croupal voice depends on two causes ; viz., the spasm of the constrictor muscles of the larynx, and an alteration of the mucous membrane lining the vocal cords, by inflammation. Hoarseness, or a raucous voice, depends on the vocal cords in croup becoming softer and relaxed, by which the air is prevented from causing the complete vibrations in health. The thicker the covering of the mucous membrane, that is, the greater the inflammation, the hoarser will be the voice; and the hoarser the voice, the more serious the affection of the glottis and larynx. This state may extend to aphonia itself, which is temporarily relieved by expectoration. A grave or base voice indicates a serious affection of the larynx and its vocal cords. An acute tone of voice is generally the result of a spasm of the laryngeal muscles, and of the smaller opening of the glottis. We cannot understand, nor give any adequate explanation of spasmodic croup, or of the fits of threatened suffocation in common croup, unless we admit the laryngeal seat of the disease. The irritating cause is in the mucous membrane of the glottis and larynx: by a reflex-motor action, the irritation of the membrane, transmitted to the brain, causes a return of innervation on the mus- cles of the glottis and larynx, and they are contracted with more or less violence. The cerebral excitement is kept up in these cases, and often augmented, 1, by the external air which is not in relation with the morbid sensibility of the inflamed organ ; 2, by the duration of the inflammation itself; 3, by the various products of inflammatory secretion, which, like so many foreign bodies, irri- tate the air-passages. Hoarseness, or an equivalent condition of voice, may be the fixed one in croup; but the modifications depend- ing on spasm of the laryngeal muscles must be considerable. The spasm may be continued, remittent or intermittent; varieties which may exist in laryngitis with false membrane from the glottis down to the bronchia. A suspension of the more violent symptoms may take place, and thedisease seem sofartobe intermittent; but itis the spasm of the muscles, not the secretion of the exuded membrane and croup CAUSES OF LARYNGITIS MEMBRANACEA — CROUP. H7 proper, which intermit. Inflammation of the membrane, like any other of the phlegmasia?, is liable to exacerbation ; but in its epoch it does not correspond with the spasm or fits of laborious breathing and imminent suffocation. The spasm of the glottis is most common at night; and hence a mucous irritant, hardly a source of complaint during the day, may, without any, or with very slight increment, be a source of imminent suffocation at night, owing to the greater sus- ceptibility of the nerves and muscles at this time. Death rarely results from the occlusion of the glottis, by the thickening of the mucous membrane, or the superposition of false membrane on this latter; but it may by the spasmodic action of the muscles. Even where the false membrane is formed and adherent, the breathing is sometimes free just before death. But, although the characteristic symptoms of croup depend on organic lesion of the larynx, we cannot render an account of all the phenomena of the disease if we overlook its tracheo-bronchial and even pulmonary complications. Of these I have already spoken. The dyspncea gives a tolerable good measure of their pre- sence and intensity. Hence, when we see the lips of a livid or violet colour, the face tumefied, the eyes prominent and shining, head- ache, somnolency, comatose stupor, convulsions, a peculiar anxiety, hurried breathing, and throwing the head back, we recognise symptoms of impeded pulmonary circulation and decarbonation of the blood, and feel ourselves more urgently called upon to remove this state of things, whether the laryngeal symptoms proper be urgent or not. Causes. — The circumstances under which croup most readily and generally appears, are in reference to locality, states of atmosphere, and age. As regards locality, we find that large bodies of water, running or stagnant, fresh or salt, predispose to the disease. A damp and cold atmosphere has a similar tendency; although we must consider cold as relative. An easterly wind with rain, and a reduction of the thermometer by a few degrees even in July, will bring on an attack in a child not suitably protected from these influences. The influence of locality in the production of croup is mani- fested very clearly at Warsaw, particularly in the spring season, at the time of the breaking up of the ice in the Vistula; in the circumstance of the disease being worse on the banks of the river and lower part of the city than in the upper. It is com- paratively rare among the children who live in the upper stories, or on the first stage. The children of the poor who reside on ground floors are the greatest sufferers. But, contrary to what we would suppose, croup is little seen at Venice, bedded in the sea; and it is more frequent in Florence, bordering almost on the Appenines, than at Leghorn, on a paludal soil, on the sea-coast. Winter and spring are spoken of as the seasons in which it most frequently makes its attacks; but the line of separation between exposure and immunity from croup is not always designated by the vol. u. — 11 US DISEASES OF THE RESPIRATORY APPARATUS. almanac. In New York the months exhibited mortality, during a period of sixteen years, in the following order: October, November, January, March, December, February, April, May, September, July, August, and June. Croup is represented to be more frequent when epidemic catarrh or influenza prevails ; but the fact is only of occa- sional occurrence, for in some influenza seasons which I have wit- nessed I have not found such coincidence. In Boston, on the other hand, the disease would seem to increase at a faster rate than that of the population, the deaths, from 1811 to 1820, were 43; from 1821 to 1830,245; and from 1831 to 1839, 376; being in these periods respectively 5 ; 21*3 and 25*9 per 1000 deaths from other diseases. Croup has prevailed at times epidemically, although we may suspect that some of the accounts of its appearance in this way are really those of its aggravated endemical occurrence. Vieusseux of Geneva, in his Memoire sur le Croup ou Angine Tracheale, re- lates that croup has been observed to be epidemic in different parts of France. Between 1772 and 1783 it occurred twenty times in Geneva; from 1766 to 1784, four times in Tarascon; from 1771 to 1783, four times in|Etampes ; and from 1780 to 1784,four times in Beziers. It is not unlikely, as the inquiries of M. Bretonneau have satisfied him, that these visitations, or someof them at least, were of se- condary croup or angina diphtherite,a\ready described, Lecture VII. Valentin (Recherches Historique et Pratiques sur la Croup, Paris, 1812), who lived for some time and travelled extensively in the United States, and is known to some of our old physicians, speaks of the epidemic returns of croup at Cremona, in Italy, in 1747 and 1748; at Frankfort on the Main in 1758; in Sweden four different times ; at Franconia in 1775; also in Warsaw in 1780 ; at Altona, Tubingen, and Stultgard, in 1807, and Vienna in 1808. He also mentions the disease having appeared in this way in Portsmouth, Virginia, in 1805. Dr. Valentin gives some statistics of croup in this country, thirty- six years and more ago, which are not without interest as forming data for comparison with its mortality at this time. Thus in the city of New York the deaths from croup in 1804 were 75, in 1805 to 70, and in 1806 they were 106. The population of that city at the time was estimated at 70,000 inhabitants. If we compare these re- turns with the mortality in 1838, which was 182, and in 1839, which was 141, and bear in mind the increase of population, we shall draw the inference that croup prevails less extensively now than for- merly in New York. The average number of deaths" annually from croup, for a period of 16 years, from 1819 to 1834, was 140; or 1 death from croup for 37-3 of other diseases. In Philadelphia, in 1807 the deaths were, in all, 2045, of which 54 were from croup; in 1808 the annual mortality from all diseases was 2271, and from croup 53. On referring to the mortuary returns for 1838, 1 find the deaths from croup in this city were 101, and in 1839 but 83; leading to the same conclusion as that just drawn respecting New York. ° SYMPTOMS OF LARYNGITIS MEMBRANACEA — CROUP. \\Q As respects age, croup may occur at any time between the second or third month after birth and puberty. The younger children are when weaned, the more liable they are to the disease. Out of 350 cases presented in a tabular form by M. Andral (op. cit), 21 took place between birth and eleven months after this epoch; 61 between a twelvemonth and two years of age ; 45 between two and three years; 54 between three and four years; 42 between four and five; 39 between five and six; 29 between six and seven; 3 between seven and eight. From the period between eight and twenty years of age, there were but 27 cases ; and between twenty- six and thirty, none. At thirty and at thirty-four years of age there were, respectively, four: and one was reported at seventy years of age. We may reasonably doubt its being genuine primary croup which assailed these persons in adult life. In the Philadelphia return for 1839, the only one before me, all the deaths were under ten years of age, viz., 19 in the first year from birth, 18 in the second year, 33 between two and five years, and 13 between five and ten years. In New York, of 88 males, I omitted to notice the females, 63 died under a twelvemonth; 25 between one and two years of age ; and 43 between two and five years. The narrower glottis of a child than of an individual who has reached puberty is adduced as a probable predisposing cause of the croup in early life. The difference, says Dr. Cheyne, between the glottis of a child of three years and that of one at twelve is scarcely percepti- ble, whereas at puberty the nperture of the glottis is quickly enlarged, in the male in the proportion of 10 to 5, and in the female of 7 to 5; the bronchia at the same time enlarging, and the voice under- going a corresponding change. Respecting the relative liability of the two sexes, it would seem that this disease is much more frequent in males than females: of 252 cases treated by Goelis, 144 were boys and 108 girls. J urine gives the proportion as 72 boys to 47 girls in 119 cases. The return in the New York Bill of Mortality for 1839, already mentioned, gives 88 males for 53 females. In Phi- ladelphia, on the other hand, for the same year, the proportion was reversed, the deaths of boys being 38, and of girls 45. Symptoms. — The symptoms of croup are precursory, or those common to catarrh and other affections of the larynx and bronchia, and imminent or special. Among the first are hoarseness, cough, and modification of the common voice, with some febrile irritation. These may exist a day or two before the others are apparent; or they may only show themselves a few hours before the more alarm- ing and distinctive manifestations of the disease. Indeed, if we are to credit even formal professional accounts, we should be led to believe that sometimes croup shows itself at once, in all its inten- sity and danger, without any prodrome. But a more careful in- quiry would have satisfied the narrator that the child, said to be thus suddenly and unexpectedly attacked, had previously some of the symptoms first mentioned, to which may be added, in certain cases, gastric derangement by the eating of some indigestible 120 DISEASES OF THE RESPIRATORY APPARATUS. substance. Hoarseness has a signification in children more dis- tinctive than in adults; since, it seldom precedes common ca- tarrh in the former, as it so commonly does in the latter; and hence, if accompanied with a rough cough, hoarseness should at once excite the attention of the parent, and induce a call on the physician. The approach of an attack of croup, which takes place almost always in the evening, and generally at an advanced hour, or to- wards midnight, is often indicated, after a day of unusual exposure to the weather or getting the feet wet, by variable spirits, greater readiness than usual to laugh or to cry, a little flushing, and occa- sionally coughing; the sound of the cough being rough, like that which attends the catarrhal stage of the measles. More generally, however, the patient, after a period of sleep, gives a very unusual cough, which it is not easy to describe in words, but which is readily recognised by a person who has once heard it. Comparison of the cough in croup have been made to the coughing through a brazen trumpet, to the crow of a cock, and to the low sharp barking of a dog, or better still, to the noise made by a dog or a cat which has swal- lowed something the wrong way, as it is called, and makes half efforts at vomiting. A repetition for a few times of this cough rouses the patient, who now evinces a new symptom in the altered sound of his voice, which is puling, or whining, and as if the throat was swelled. The cough is succeeded by a sonorous inspiration, not unlike the kink in pertussis; the breathing, hitherto inaudible and natural, now becomes audible and a little slower than common, as if the breath were forced through a narrower tube; and this is more remarkable as the disease advances. The ringing followed by crowing inspiration ; the breathing as if the air were drawn into the lungs by a piston ; the flushed face; the tearful and bloodshot eye; quick, hard, and incompressible pulse ; hot, dry skin; thirst, and high-coloured urine; — form a combination of symptoms which indicate the complete establishment of the disease (Cheyne). The sensation of pain about the trachea is indicated in young children by a frequent application of the hand to the throat. The patient exhibits great anxiety and restlessness, and frequent desire to change from place to place ; he is thirsty, and drinks, and in many cases without difficulty, although, by some writers, difficult deglutition is mentioned among the diagnostic signs of the disease. At each inspiration the tumid larynx descends rapidly towards the sternum, whilst the epi- gastrium is drawn upwards and inwards. Such are the symptoms which indicate the first, confirmed, or inflammatory stage of croup, and which, violent as they are, sometimes subside about midnight, even without medical treatment; to return, perhaps, in the course of the following evening. But in general, unless the disease be treated with promptitude and judgment, the second stage, charac- terised by a new order of symptoms, comes on the following day, and terminates fatally. This second stage is called the purulent, the suppurative, or SYMPTOMS OF LARYNGITIS MEMBRANACEA — CROUP. 121 the suffocative. It may commence from the second to the seventh day, or, in the suddenly fatal, it may succeed the other in a few hours. This period is characterised by the absence of any remis- sion, and the increased severity of all the symptoms, particu- larly the acceleration and diminished power of the pulse, and of respiration. The cough, from being loud and sonorous, becomes husky and suffocative; it resembles the cough which attends tracheal phthisis, and cannot be heard at any distance from the bed; the voice is whispering; the respiration wheezing; the countenance pale; lips livid; the skin motley; the eyes languid; the pupils are dilated ; the iris with less colour than natural; a symptom, this last, which attends the advanced stage of diseases of the lungs ; and men- tioned by Dr. Cheyne, with a remark that it has been, he thinks, overlooked. The tongue is loaded and has purplish edges; thirst considerable; skin much less hot, and the stools dark and fetid ; the surface of the body is covered with a cold, viscid perspiration ; the feet and hands swelled. In this, the second stage, or that of suppu- ration, the breathing may be often remarked as most free in positions which are generally least favourable to easy breathing, as, for ex- ample, when the head is low and thrown back. There is seldom recovery from this stage, last described. Sometimes temporary relief is "obtained by the expectoration of a portion of the albuminous, membranous, and muco-puriform matters obstructing the larynx and trachea. When the excretion is free, recovery may take place, but slowly; but when it is scanty, or if the inflammation has ex- tended downwards, through the bronchia, as it usually does when thus severe, the issue is commonly fatal. In this case the patient tosses about in great distress ; he seizes on objects around him, and grasps them convulsively for a moment; he throws his head back, seizes his throat as if to remove an obstacle to respiration, makes forcible efforts to expand the lungs ; and after a longer or shorter time of such distress, seldom above twenty hours, he expires, some- times with signs of convulsive suffocation, but as frequently with continued increase of the foregoing symptoms, and evidences of exhaustion of the vital energies, and in a state of lethargy. The stethoscope generally furnishes information in this period of the extension of disease to the larger bronchia. This extreme state of disease seldom lasts more than twenty-four hours: it corresponds with the stage of collapse, of some writers. When fatal, croup, at an average, occupies a period of four days: it has destroyed life in twelve hours. Sometimes, however, the second stage is prolonged for two or three weeks, and the patient, expectorating freely, emerges slowly from that which had seemed to be an utterly hopeless condition. Along with puriform fluid, of which the sputa chiefly consists, there is sometimes expectorated a white, soft, tubular matter, like macaroni stewed in milk, which is called the membrane of croup. We can hardly admit the chronic character of true croup, laryngitis membranacea. That the patient, relieved from the inflammation and its consequent morbid produc- U* 122 DISEASES OF THE RESPIRATORY APPARATUS. tions in the larynx, should suffer for many days, perhaps weeks, from the extension and persistence of a sub-acute disease of the bronchia and lungs, we can well understand. I have seen cases of this nature myself; and believe them to be of more ready occurrence, and, I may add, more frequently mortal in children of a strumous habit. Mortality. — The mortality from croup has varied at differ- ent periods, and is rated very diflerently by writers in different countries. M. Andral estimates the recoveries to the deaths as barely 1 in 10; add.ing, that in a small village in France (near Treste-sous-Jouarre), during a period of epidemic croup, in 1825, of sixty children attacked, the entire number perished with the disease. It is encouraging to know that the treatment is more successful now, or, at any rate, the relative mortality is less than it was at the beginning of the present century. M. Double (Traite" du Croup) has taken the pains to prepare a table exhibiting the results of the practice of fifty-eight writers who have published their ex- perience in this disease, from which it appears that the number of cures is rather more than a third part of the whole. The authors being ranged in chronological order, we can make at once two classes, twenty-nine in each; and show that, whilst nearly four-fifths died of croup of those who had been attacked and who had been attended by the first class, not quite one half of the entire number attended by the second, or more modern class, fell victims to the dis- ease. In the spring of 1760, that of its first appearance in the county of Lancaster, England, Mr. Fell, a surgeon, who announces this fact, adds that, during the season, six children labouring under croup were cQmmitted to his care, to all of whom it proved fatal. But even at the present day our professional vanity is rebuked at the great mortality from croup in different parts of Europe. In a capital like Paris, where all the knowledge and resources of the art would, we might suppose, be brought to bear for the cure of disease in every form, the American reader will be not a little surprised at the results of hospital practice, in croup, as exhibited in the prize essay on the subject by M. Boudet (Archiv. Gen. de Medicine, Fev. et Avril, 1842). Thus, of twenty-six cases of croup, received into the Children's Hospital in Paris, for a period of six years, or from 1834 to 1839, the deaths were twenty-two in number. In this year (1839), and in the two following years, croup was epidemic in Paris; the deaths from this disease having been in 1838, '39, and '40, re- spectively, 187, 286, and 326. In the Children's Hospital, in 1840, the deaths were 23, and the recoveries but 2; in 1840, during the first six months the deaths were 12, being the entire number of all the cases received in the hospital. This terrible mortality might reasonably be attributed to the deteriorated constitution of the poor children brought to the hospital, did we not read in M. Boudet's essay, that a physician, whom he names (M. Loyseau), living in Mont- matre, near to Paris, lost twelve out of fourteen cases, which he was called upon to attend at the houses of'his patients. I have not the requisite data on which to express an opinion of the proportionate VARIETIES OF LARYNGITIS MEMBRANACEA — CROUP. 133 mortality of croup in the United States ; but, adding my own ex- perience to that of my professional friends, I should say, that it is not nearly so great as that given in any of the preceding statements of European authors, particularly the continental ones. Cases of croup are of very frequent occurrence with us — the deaths com- pared to the number attacked, are few. Before I speak of the treatment of croup it will be necessary to say something of its varieties and complications; for, on a clear understanding of these points will depend very much our selection of appropriate remedies. Laryngeal croup is distinguished by the symptoms already mentioned, and more especially great aggrava- tion of the disorders in voice, speech, and breathing, with more or less feeling*of strangulation and pain in the larynx. In the tracheal croup, in which, although the larynx is not free by any means from disease, the trachea is chiefly affected; there is a dry, shrill, or sonorous cough, and a sharp, lancinating pain in the course of the trachea, sometimes with slight tumefaction. The patient speaks in an undertone; but there is little hoarseness, and the voice and speech are not lost, or at least not so much affected as when the disease is seated partly or chiefly in the larynx. The cough, as the disease advances, although frequent and severe, has not the dis- tressing sense of suffocation which accompanies the laryngeal variety. The fits of coughing are often followed by vomiting, or the rejection of membranous shreds, with a thick, glairy, and sometimes sanguinolent or purulent mucus. Generally the excre- tion of this substance is productive of much relief, which is increased after each discharge, unless the inflammation has extended down the ramification of the bronchia; and then the respiration continues to be extremely difficult, and the disease assumes all the characters of an acute bronchitis, and frequently terminates unfavourably. Cases of this description seldom run their course so rapidly as those do which chiefly affect the larynx. All the symptoms evince less severity, especially when treated early; and it sometimes continues twelve or fifteen days, but usually from five to nine. Croup with predominance of bronchial inflammation. This variety corresponds with the Cynanche Trachealis Humida of Rush, and the Mucous Croup of some still more recent modern authors. I follow the specifications of its character as laid down by Dr. Copland (op. cit.). It is not unfrequent in young children of the lymphatic temperament, who are fat and flabby, with a white soft skin. It is often met with soon after the period of weaning, and in those who are brought up without the breast. It commences with coryza and the other symptoms of catarrh, and often with a little fever. After these have been present for some time, the child is attacked in the evening, or during the night, by a sudden hoarseness, and a suffocating, dry, sonorous, or shrill cough, with a sibilous inspiration. The counte- nance is pale and covered with perspiration, and the lips are violet. Several slight fits succeed to this first attack ; the voice remaining hoarse and low, the respiration sibilous and slightly difficult; but a 124 DISEASES OF THE RESPIRATORY APPARATUS. remission usually takes place in the morning. In the following evening there is a return of the croupal cough in a slighter degree. Sometimes the invasion is more gradual; the remissions but slight, or hardly evident, and the accession of expectoration much earlier; the disease approaching nearer as respects its seat and character to acute bronchitis. After the first, second, or third day, the cough is no longer dry, its fits become shorter: it is sometimes accompanied with a mucous rattle, and begins to terminate in the expectoration of a thick, glairy mucus. The disease now assumes many of the features of, or passes into, bronchitis. It is the bastard or false croup of M. Guersent, more properly the laryngeo-bronchial variety of M. Duges, milder in its character than the first, which I have described at length. Thus far there can be no doubt about the inflammatory nature of croup, whether it be simply laryngeal, larnygeo-tracheal, or laryn- geo-bronchial. The difference is simply in the degree and diffusion of inflammation along the mucous membrane of the air-passages; and the treatment in all must be of the same kind. But another variety with more distinctive peculiarities is alleged to be common in children, and every now and then to be seen in adults: it is called laryngismus stridulus or spasmodic croup, and is represented to be dependent on a temporary affection of the nerves, by which the muscles of the larynx are thrown into spasmodic action, and thus diminish so rapidly and greatly this canal as to cause feelings of imminent suffocation, and on occasions death itself. This variety of croup occurs chiefly in weak, irritable children of a nervous tem- perament and liable to worms. A quite different view of the cause of this affection was presented a few years ago in a work on the subject by the late Dr. Ley. He attributes it to a suspended or im- perfect function of the branch of the eighth pair of nerves which is distributed to the larynx, caused, as he supposes, by the pres- sure of the enlarged cervical and bronchial glands. Children of a strumous and scrofulous habit are the greatest sufferers. Dentition is an exciting cause, by the swelling and inflammation of the glands to which it gives rise. The distressing symptom of crowing and prolonged inspiration is not, Dr. Ley thinks, owing to to a spasmo- dic closure of the glottis, but rather to an inability of this part to en- large to its normal size, owing to the want of innervation from the diseased glandules concatenate. From the same cause, the trans- verse fibres, behind and connecting the rings of the trachea, losing their contractile power, the sputa accumulate; hence the " prodigous rattling in the upper part of the aspera arteria, resembling the sound which attends when there is phlegm that cannot be got up, scarce sensible when they are awake, but very great when they are asleep, described by Dr. Molloy; 'that kind of noise which an increased secretion of the mucus on the air-passages would produce,' noticed by Dr. North." The approximation of the sides of the glottis, thus produced, Dr. Ley argues, is owing to defective power of the open- ing muscles, and may be either complete or partial. If complete, VARIETIES OF LARYNGITIS MEMBRANACEA—CROUP. 125 the child may be carried off by convulsions, or by asphyxia without convulsion. More commonly, however, the glottis, becoming gra- dually, but partially open, air rushes through the still contracted aperture, producing the sonorous inspiration so characteristic m this disease; and this commonly announces the partial recovery of the child. The pathological views of Dr. Ley would lead to a prophylaxis which consists mainly in removing both the enlargement of the ob- structing glands, and in giving tone to nutrition, so as to prevent their becoming subsequently diseased. But whilst admitting the pro- priety of this course as far as it goes, we cannot give our adhesion to the pathology on which it is founded. Croup is too readily as well as promptly curable, and yields too frequently to a removal of specific irritation, such as dentition, indigestion, &c, for us to sup- pose that it could depend on a cause so decidedly organic as that advanced by Dr. Ley- In reference to spasmodic croup, in general, there is no sufficient diagnosis to enable us to distinguish it from common inflammatory croup. Cases of pure and unmixed spasmodic croup are rarely met with in practice, the intermediate states between it and the in- flammatory variety being more constantly observed. It is worthy of notice, also, that, in the undoubted inflammatory and membra- nous variety of croup, the obstruction of the larynx, or the laryngeo- trachcal canal, by new formations, is not sufficient to prevent the access of air to the lungs, — but that a great part of the phenomena and consequences of the disease are to be attributed to spasm of the larynx and trachea. This, however, it has been justly remarked, is spasm caused by inflammation, for which no antiphlogistic will be equal to venesection. Its nature may be understood from my preceding remarks on the laryngeal seat of croup. Dr. Copland says, that he has scarcely ever seen a well-defined case of spas- modic croup unconnected with dentition ; or one terminate fatally without the concurrence of convulsions in its advanced stages, or towards its termination; and it has very commonly presented evi- dences of cerebral congestion. Dissection has revealed, in some cases, albuminous concretions, sometimes extensive, but more fre- quently consisting of small isolated patches in the larynx ; sometimes an adhesive glairy fluid, with vascular spots in the epiglottis and in the larynx. The congestions of the brain, particularly about its base and the medulla oblongata, and of the lungs, cavities of the heart and large vessels, which were also found, were most probably conse- cutive changes. Still it must be conceded that there is a variety of croup of primary origin meriting the name of spasmodic. It may be induced by a preceding attack of the inflammatory; it appears to be most common in strumous and scrofulous habits. To a sudden invasion of croup, following and apparently caused by indigestible substances, such as nuts, apples, &c, and which is promptly re- moved by their expulsion, the title of spasmodic would seem to be 126 DISEASES OF THE RESPIRATORY APPARATUS. applicable enough. In using it I could wish that we had a termi- nology which would serve to designate croup thus occurring in children, and sometimes, though but very rarely, it is true, in adults, W which there is a temporary congestion of the mucous membrane of the larynx and, often, trachea, and thickening of the vocal cords, constituting a morbid change very analogous to that which takes place in the bronchial ramifications, in nervous or dry asthma. The suddenness of the attack, its frequently gastric origin, and im- mediate removal, sometimes by an emetic, sometimes by a common antispasmodic, or opium or other narcotic, are farther points of re- semblance between this nervous or spasmodic croup, and nervous or dry asthma. With both of these may be associated not only con- gestion, but actual inflammation of the mucous membrane, — that of the larynx in croup, that of the bronchia in asthma, — and both with very slight modification of symptoms may require decided an- tiphlogistic remedies, antecedent to and sometimes in place of those of the antispasmodic, opiate, and narcotic class just referred to. In our differential diagnosis it is very important that we should not confound primary and idiopathic croup, either inflammatory or spasmodic, with secondary and symptomatic croup, in which the false membrane or puriform exudation is consecutive to an exten- sion of that which lines the fauces and pharynx. The latter state is found in angina maligna, or diphiherite, by which latter term of late years it has been called by Bretonneau, and others after him, and under which it has engaged our attention. We are the more required to study this complication, as, unfortunately, some of the French writers, including even Laennec, have thought that it represented true croup, which, on this account, they have spoken of as not only epidemic but contagious. Such confusion in patho- logy must of course greatly obscure the treatment; and physicians, by an erroneous refinement, would be tempted to a practice in true croup that must be unfortunate and destructive, since it would recognise typhoid complications, which only exist with the mem- branous angina and secondary croup. The contrasted features of the two diseases are so well exhibited by Dr. Stokes (op. cit.), that I shall give them entire: — primary croup. secondary croup. (Angina Maligna vel Membranacea. — Diphtherite.) 1. The air-passages primarily en- 1. The laryngeal affection secondary gaSed- to disease of the pharynx and mouth. 2. The fever symptomatic of the 2. The local disease arising in the local disease. course of another affection, which is generally accompanied by fever. 3. The fever inflammatory. 3. The fever typhoid. 4. Necessity for antiphlogistic treat- 4. Incapable- of bearing antiphlo- ment, and the frequent success of such gistic treatment; necessity for the to- treatment. nic, revulsive and stimulating modes. 5. The disease spasmodic and in 5. The disease constantly epidemic certain situations endemic, but never and contagious. contagious. VARIETIES OF LARYNGITIS MEMBRANACEA — CROUP. 127 PRIMARY croup. secondary croup. (Angina Maligna vel Membranacea. — Diphtherite.) 6. A disease principally of child- 6. Adults commonly affected. hood. 7. The exudation of lymph spread- 7. The exudation spreading to the ing to the glottis, from below upwards, glottis from above downwards. 8. The pharynx healthy. 8. The pharynx diseased. 9. Dysphagia either absent or very 9. Dysphagia common and severe. slight. 10. Catarrhal symptoms often pre- 10. Laryngeal symptoms superven- cursory to the laryngeal. ing without the pre-existence of catarrh. 11. Complication with acute pulmo- 11. Complication with such changes nary inflammation common. rare. [Gastriccomplications common.] 12. Absence of any characteristic 12. Breath often characteristically odour of the breath. fetid. In the accuracy of one of the features (7) of true or primary croup, I must, however, express my disbelief. I need not go over th« argument again, nor repeat the proofs of the downward exten- sion of the lympaihic exudation from the glottis and larynx to the trachea, and thence to the bronchia. I will just add one familiar fact to the proofs already presented, viz., alterations of the voice, of course glGtteal disorders, preceding the other symptoms of the disease. The occurrence of secondary croup, or of angina membranacea, with extension to the air-passages, is frequent in times of real epide- mic croup; of which proof is furnished in the late epidemic at Paris, before referred to. The prevalence of exanthematous dis- eases, and great tendency to mortification of tissues, particularly gangrenous tonsillitis, was also apparent to all, and is so described by M. Boudet (op. cit.). This writer speaks of epidemic croup having been contagious, but without specifying the form of the dis- ease which manifested this property. In many instances of the malignant sore throat, the exudation thrown out from the inflamed surface forms a pellicle coextensive with the spread of the morbid process from the fauces to the pha- rynx and air-passages. In some cases, ulceration and slight appa- rent sloughing occur in the central parts and those first affected, whilst the surrounding surface and the parts subsequently diseased, become covered by a soft and easily lacerated exudation. The complication, with croup, of various states of angina or sore- throat— malignant or epidemic — whether commencing in the pharynx or in the fauces, and extending to the pharynx, is not uncommon. Bretontieau describes a remarkable epidemic affec- tion of this nature, which he called scorbutic angina, or angina ma- ligna. In eighteen cases of which he gives the dissections, the air- passages were affected. In five the disease occurred in children, aged from eight months to seven years, and in all of them the exu- dation was first formed in the pharynx. In one case it descended into the minute bronchia. The remaining thirteen cases proved 1 23 DISEASES OF THE RESPIRATORY APPARATUS. fatal by the air-passages having been attacked; and in one case the laryngeo-bronchial membrane seemed to be alone affected. The lymphatic exudation is sometimes formed in the course of other diseases, as typhousfever,gastro-enteritis, chronic pleurisy,&c. In some cases the morbid action originates in the tonsils, and extends to the adjoining parts. In the croup epidemic in Bucking- hamshire, in 1793, described by Rumsey, the croupal symptoms were stated to have been coeval with inflammation of the tonsils, uvula, and velum pendulum palati; and large films of a white sub- stance were formed in the tonsils. Croup may also be complicated with thrush; and with all the exanthematous fevers, — measles, small-pox, and malignant scarlatina. Treatment.—The intentions of cure of croup are properly defined by Dr. Copland to be,— 1st, to diminish inflammatory and febrile action, when present; and to prevent, in these cases, the formation of a false membrane, or the accumulation of albuminous matters in the air-passages; 2d, when the time for attempting this has passed, or when it cannot be attained, to procure the discharge of these matters; 3d, to subdue spasmodic symptoms as soon as they appear; and, 4th, to support the powers of life in the latter stages, so as to prevent the recurrence of spasms, and to enable the system to throw off the matters exuded in the larynx and trachea. Called up in the night to see a child who, after having gone to sleep in the evening, is at this time suffering from well-marked croup, the physician ascertains the antecedent and collateral cir- cumstances, in regard particularly to prior attacks, their duration and treatment, and the general habit and morbid predisposition of the patient, and then prescribes an antimonial emetic. He may find that, before his arrival, either ipecacuanha or antimonial wine, or the compound honey or syrup of squills, had been administered. If already nausea has ensued by means of some one of these, and the system shows a readily excitable impression to their action, it will, sometimes, be enough to continue the article in perhaps larger doses than had been given before his arrival. But if no ameliora- tion has been produced, he should at once proceed to administer a solution of tartar emetic in a dose of from a quarter to a third of a grain, to be repeated every ten or fifteen minutes, until either emesis and the accompanying relaxation are brought about, or the medicine fails to vomit at all, or to abate materially the violence of the symptoms. In reference to the dose and frequency of its repe- tition, and the entire quantity of tartar emetic to be given at this time, we must remember, that the greater the phlogosis in general, but more particularly of the thoracic viscera, the greater will be the toleration by the system of the medicine; or, less equivocally expressed, the longer will be the time before its ordinary effects are manifested. Commonly, between one and two hours will be the interval in which the salutary operation of the tartar emetic may be expected. If after two hours' administration of the medicine in full doses it fails to even nauseate, recourse must be had, not to TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 129 other emetics, but to means calculated both to abate the now evi- dently violent disease, and to renew the susceptibility of the system to the tartar emetic. The remedy next in order, and the one indi- cated by the symptoms and our knowledge of the pathology of the disease, is bloodletting. If a vein in the arm can be found it should be opened — if there be failure in this respect, we may sometimes procure blood near the ankle-joint or the instep, both feet being immersed during the time of the flow of blood in warm water. You frequently will be recommended to open the jugular vein, on ac- count of its being superficial. The operation is simple, but not quite so easy as you might be Jed to suppose ; and the appearance of the thing is revolting to the mother and others present. But as essen- tials ought never to be sacrificed to appearances or prejudices, if we cannot open a vein elsewhere, we must not hesitate to draw blood from the jugular, even although there be sometimes difficulty, which I have not myself experienced, in stopping the flow. A diminished pulse, paleness overspreading the face, and a feeling of sickness, nausea, and even vomiting, are frequent effects of the detraction of blood, and evidences, in this case, of its having been carried to a suitable extent. Often, after venesection, free vomit- ing will be caused by the tartar emetic, which had been given before the operation, but often without any such effect resulting. Associated with the two remedies already mentioned, viz., tartar emetic and the lancet, is the warm-bath ; and hence it is proper that the physician, immediately on his arrival, should ask to have warm water in readiness in case of need. Failing to produce the desired impression with the tartar emetic, and either fearing to draw blood from a vein on account of the prior state and diseases of the patient, or unable to perform the operation, owing to the vein being imbedded in adipose and cellular tissue, it is proper, if a regular bathing-tub is not at hand, to have a large wash-tub three parts filled with water of the temperature of 94°, in which the child should be immersed up to its neck. If the vessel is not deep enough for this purpose, a blanket must be drawn over its back, so as to cover the shoulders and leave the head alone free. The period of immersion will vary from one hour to two or three hours, according to the effect produced by the bath, and the other remedy or remedies which may be had resource to conjointly with it. The system which, before immersion, was intractable to the tartar emetic, will after a time evince its renewed susceptibility by nausea and free vomiting. It may be, also, that the attack is so violent and the danger imminent, as to require recourse to the ap- propriate remedies in quick succession: so that immersion in the warm bath will accompany the administration of the emetic tartar, and whilst the patient is yet subjected to the trial of this treatment, blood will be drawn from the arm or jugular vein. It rarely hap- pens that a decided and salutary impression is not produced by these three agents in the cure of croup. I have found vomiting and the warm bath adequate to produce a complete solution of th? VOL. II. —12 130 DISEASES OF THE RESPIRATORY APPARATUS. paroxysm in cases in which, but for the fatness of the children and consequent difficulty of finding a vein, I should like to have bled. The free perspiration begun in the bath is kept up the remainder of the night by having the patient enveloped in blankets, and adminis- tering minute doses of tartar emetic and a little sweet spirits of nitre, with a drop or two of laudanum each time. In the city, when the indication is urgent for the abstraction of blood, we can obtain the desired end by the use of leeches applied to the upper part of the sternum, or directly above the clavicle, on each side of the trachea. The same object is attained also by cupping between the shoulders, or on the nape of the neck. The quantity to be thus abstracted is a little more than an ounce and a half for every year that the child has completed. In the few more severe cases, in which the course of the disease is still unchecked by vomiting-, bloodletting, and the warm bath ; or in which after partial relief there is a renewal of the symptoms, we direct leeches to the throat. If we are not called on until the sup- purative stage is begun, and the distressing symptoms undergo scarcely any remission, we must endeavour to act on the mucous surface, and procure a detachment of the false membrane, by com- bining with tartar emetic calomel in full doses; and if the bowels have been already freely acted on, we add a little opium. Impressed, as we should be, with a belief in the diffusive opera- tion of mercury, and of its more especial action on the mucous membranes, we cannot hesitate to have early recourse to it in those cases of croup which do not yield promptly to tartar emetic and the lancet, as well as in those which evince complications of bronchitis or of gaslro-hepatic disorder. To Dr. Benjamin Rush are we indebted for the free use of this valuable remedy in croup. Dr. Hamilton, on the other side of the Atlantic, soon adopted the practice, which he carried to a still greater extent than our Philadelphia professor. As the ultimate effects of mercury, when given in large quantities, are to attenuate the blood by de- stroying its fibrin and colouring matter,and to produce a cachectic state of system utterly incompatible with the existence of adhesive inflammation, we have indications for its use in croup. It may be given in doses of one to three grains,combined with a fourth or a sixth of a grain of tartar emetic, every two hours, until its effects are evinced on the bowels by increased and green alvine discharges. Af- terwards, especially if the skin have lost its febrile heat and the ex- citement generally be diminished, a minute portion of opium may be added to the articles already mentioned ; the more readily, too, if at intervals there is an aggravation of the distress in breathing by an apparent spasm of the glottis. -The calomel once begun to be administered, its use should be persisted in until its desired effects are obtained ; care being taken all the while to adapt other reme- dies, which may be employed at the same time, to the varying states of the general system. Thus, if there be a suffused blush of the face, turgid jugular vein, strongly throbbing carotids, with a TREATMENT OF LARYNGITIS MEMBRANACEA—CROUP. 131 heaving of the chest, we may venture, even though venesection has been freelvused,to apply leeches in the manner advised already, and sinapisms'to the extremities. Evidences of depression of the vital powers, in a paleness of the face, coldness of the skin, and smaller pulse, will, on the other hand, require abstinence from the tartar emetic and recourse to the hot-bath, frictions of the surface, and warm infusion of the root of the polygala senega, and oxymel of squills, and even the addition of a little carbonate of ammonia. During all this time, the calomel will be regularly administered, until the breathing is free and equable, and the expectoration loose and abundant. In the suppurative stage, or that of approaching collapse, we should stimulate the cutaneous surface by sinapisms to the extremi- ties, volatile or turpentine liniments and epithems to the chest, or by a blister between the shoulders. More stimulating expectorants, con- sisting of the fetid gums, as assafcetida or ammoniacum, mixed with squills and ammonia, are also to be administered by the mouth, and enemata given, both to evacuate the bowels and to produce derivation from the seat of disease. A warm hip-bath will contri- bute to the same end. The inhalation of watery or other vapours, never easy to be done by adult patients, is still less so in the case of children: when it can be accomplished it is no doubt of considerable service. The treatment of croup with bronchitis, or of croup followed by bronchitis, is nearly the same as for this latter disease. Cups to the chest, or between the shoulders, succeeded by blisters; and calomel with very minute doses of opium, and tolerably free purg- ing, are leading means of cure at this time. Having thus sketched the outlines of the treatment of croup of the severer kind, I must add a remark, that, in a majority of cases of this disease, an antimonial emetic will suffice to give immediate relief, and a purge in a few hours afterwards complete the cure. In spasmodic croup, or in that kind supervening suddenly on catching cold, or on indigestible matters in the stomach, even if it should be inflammatory, these remedies will generally suffice, on the day following an attack of croup. Febrile irritation, and unusual ful- ness of face and cough still remaining, we ought either to bleed, or to give full doses of calomel, until the mucous membranes of the air- passages are relieved. This is done both by the direct removal of their congestion and inflammation, and indirectly by the full action of the medicine on the gastro-hepatic apparatus. ' It ought to be laid down, as an invariable rule, that a purgative is to be given in the morning following an attack of croup of the preceding evening, if we would greatly diminish the probability of a fresh attack the second night. A croupy cough, without much fever or symptom of laryn^eo-bronchial irritation, may often, in delicate subjects, be treated wiih antispasmodics,^ which a little ipecacuanha or squills has been added. I have relieved entirely an adult from a second attack of croup by the extract of stramonium and blue mass given in pill. 132 DISEASES OF THE RESPIRATORY APPARATUS. Before speaking of local treatment in croup, and the probable utility ofbronchotomy, —laryngotomy and tracheotomy, —let me bespeak vour attention to some remarks on the curative powers of tartar emetic and of calomel, and, likewise, of some other remedies, in croup. The first two are not, I think, regarded in all their thera- peutical bearings as they ought to be. But I postpone these subjects to another lecture. LECTURE LIX DR. BELL. True therapeutical action of tartar emetic and of calomel in croup—Practitienera who have employed calomel—Venesection—its advocates—Leeching—Expec- torants; those of the antiphlogistic kind to be first used—Tartar emetic and opium; calomel and opium—Squills—The alkalies—Polygala senega; its alleged powers and true value—Diaphoresis; is sometimes critical; when use- ful, and how procured—Tartar emetic, as a diaphoretic, to be given in the smallest doses—Warm pediluvia and counterirritants to the lower extremities —Vapour bath—Warm bath not to be confounded with the hot bath—The arm bath—Antispasmodics; the best antispasmodics, venesection, tartar emetic, calomel, and the warm bath; opium, and afterwards assafcetida, camphor, &c.— Topical remedies; blisters—when and where to be applied—Stimulating liniments—Cauterization of the fauces and pharynx—Tracheotomy.—Laryn- gismus Stridulus; not identical with spasmodic croup as often met with —Description of L. stridulus—With affection of the glottis are associated spasms in other parts—Causes of the disease; the children most liable to it.— Treatment; commonly mild—mixed, hygienic, and medical.—Pre- vention. Not unfrequently the relief from an attack of croup will be as per- manent as it was speedy, by means of vomiting and its accompanying phenomena ; and no other remedy after an emetic will be required for the solution of the paroxysm. I would lay stress on the words' accom- panying phenomena,' which I have just used; for it seems to me that they are overlooked by not a few practitioners, who think that the simple act of vomiting is itself the prime and sole means of detaching and expelling the morbid accumulations in the air-passages; and that the chief mischief from the disease consists in the mechanical obstruction of these passages. VVrith such persons the selection of an emetic is a matter of comparative indifference, provided thev can cause their patients to vomit. But a very slight retrospect o'f the pathology of croup must convince us, that, from the outset, our remedies should be selected with reference to their power of abat- ing morbid arterial and secretory action, not only in the larynx and trachea, but in all the bronchial ramifications; and, also, sedation of the vessels of the lungs proper, as well as those of the brain. The effects produced by an emetic should harmonise with, and in degree be a substitute for, those caused by the next remedy, to which, if the paroxysm persists, we must immediately have recourse. This next remedy is venesection. Now, we know of no emetic substance which is comparable in TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 133 these respects with tartar emetic. It diminishes the excitement of * the heart and arteries, is a sedative also to the capillary tissue, checks morbid secretion, itself dependent on capillary excitement, and allays spasm — effects these manifested after vomiting, but which often precede this latter, and are independent of it. The mere act of vomiting is an evidence, rather than a cause, of relaxa- tion : it will serve to eject mucosities and albuminous shreds and j membranous exudations from the larynx and trachea ; but there ; must have been an antecedent state of diminished excitement and turgescence of the mucous membrane, and its withdrawal from the adherent plastic lymph, before this latter can be readily de- tached and new formations prevented. It is true that certain substances, by a peculiar irritation of the gastric nerves, will call the muscular parietes of the stomach and the diaphragm and abdo- minal muscles into combined action, and give rise to vomiting: but their effect is confined merely toevacuating the contents of the organ; and if their dose have been large, they cause continued straining efforts to vomit, with, at the same time, little or no increased secre- tion from the tracheo-bronchial vessels and mucous follicles; but rather an accumulation or temporary congestion of the thoracic and cranial cavities. Such emetics as these, sulphate of copper, for instance, may produce continued expulsive motions; but their sedative effect on the mucous membrane of the air-passages being slight, or none at all, they fail to arrest its morbid secretion,' or to produce a separation of that which is already formed. The notion, that the mere act of vomiting will separate, to any nota- ■ ble extent, adherent false membrane; or that the mere scraping off of membrane and glairy mucus will give much relief to a croupy i patient, the mucous tissue of whose larynx and trachea is inflamed, is too purely physical. Our object, then, being to abate and speedily remove the morbid excitement manifested by abnormal secretion, and the turgescence and injection of the mucous membrane of the air-passages, and parti- cularly of the upper portion, we shall have recourse at once to the agent best calculated to attain this end. Some writers recom- mend us to use, in the precursory or forming stage of croup, ipe- cacuanha wine, or syrup of squills, and to reserve the tartar emetic for the inflammatory stage. Dr. Cheyne, who advises an emetic in the inflammatory stage, but without specifying the substance to be used, lays great stress on the peculiar advantages to be de- rived from the administration of tartar emetic in the suppurative stage. Having myself seen so repeatedly the failure of attempts to arrest the forming stage of croup by the domestic prescriptions of ipecacuanha wine, or even by the compound honey of squill (Coxe's Hive Syrup), I uniformly prescribe at once a solution in water of tartar emetic, proportioning the dose to the exigency of the case, that is, to the probable duration and degree of inflammation. By this means, the disease is either at once prevented from matur- ing, or we acquire a measure of its violence and an index to a speedy 134 DISEASES OF THE RESPIRATORY APPARATUS. recourse to the lancet. In a majority of cases of even distinctly formed croup, tartar emetic will be found adequate to stop the paroxysm, by removing the peculiar cough, restoring the voice to its natural tone, and giving ease to the respiration; while at the same time it procures the discharge of mucus, and, it may be, of albuminous shreds and portions of false membrane. The little patient in a state of languor hardly unpleasant, induced by the operation of the tartar emetic in the manner already described, now goes to sleep; and the anxious mother is in a great measure relieved from her solicitude for the remainder of the night. Not only in the incipient stage, but in the milder forms of actual croup, are other substances preferred by some practitioners to tartar emetic ; on account of ihe prostrating effects of the latter. Were our diagnosis so certain that we could ascertain positively the pre- cise degree and duration of the changes in the mucous membrane, from its first increase of natural secretion to the exudation of plastic lymph, and the congestion and thickening of the membrane itself, a graduation of medicines at this time might be attempted; but as this is not in our power, and as we know that, from the first coming on of hoarseness and cough, precursory of croup, there is a tendency to increase of excitement and phlogosis of the pas- sages, the safe practice seems to me to be that which shall prevent these probable and often dangerous and fatal results, even though *it be at the expense of momentary strength, and with the tax of temporary prostration. I believe, therefore, that the early use of tartar emetic is not only the safer but the milder practice, as it will most probably prevent unpleasant consequences, and save the necessity of recourse to harsher and complex measures, which would be called for if medicines of less power had been used in the beginning of the disease. I have met with but one case in which alarming prostration was caused by a persistance in full doses of tartar emetic, after the violence of the paroxysm of croup had been subdued by the medicine. The mother mistook my direction, to give the solution conditionally, that is, if the symptoms returned after my departure, for a positive injunction; and the result was a sink- ing of the vital powers, and deliquium of my patient; from which state, however, I soon succeeded in restoring her by active frictions, sinapism to the epigastrium, and laudanum and ammonia internally. You must by this time be fully aware of the therapeutical basis on which I rest my use of tartar emetic in croup, as well as in so many other of the phlegmasia?. It is not merely as an emetic, but as a contrastimurant or sedative, opposed to inflammatory action irrespective of its procuring evacuations, that I habitually use this medicine. Its utility in this way is beginning to be pereeived by some of the practitioners of Great Britain, one of whom, Dr. Wil- son, of Kelso, relates his successful use of tartar emetic in croup; he having cured ten out of twelve cases. He gave, after leeches had been applied to the larynx, followed by warm poultices fre- quently renewed, the antimonial salt, in doses of one-fourth to one- TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 135 third of a grain, at first every hour, until a decided impression was made, and afterwards everv two hours, till the patient was consi- dered in safety. The toleration of the medicine did not extend so far as that it did not vomit at first quite freely; but it had no action on the bowels, which required castor oil or some other laxative to ob- viate costiveness. For children,Dr. Wilson properly directs from half a minim to a minim of laudanum in addition to the tartar emetic. With these opinions, and the ground on which they rest respect- ing the operation of tartar emetic, you may readily suppose that I put no faith in blue vitriol (sulphate of copper). Its astringency following emesis is not a property which we want at this time. It is not a little vexatious to find writers of established and de- served reputation take such limited views of the effects of calomel on various diseases. One will tell us, that unless it purges it will do little good ; another assures us, that its administration will be useless in this stage of croup, because time is not allowed for it to touch the mouth. This last notion, that we cannot procure the full revo- lutionising and alterative effects of mercurial preparations in gene- ral, unless the salivary glands are inflamed and incipient ptyalism caused, is rank empiricism, and has completely blinded us to their therapeutical operation. Calomel, which we may'speak of as in a great measure'representing the other preparations of mercury, when taken into the stomach, acts very speedily on the mucous membrane of this organ and of the small intestines ; and, in a short time, on the liver and pancreas, which, by means of their excretory ducts, are placed in close and continuous relation with the intestinal mucous surface. Soon the large intestines are affected, and increased defe- cation is the consequence. • But the operation of the medicine even in purgative doses is not confined to the gastro-intestinal canal and its subsidiary glands: it is extended to all the other mucous surfaces— the respiratory in one direction, and the genito-urinary and its secre- tory apparatus in another; and is followed by increased expectoration and diuresis, together with an abatement of prior irritation which may have prevailed in one or other of these divisions. Calomel acts in a more especial manner on all portions of the mucous system, and through it on their glandular appendages; and hence its use is more immediately applicable to irritations and inflammations of the mucous membranes and their glands than to other forms of disease. Most mischievous has proved the notion that the general system is not affected by mercury, and notably by calomel, unless and until ptyalism is produced. Under the influence of this error, immense quantities of the medicine are introduced into the stomach, with the effect often of a great depression of the vital powers, and particu- larly of the functions of the nervous system, cold skin, excessive inertia, 6cc.; the prescribing physician all the while waiting for the action of the calomel. In this way the patient may be actually de- stroyed by mercury* without any suspicion being entertained of the fact by the doctors of the salivating school. Calomel, says Delafontaines, Inspector-General of Military Hos- pitals, at Warsaw, is the first and the most efficacious of all the reme- 136 DISEASES OF TIRE RESPIRATORY APPARATUS. dies employed in croup. I regard it, he says, as a specific, at least as certain against croup as against syphilis. Albers and Olbers recommended and used calomel; sometimes alone, after venesec- tion, sometimes alternating it with kermes mineral and musk. Frank, at Wilna, relies on calomel after venesection, general and local. Autenrieth used it to act on the stomach and bowels as a revulsive, and to prevent the formation of a false membrane. Co- pious and fetid alvine discharges were followed in a surprising manner by a removal of the affections of the larynx. Dr. James Hamilton, the younger, gave a grain of calomel every hour to children within the year, and two grains and a half for those two years old, until relief was obtained; then he gradually diminished the dose. Commonly, evacuations upwards and downwards re- sulted. A child, five months old, took thirty-two grains of calomel in twenty-four hours, and another took eighty-four grains in seventy- two hours. Two children were lost by the weakness which resulted from continuing the calomel after the symptoms of the croup had sub- sided. Drs. Kuhn, Redman, and Rush, gave calomel in large doses. Dr. Rush gave six grains two or three times a day. Dr. Physick gave thirty grains one day to the child three months old which was bled three times in the day. Bond first recommended it. Bayley used it. Bard also praised it, as augmenting the secretions and render- ing them more fluid, and thus diminished or prevented the secretion and adhesion of the membrane. The use of calomel and enemata made up the chief treatment of Autenrieth, in croup. On our chief remedy in croup, bloodletting, some remarks will appropriately find a place at this time. Venesection was first recom- mended by Ghisi, who was also among the first (in 1737) to describe the disease; then by Home, Crawford, Michaelis, Ferriar, and Cheyne. Balfour, Bayle, Middleton, and Cheyne, opened the jugular. Vieusseux (of Geneva), recommends, in the case of a child three years old, that venesection to the extent of six or eight ounces be practised, and then that leeches be applied to the neck, to be re- peated if necessary. Michaelis recommends large bleeding; he has taken seventeen ounces of blood at once from a child six years old. But large and small are relative terms ; the large bleeding is that which produces a decided impression at the time, by lowering the pulse, causing paleness, relaxation, and approaching syncope. This is the kind required in croup. Dr. Rush preferred frequent to copious bloodletting; he has taken altogether twelve ounces, in three different times, in one day. Dr. Physick has bled a child three months old three times in one day. Both these children recovered. Muller advocated and practised venesection. Dr. Dick, of Alexan- dria, carried it ad deliquium: thirty cures in a winter attest the value of his practice. Dr. Stearns, of New York, on the other hand, tells us that, of fifty cases of croup which he has treated without bloodlet- ting, he lost but two, and in these there were complications. He does not think that venesection ought to be used in simple croup, because he does not believe the disease to be inflammatory. My own expe- rience leads me to believe that in the majority of cases of croup the TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 137 lancet may be dispensed with, if tartar emetic be early used and persisted in, until an adequate impression is produced ; but if this remedy fails to arrest the progress of the disease, and to remove the urgent symptoms, no time should be lost in having recourse to the lancet, or analogous means of sanguineous depletion. Arte- riotomy has been practised by Drs. Olbers and Duntze of Bremen. Local bloodletting by leeches is a common and favourite method with a great many practitioners. It is that preferred by the French, who direct the leeches to be applied to the neck, or between the ears. Some have pretended to specify the number which should be put on at a time, but,asin the case of venesection, the bleedingmust be relative to the violence of the attack and robustness of frame of the little patient; and, also, to the vigour and quality of the leech. Michaelis recommended eight to twelve; Reil of Halle, ten to twelve; and he allowed the blood toflowafterwardsuntilfaintingwas induced. This, generally speaking, in the first stage of the disease, is the proper practice. It is that followed and recommended by, among others, Mr. Robins (Lond. Med. Gaz., 1840). He applies " a dozen or more leeches, as the case may require, to the upper part of the sternum, so as to produce a state of syncope as soon as pos- sible, and then to check any excess of bleeding by the application of the nitrate of silver." Whenever the bleeding from leech-bites continues after the desired full effect is produced, measures ought to be taken at once for stopping it; and in order to prevent a repe- tition of sinister results, such as death itself, from the continued hemorrhage by leech-bites, the physician should give special injunc- tion on this score; first, that the nurse or mother look, at short intervals, to ascertain whether the bleeding still continues, and then that she apply the prescribed means for arresting it; failing in which he himself is to be sent for. Mr. Yate, in commenting on Mr. Robins's practice just quoted, thinks that six or eight leeches are enough to put on any child under four years old; and after that age we may readily have recourse to the lancet. In drawing any deductions from the remarks of European writers respecting the number of leeches which they recommend, we must bear in mind that one European is nearly equal to three American leeches. At Geneva (Switzerland), where croup is so common, one of the funda- mental parts of the treatment of this disease is leeching. M. Odier speaks of it as the most sure and expeditious means of curing croup. It is so well known, as he informed Dr. Valentin, whose work furnishes me with these comparative therapeutics in croup, that most of those persons who pass the summer in the country with their children provide themselves with leeches, in order that they may be able to apply them themselves, at once, in case of need ; " and I know," continues M. Odier, " that several cases of croup have been cured in this way before the arrival of a physician." The very tender age at which we can draw blood by means of leeches is in favour of the practice. In the case of a child but a few weeks old, who was severely attacked with croup, and to whom I gave ipecacuanha, and even tartar emetic, without either vomit- 138 DISEASES OF THE RESPIRATORY APPARATUS. ing or relief following, I directed leeches to the fore-part of the neck, with the effects of almost immediate ease, and speedy cure. My own belief was coincident with that of the parents, that but for the timely application of the leeches the infant would not have lived, even if it had survived the night. Expectorants. — While we recognise, as one of the chief indica- tions of croup, the procuring a solution of the inflammation of the mucous membrane of the air-passages, and a detachment of lympha- tic exudation which may have been formed on it, we cannot, as an inference, admit with equal readiness the propriety of giving expecto- rants, without a rigid inquiry into their mode of action. Emetics are expectorants, and of the best class; because they depress the system, while they encourage secretion from the laryngeo-bronchial appa- ratus. But, although we cannot continue for any length of time to vomit our patient, we can direct those medicines which make a near approach, in their sensible effects, to the emetic class, and in this way render them instrumental both in keeping down excitement and favouring expectoration, which last is not so much a cause or means of reducing congestion and inflammatory excitement of the air-passages and lungs, as an evidence and an effect of such reduc- tion. Coincident with this view will be the administration of small doses of tartar emetic, combined with very minute doses of opium, or of calomel with the same addition ; or of tartar emetic, calomel, and opium. These remedies will come in as adjuvant to the lan- cet and purgatives. When direct depletion has been carried suffi- ciently far, we may substitute the squills, in form of syrup, for the tartar emetic, unless the excitement runs high ; and direct at the same time polygala senega in syrup, or, what is preferable, in the form of sweetened decoction, with nitre — letting one or both of these be given alternately with calomel and opium. As more nicety is demanded in the use of opium at this time than of any other medi- cine, it will be well, whilst administering regularly the other arti- ticles mentioned, to direct it conditionally, according to the state of the bowels, and the restlessness, agitation, and wakefulness of the patient, and to leave word with the nurse or attendant to either add a drop or two of laudanum in every second dose of the other medi- cines; or to mix with the latter a definite proportion at these times of a syrup of laudanum or of acetate of morphia, prepared for the occasion. Together with squills, the most approved expectorants in croup,under the supposition that we have reduced the general excitement as much as in our power, without producing a too great and alarming pros- tration of the system of our patient, are ammoniacum, senega, and the carbonates of the alkalies, to which some add, but not, as it seems to me, on sufficient grounds, camphor. Of these the alkalies are best calculated to diminish the plasticity of the blood; and hence they are entitled to be used in a state of arterial excitement and phlogosis, in which some other medicines of the class would be im- proper. We direct, according to the degree of excitement, either the carbonates of potassa and soda, or the carbonate of ammonia. The last is commonly reserved for states of great and commonly TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 139 alarming depression; but much more good would be procured from its"1 earlier and freer use in this, as well as in many other of the diseases of the respiratory apparatus. Both it and its congeners, the fixed alkalies, ought to be steadily given at short intervals, with diluent drinks at the same time. Palloni gave sub-carbonate of potassa with assafcetida. In the United States the polygala senega acquired for a time great vogue, as of itself commonly competent to the cure of croup. Dr. Archer, the father, and afterwards his twosons, Drs. Thomas and John Archer, of Maryland, most contributed to confer this reputation on the senega. It was the subject of the inaugural essay of the latter, when taking his degree at the University of Pennsylvania. To the outlines of treatment of croup laid down by Dr. Archer, few of us at this time will make objections. He recommends, in the first period of croup, venesection, mercurial purges and diaphoretics, chiefly tartar emetic. He has no reliance on blisters. After this comes his favourite senega, which ought, he thinks, never to fail, if the false membrane is not entirely formed ; and when it is formed, the medicine will cause its expulsion, by the irritation of the throat and the cough which ensues. The decoction, which he prefers, is made by boiling half an ounce of the root in eight ounces of water down to four ounces. Of this a teaspoonful is to be given every hour or half hour, according to the augury from the symptoms. It stimulates, we are told, the throat, and acts as an emetico-cathartic ; but it has cured without exciting vomiting. In the second period, calomel is advantageously given at the same time with the senega. Now, that the charm of novelty and the fervour of admiration in consequence have subsided, we are better able to estimate the senega at its real worth; and while we admit that it is a good adjuvant to other reme- dies, we must also add that it is one on which alone we cannot place much reliance. The emetised polygala senega of Dr. Bouriot may be en- listed more frequently in our service in the treatment of the first stage and more violent forms of croup. It is made by adding to Archer's formula an ounce of the syrup of violets and two grains of tartar emetic Of this compound Dr. B. gives a table-spoonful every quarter of an hour, in order to procure four or five ejections from the stomach; and then a tea-spoonful every hour or two as an expec- torant. Gradually as the laryngeal and pulmonary oppression is relieved, the interval for giving the mixture may be increased. Among the means occasionally employed to promote expectoration is the inhalation of the vapour of water, or of vinegar and water. In one case, the child, a patient of Mr. Coigne, of Courbevoie, expectorated a membraneous sac, two inches and a quarter in size, after having eagerly snatched up a vessel holding pure vinegar for the purpose of fumigation, and swallowed four or five mouthfuls. The child was immediately seized with violent cough, threw up the false membrane, and was cured. Diaphoresis is occasionally critical in croup. At least I have seen a child, whom I kept for upwards of an hour in a warm bath where I administered to it tartar emetic so as to excite vomiting' 140 DISEASES OF THE RESPIRATORY APPARATUS. on its being afterwards wrapped up in a blanket, remain for several hours in a copious sweat, during which time the breathing became more and more easy. In the morning the patient awoke quite free from oppression, and only suffering from a little fever and some cough, which were removed by a purgative. In a somewhat more advanced period of the disease, after venesection and analo- gous antiphlogistic remedies, the coming on of diaphoresis is ac- companied often by a relaxation of the laryngeal mucous mem- brane, freer breathing, and occasional excretion of tough mucus or muco-purulent matter. When the skin is of unequal temperature, the pulse frequent and contracted, and the breathing hurried, we may give with advantage saline sudorifics — the acetate or citrate of potassa, or of ammonia — in conjunction with minute quantities of tartar emetic or ipecacuanha wine, and a few drops of laudanum. The doses of tartar emetic should be decreased in the order of the following series of its therapeutical effects, from an emetic to a contrastimulant or sedative, then expectorant, and finally diapho- retic. It is a great mistake to suppose, as is, however, so com- monly taught, that its property of causing sweat is manifested or bears any proportion whatever to the nausea it produces. Never are the diaphoretic effects of this medicine so satisfactorily exhi- bited as when the patient makes no complaint of sickness, nausea, or pain, nor experiences any sensation at the stomach or other organ. The full effects of sudorifics will be not a little increased by warm and stimulating pediluvia, or, in their stead, warm flannel wrapped round the feet, and friction of these parts with a warm hand. It was early remarked in the history of croup, by Ghisi of Cre- mona, that patients were cured by an abundant sweat towards the end of the disease. Dr. Walbourg informed Dr. Valentin, that in parts of Russia the Jewish women run with their children in their arms, when the latter are seized and almost suffocated with croup, to vapour baths, and remain there until a copious perspiration is induced. Returning home, they covered them up carefully. Some, he adds, are cured by this means, and slight remedies in ad- dition. One of the best aids to other remedies, and itself one of our best diaphoretics, is the warm bath. But in directing it, you must not fall into the careless, it may even be called blundering fashion, so common among otherwise exceedingly well informed physicians, of confounding the warm with the hot bath. You will read of objec- tions to the former, which are only applicable to the latter, such as its unduly exciting the patient, determining blood to the neck and head, and flushing the cheek; and, in fine, inducing efforts the very reverse of those which we most wish for at this time. Direct the warm bath of the temperature I have mentioned in my last lecture, and you will find that your patient will be soothed and comforted, and inclined to go to sleep in a warm, diffused, and febrifuge sweat. Dr. Grahl, of Hamburg, adduces cases in proof of the signal effi- cacy of arm baths in croup. They are indicated, he thinks, at the commencement of the stage of exudation. He recommends TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 14I that the arms of the patient be placed in a vessel sufficiently deep to admit them to a hand's breadth above the elbow-joint, and filled with water as hot as can be borne. A cloth should now be thrown over the head of the patient, which, falling down round the edges of the bath, retains the vapour; and this the patient should be allowed to respire for a quarter of an hour at a time, repeating it at short intervals. The first application usually induces some degree of moisture in the Schneiderian membrane, and diminishes the dyspnoea. With its repetition the cough usually loses its hoarse tone, and the patient expectorates exuded lymph. Dr. Grahl admits, however, that when the symptoms are extremely urgent, calomel in large doses should be given, and adds a recommendation of much more doubtful propriety, that a blister be applied to the throat. Antispasmodics. — Witnesses to the spasm of theglottis and larynx in croup, which often threatens suffocation, and at any rate inter- feres with the full expansion of the lungs and circulation through them, you will be naturally very desirous of removing it. With this view you may perhaps be induced to have recourse to antispasmo- dics. These medicines, in the common acceptation of the term in Materia Medica, are not, however, those on which you must rely in the early stage of croup. The best antispasmodics, experience will soon prove to you, are venesection, tartar emetic, calomel, and the warm bath, in the phlegmasia. After this opium is entitled to a preference, alone, or what is better, combined with the tartar emetic and the calomel. In proportion as the inflammation sub- sides, recourse will be had to the recognised antispasmodics, such as assafcetida, castor, camphor; and, I may add, extract of conium, and at this time digitalis, which sometimes serve very well to allay this irritability of the glotto-laryngeal muscles, by which they con- tract with spasmodic frequence and force under a slight irritation of the lining mucous membrane. They are used by friction, enemata, and inhalation, as well as by the stomach. Underwood praises highly assafoetida, both by the mouth and per anum, in which he is joined by Millar, Cheyne, Thomson, and others. Olbers and Albers place great reliance on camphor, and still more on musk. The practice of Dr. Rush was the simplest and best, viz., to pre- scribe a few drops of laudanum towards the decline of the disease. I would not go so far as Gregory and others, in recommendingfull doses of opium or laudanum afler venesection and vomiting, in croup; but I well know that after these operations, and when we are giving the tartar emetic and calomel as antiphlogistics, or, as I prefer terming it, counter-stimulants, if we join a minute dose of an opiate to these medicines, as already recommended, we shall do more to mitigate and remove spasm and oppression, than by any of the more com- mon antispasmodics, at the same time that we carry out, undis- turbed, the indications of cure. Of topical remedies, blisters are the chief ones, and those in most common use. The application of a blister ought always to be withheld vol. 11. —13 142 DISEASES OF THE RESPIRATORY APPARATUS. until a reduction of phlogosis has been obtained by emetics, anti- mony, and bleeding. The remedy is best adapted to the second stage, after the skin becomes cool and damp, and the pulse has lost its resistance and fulness. It will often cause a salutary cutaneous re- action, and aid the operation of tartar emetic and opium, or calomel and opium, in bringing on diaphoresis. Opinions are not^ uniform, as to the precise spot where a blister should be applied. The most common.practice is, to place it on the fore-part of the neck, over the larynx and trachea ; but there is no special advantage can be promised for its use in this way, to compensate for the probable in- creased afflux to the larynx and trachea; to say nothing of the pain and continued irritation at every movement of the head and neck which are felt until the vesicated surface is healed. We are deprived also of the privilege, if it should be thought desirable, of after- wards putting leeches on this part, the call for which may come up at different periods of the disease, even after we have begun to use blisters and other counter-irritants. The three spots for the application of a blister in croup, are the nucha, on the upper part of the sternum, and between the shoulders. Vieusseux regards them, after venesection, as the chief means of cure, — an opinion certainly, which greatly overrates their value. In bronchial com- plications good may be expected of them; but in order to be fully efficient, they ought to be kept in a state of suppurative discharge, by the repeated application of blistering or other irritating ointments to the vesicated surface. Stimulating liniments, such as sweet-oil and aqua ammonia, oil of turpentine and tincture of cantharides, and acetic ether, rubbed over the larynx and trachea at short intervals, so as to keep up a permanent redness and injection of the cutaneous capillaries, have been had recourse to at different times with reputed benefit. Am- moniacal cerate, made of simple cerate.gi., mixed up with carbonate of ammonia, ji., has been applied every four hours in quantities of 3ij', on the fore-part and sides of the neck, which are then to be covered with a bag of hot ashes. The skin is soon studded with little pustules, which cause itching and a pricking pain for two or three days, after which the cuticle is separated and falls off. Dr. Copland speaks very highly of oil of turpentine sprinkled on a fold of flannel just wrung out of hot water, and then applied around the neck and throat. I may, in this place, as it is classed among the topical remedies, men- tion cauterisation of the fauces and pharynx, by rubbing these parts over quickly with lunar caustic. The alleged effects of this process are to arrest, if it be done early, the spread and formation of pseudo- membrane in the air-passages, and at once to relieve the breathing and cough. In primary and common croup, while we do not forget cauterisation, we should be aware that it must not divert our atten- tion from the more active and heroic measures so fully and pointedly recommended already. Tracheotomy has been recommended as the last resource in LARYNGISMUS STRIDULUS, ETC. 143 croup. Apart from the reasons, h priori, which would either forbid recourse to it, or show its nullity, we have unfortunately general experience adverse to its success. The different state of the mucous membrane of the larynx and trachea, owing to the lymphatic ex- udation on its surface in the advanced and last stage, from that in (edematous laryngitis of adults, independently of the complications or congestions of the lungs, common to both, forbid us to hope for the same benefit from the operation in croup that has followed it in the latter disease. Still, we have the favourable experience of MM. Bre- tonneau and Trousseau, who have performed it ninety-eight times. Of 110 cases of croup in which it has been performed of late years by different French surgeons, 20 per cent, have terminated in recovery. Laryngismus Stridulus—Thymic Asthma — Spasm of theglot- Tis. —I have already expressed my doubts whether laryngismus stri- dulus is properly identical with spasmodic croup. The latter mostly exhibits all the distinctly marked symptoms of the inflammatory variety, with the addition of increased difficultyof breathing and sense of imminent suffocation ; the spasm being an incident in the train of inflammatory symptoms. In the laryngismus stridulus, on the other hand, the attacks will come and go, will return frequently, and, on oc- casions, without any sinister result, although in general a first attack should excite watchfulness on the part of the mother or nurse, and induce her to give early notice to the physician of a repetition of the disease. The period is still more restricted than that of croup, in which laryngismus stridulus is manifested; rarely exceeding three years from birth. Dr. Kerr (Edin. Med. and Sur. Journ., 1838,) has known the symptoms of the latter to appear as early as eight days after birth. He agrees with Drs. Ley and Marsh, in the opinion, held also by Kopp, that the children who are most liable are those of a very full and large habit of body, and who exhibit marks of the strumous diathesis, or have sprung from scrofulous parents; but he also adds, and my own experience is confirmatory of the fact, that he has seen it in thinner habits, and in whom no scrofula could be suspected. It is characterised by attacks of spasm of the chest and severe fits of suffocation. The breathing suddenly stops, or rather there is an extremely slight, piping, imperfect inspiration, forced, as it were, through the contracted glottis. The respiratory sound has some resemblance to the crowing inspiration of hooping-cough, but is much smaller and more acute; it is still more like the choking attempts at inspiration made during the hysteric paroxysm. In some cases, but rarely, there may be five or six piping or whistling inspirations, and then a few deeper and stronger, alternating with expirations so slight as scarcely to be perceived. In extreme cases the respiration stops entirely ; the small inspiratory pipe then takes place, either in the beginning of the paroxysm or on its termination, being quite suppressed by the strength of the attack; and this symptom is pathognomonic of the affection. In addition to the affection of the glottis, when it has occurred with such intensity and frequency as to excite attention and alarm, there are commonly other symptoms associated. The chief of 144 DISEASES OF THE RESPIRATORY APPARATUS. these are exhibited in the thumbs being turned into the palms, and the hands more or less clenched, and when opened by force imme- diately returningto their former position. The feet are turned inwards and downwards, and the backs of the hands and feet are swelled. These symptoms are most distinct when the crowings are numerous, or, as just remarked, when convulsions are threatened; at other periods they are seldom present. The disease frequently terminates by convulsions; and more rarely is ushered in by them. Other parts of the muscular system are affected, as when the child is unable to stand or walk erect, or to swallow liquids, except when given in small quantities. In severe cases, the child does not void urine as frequently as in health, and the quantity of the secretion is diminished. In a few cases, continues Dr. Kerr, the buttocks, or groins, become tender, and exude watery lymph; and in perhaps every case of the disease, the buttocks, even when well covered, are as cool as if newly washed. Mental emotion, such as any vexation, is apt to bring on a pa- roxysm. Frequently the child is awakened out of sleep by one. A current of cold air will produce the same effect. In some days from twenty to thirty attacks of crowing will occur. During some weeks the crowings will be numerous, and during other weeks there may be very few. During an attack, the sufferings appear to be occasioned wholly by the want of air, and are not unfrequently so great that the child becomes somewhat livid. Instances have occurred of a paroxysm of crowing terminating life by the glottis remaining so long shut as to occasion suffocation ; but in general danger proceeds from the occurrence of convulsions. These are to be expected whenever the crowings become numerous. Sometimes they are succeeded by insensibility, and at other times the child be- comes sensible as soon as the fit is over. In general, when the disease is approaching a fatal termination, the epileptic fits become more numerous, and the child dies apparently rather from the effects of convulsions than from any affection of the glottis. Dr. Kerr thinks that laryngismus stridulus is almost always a con- sequence of cold : occasionally indeed it commences in summer, but only when the weather is cold, and especially if the child resides in a cold or damp house. Dr. Kopp, who has written fully on the disease,which he also terms thymic asthma, states, that alfdiseases of the respiratory organs predispose to it, — such as catarrh, bron- chitis, croup, measles. Teething also predisposes to it. Autopsic examinations have not revealed any deviation from health in the larynx or trachea. If convulsions have occurred, the morbid ap- pearances in the brain are similar to those produced by convulsions unaccompanied with laryngismus (Dublin Journ. Med. Science, 1838). This disease is obviously the same in its essential features as that described by Dr. Underwood under the head of Inward Fits, p. 109-10, and by Dr. Clarke as " A Peculiar Species of Convulsion in Children," whose account of it is introduced in a note by Dr. Hall, P'1!1_12't0 tne ^st edition of Underwood. It also closely resembles, if it is not identical witb,the thymic asthma, a detailed description and TREATMENT OF LARYNGISMUS STRIDULUS, ETC. 145 pathology ofwhichare furnished by Dr. Montgomery (Dublin Journ., 1836). Mr. Hood had previously (Edinb. Med. and Surg. Journ. vol. hi., 1827) pointed out, after numerqus dissections, the enlarged thymus gland as the cause of thisdisease. Taking into consideration all the phenomena of the disease, we must go farther in our expla- nation of its organic cause than Dr. Ley, who supposes a paralysis of the glottis to be induced by pressure of swelled glands on the re- current nerves, and of Dr. Marsh, who suggests that the seat of the disease may be at the origin of the pneumogastric nerve. The real cause is, a lesion which will give rise not only to the affec- tion of the glottis, but also to the convulsions, and occasionally paralysis in the muscles of the limbs as well as those of deglutition. This must necessarily be in the brain, or more particularly at the medulla oblongata. The explanation furnished by Drs. Montgomery and Kopp, of the disease they describe being caused by pressure of the thymus gland on the nerves, is too partial; the disease has came on from other causes. Dr. Griffin (Dublin Journ. of Med. Science, 1838) sums up the essential facts connected with this disease, at the conclusion of an elaborate critical inquiry on the subject, as follows: " 1. By the concurrent testimony of almost all who have noticed the affection, it occurs for the most part, if not wholly, in strumous habits. 2. It is frequently found in connexion with enlarged glands in the neck* and perhaps in the thorax. 3. It is frequently found in connexion with eruptions on the face, ears, or scalp. 4. It frequently termi- nates in convulsions, and is sometimes, though very rarely, ushered in by them. I believe it may be said, that nearly half the fatal cases on record terminated in convulsions. 5. It is met with in families in which children are subject to head affections or convul- sions, but who have also the strumous disposition. 6. It is sometimes met with in connexion with an apoplectic or comatose state from the commencement, as in the cases of crowing apoplexy which I have described. 7. In a great proportion of the cases which terminated fatally there was not the least symptom of head affection through their whole course, if we do not look upon the occasional fits of brealhlessness and crowing asindicative of it; and the children were as well, apparently, a few moments before death, as they were pre- vious to the first attack of the disease, or as any children could be. 8. The complaint is sometimes, but rarely, attended by cough and permanent difficulty of respiration. 9^ Perhaps it may be said that from one-third to half of all the cases of which we have any account, terminated in death." Treatment.— That of the paroxysm would seem to be first in order from the nature and danger of the symptoms ; but the dura- tion of the fit is so short, that it is over before the physician can arrive on the spot. On the mother or nurse, then, will devolve the first measures in the emergency. The little patient should be raised and placed in a sitting posture, or with the body inclining slightly forwards, so as to allow the respiratory muscles their full power5 146 DISEASES OF THE RESPIRATORY APPARATUS. then he must be slapped on the back, cold water thrown on his face, and ammonia held to the nostrils. By these means the respiratory organs are powerfully stimulated ; and crying, sneezing, or some other strong expiration is produced, so that the glottis opens, and the fit is terminated. Other remedies, and they are the same with those adapted in inflammatory croup, or where there is any doubt in the diagnosis, will then be had recourse to, viz., an emetic and the warm- bath. These failing, and life becoming rapidly, or being, in fact, extinct, artificial inflation of the lungs has been recommended, and laryngotomy practised, as the speediest method of accomplishing this purpose. When the attacks of crowing are severe and numerous, or the attack of one is prolonged, the lower bowels should be emptied by an enema and some purgative medicine, such as calomel and rhu- barb, or turpentine and castor oil administered by the mouth. Both constipation and diarrhoea occur, and may even alternate in the same subject, in this disease ; the latter, however, will, I suspect, be found more an attendant on the former and apparently opposite state than is imagined ; for when diarrhoea is present, the first part of every stool is hard and dry, and the last nearly as liquid as water; and if laxative medicine is given, the stools are more natural, that is, less tenacious and less watery. The looseness, in fact, here as we every now and then see it in adult subjects, is the effect of irri- tation of the rectum by hardened feces higher up. Commonly the rule is a good one, to procure two stools daily for the child affected with laryngismus, or threatened with it, and to avoid carrying the purging any farther; hence, if diarrhoea should follow, a purgative, or some magnesia or oil, with a drop or two of laudanum, may be given. Laudanum or its like given with other views, such as of allaying irritation or of procuring sleep, will generally fail. In illustration of the direct action on the larynx of morbid impressions or irritants in the stomach, I may state that I have carried off at once all the symptoms of spasmodic croup by an emetic, which dis- charged from the stomach an apple that had been eaten and very imperfectly masticated a few hours before. I have seen, also, most of the symptoms of laryngismus brought on in a child by its having eaten stramonium seeds, the discharge of which from the stomach by an emetic, which I prescribed, was promptly followed bv a removal of all the symptoms. Some of the German practitioners (Kopp, Hirsch, &c.) recom- mend a more active course, to diminish and prevent, as they allege, the recurrence of all undue congestion and nervous excite- ment in the heart and lungs, by low diet, large and frequent blood- lettings (every four or eight days), blisters and issues on the chest, constant powerful purgatives, &c: also, to lessen the size of the thymus, by anti-scrofulous resolving medicines, such as mercury, iodine, &c. The difference of practice in these two outlines of the plan of cure, will depend entirely on the difference in robustness of frame and constitution of the child. A knowledge of the predisposing and exciting causes of laryngis- TREATMENT OF LARYNGISMUS STRIDULUS, ETC. 147 mus stridulus will guide us in the modification or abatement of the former and removal of the latter. Of these, cold has been already mentioned as the chief. A uniform temperature of the skin should therefore be maintained by suitable clothing, made not after the absurd requirements of fashion, but so as to protect the chest and shoulders effectually against currents of air, and the sudden transi- tions from a hot to a cold room, or damp entry, or the outer door. The upper garment should be of a woollen stuff or cloth, in winter, and made to fit up to the neck. A neglect of this rule by weak- minded and ignorant mothers, who are more afraid of the ridicule of their visiters at their children being dressed unfashionably, than of the imminent danger, and even prospect of death itself, of these same children, as pictured forth to them by their observant and conscien- tious physician, has produced incalculable mischief. That the feet should be well protected by thick shoes and warm stockings, is a point which is less contested. The notion that children, particu- larly those of the city, can be made hardy by partial exposure of their persons and irregular exercise in the open air, is as absurd in physiology as it is cruel and destructive in fact. Often a change of habitation, from a damp and well ventilated one to another that is dry and airy, will prevent the recurrence of laryngismus. A predisposition most commonly met with, and necessary to be obviated if not entirely removed, is that of a strumous habit and scrofulous diathesis, sometimes associated with full and plump- bodied and well-complexioned children, and sometimes with pale, thin, and sallow ones. In both, the lymphatic glands are in a state of either unnatural development or of irritability; and in both diges- tion is more or less impaired. To the restoration of this func- tion by the alternate administration of aperients and mild tonics, and the use of plain nutritive food, the attention of the physician will be therefore directed. The tepid bath, frictions of the skin, exercise in the open air, and a residence for a season in the country, will materially contribute to healthy nutrition, and an abatement of Ihe scrofulous diathesis. With this particular view, the iodide of po- tassium and the iodide of iron will be usefully prescribed; and an ointment of the former rubbed on the enlarged glands of the neck. The irritation from dentition will be diminished by occasional cutting of the gums down to the tooth, so that the lancet shall grate on it. Disorders of the scalp, which we are told to treat with great delicacy and caution in children, ought not, however, under the influence of this, on occasions, proper timidity, to be allowed to remain a source of irritation to the child, and one of the exciting causes of laryngismus. They can best be managed at the time when the child is under the regular operation of purgative medi- cines; and it will be found that their removal will contribute not a little to the comfort of the patient. Convulsions occurring during the course of the disease will require a somewhat more active treatment than that which has just been sketched; not so much, however, with a view to cure the convulsive paroxysm, which would for the most part subside of 148 DISEASES OF THE RESPIRATORY APPARATUS. itself, but to remove the morbid condition of the parts and notably the brain, irritation in which would endanger a return of the convul- sion. In milder cases, five or six leeches applied on each side of the trachea will suffice: in more severe cases, the external jugular should be opened with a lancet, if we cannot have recourse to venesection in the arm, for the causes already mentioned. Atten- tion should be paid to the state of the bowels, and means used for their being promptly evacuated, if constipation have existed. A troublesome attendant on this disease is free and almost con- tinued, and consequently exhausting, perspiration, by which the chances of fresh attacks are increased on exposure to any little inequality of temperature, and especially to humid cold. The curative measures in such a case will be frequent changes of clothing; sponging the skin every morning with tepid, and after a while cold salt water, and careful rubbing of it afterwards with a moderately coarse towel; carrying the child out of doors, or if this is not advisable, having the apartments better ventilated and cooler, if they were too warm before. One of the best means of restoration is a change of air, even from one part to another of the same city; but if the child can be taken into the country, or to the sea-shore, its prospect of recovery will be greatly increased. See, on the subject of thymic asthma and morbid states of the thymus gland, the interesting papers by Drs. Roberts and Lee, of New York, in the American Journal of the Medical Sciences. LECTURE LX. DR. BELL. Chronic Laryngitis—Its synonymes—Seat of the disease—Structural changes— Applicableness of the title, laryngeal phthisis.—Large proportion of ulcerations in the epiglottis, larynx, and trachea, in phthisical subjects—Symptoms: sensa- tions, voice, aphonia, cough, breathing—Different species of chronic laryn- gitis,—a knowledge of, necessary for prognosis and treatment—Examination of the fauces and pharynx—To determine the state of the lungs: auscultation, percussion, and expectorated matter—Duration of the disease—Causes: age, sex, prior disease, vocal strain, atmospherical vicissitudes, habits. The disease which is the subject of the present lecture has been variously named. In addition to its technical designation of Chronic Laryngitis ; Laryngeal Phthisis ; Laryngitis with Secretion of Pus ; it has received the popular ones of Clergyman's Sore Throat; Throat Consumption, &c. Chronic laryngitis may be the consequence of primary acute laryngitis and idiopathic; or it will show itself after a very brief, and by no means violent stage of acute phlogosis of the organ, and be combined with and a symptom of chronic affections of other parts, particularly of pulmonary tubercles, and occasionally of secondary syphilis. The effects of chronic irritation of the larynx vary, from a slight vascularity and thickening of the mucous mem- brane, to changes so extensive as completely to alter and destroy CHRONIC LARYNGITIS. 149 the natural appearance of the canal. The successive changes in the laryngeal mucous membrane maybe redness; thickening or diminished consistence; softening, partial or general; sometimes vegetations or excrescences of a considerable size. Pus may be met with on its surface ; and often M. Andral has seen false mem- branes which, by their firm consistence and site, perfectly re- semble some of the numerous varieties of the false membrane in croup. The inner surface of the epiglottis has been covered and incrusted, as it were, with a layer continuous from the larynx. The greater breadth of the larynx and rima glotlidis in the adult than in the child, explains why the formation of false membranes is so much less alarming in the former than the latter. Partici- pating in these alterations, the mucous follicles may become en- larged and thickened, and secrete more abundantly than common. They are often raised into small rounded spots, of a dull while or yel- lowish colour, and then they have been called tubercles. Ulcerations are met with, which, according as they are above or below the vocal chords, will cause impaired voice or complete aphonia : they have been chiefly met with in the epiglottis, the aryteno-epiglotti- dean ligaments, the vocal chords, and the base of the ventricles; and they may become so extensive as to give rise to fistulas. The number of ulcerations is generally in the inverse ratio of their size. They often extend to other tissues, and when they do, the thyro- arytenoid ligaments are the chief sufferers. The sub-mucous cel- lular tissue may be thickened, and appear under the form of schir- rous chords, or be distended with effused serum. In this tissue have been found purulent collections and tubercles in every stage of development. The muscles of the larynx are, at times, reduced in size; softened, or even entirely removed : and again they are in a state of hyper- trophy. The disease being protracted, the cartilages become affected ; the epiglottis may be thickened, ulcerated, carious, even completely destroyed. The thyroid cartilage is less frequently changed ; the cricoid is sometimes hypertrophied and carious; the arytenoid may be destroyed; and, on the other hand, all the carti- lages may be ossified. In general, the ulceration begins in the mucous membrane, and extends to the cartilages. Serous cysts, and even calculous concretions have been found in the ventricles of the larynx. — (M. Andral, Cours de Pathologie Interne.) The propriety of the term laryngeal phthisis is supposed to rest on the occurrence of the symptoms of consumption and its fatal termination, in consequence of organic changes which take place in the larynx. That such cases have been met with is not denied; but the number is very small. In a great majority of those persons who have sunk under disease whilst attacked with chronic laryn- gitis, there has been found to coexist tubercles of the lungs. Some- times these last follow, but more frequently precede the laryngeal affection. The upper portion of the air-passages chiefly suffers from ulceration in phthisis. Of one hundred and two consumptive 150 DISEASES OF THE RESPIRATORY APPARATUS. patients noted by Louis, the trachea was found to be ulcerated in thirty-one, the larynx in twenty-two, and the epiglottis in eigh- teen. In the whole of his researches up to the time of making this record, he met with only seven cases of ulceration of the bronchia. Hastings gives, it is true, a larger proportion; the mucous membrane of this part having been, according to him, ulcerated in all those (leather-dressers of Worcester) who died of chronic bronchitis. Andral tells us (Clinique Medicate), that of the whole number of cases of phthisis which have come under his observation, in three-fourths of them there were ulcerations of the mucous membrane of the larynx. Even though chronic laryngitis without complication should sel- dom be productive of consumption, the designation phthisis laryn- gea will still be applicable to those cases of tubercular pulmonary consumption in which the disease is aggravated, the symptoms in a degree characterised, and its march accelerated by the laryngeal affections. The symptoms of chronic laryngitis are local and general. The local are derived from the feeling of the part, the voice, cough, expectoration, state of the respiration, and deglutition. The general symptoms are often slight, and are only manifested towards the last stage, or occasionally at the'onset of the disease. The uneasy sensations are chiefly confined to the larynx, and in this are commonly in one spot only; as at the upper and lateral part, for example, of the thyroid cartilage. Sometimes there is a simple, pricking pain; at other times no complaint is made what- ever, even when the larynx is the seat of extensive ulcerations. There is usually a tickling which excites cough, — sometimes a feeling as if an extraneous substance were lodged in the larynx; and again of erosion and burning, and even a lancinating pain. This pain is aggravated by coughing, speaking, and swallowing; especially if the ulcerations are above the ventricles of the larynx, and also by inspiring cold air, and by pressure on the larynx. But by far the larger number of persons with chronic and sub-acute disease of the larynx complain most of suffering, and that in some cases acutely, when they swallow. So continued and decided is this symptom that, in one case, my patient called on me, for the first time, to have an obstacle removed from his throat — retained pieces of fish-bone, as he thought. To reassure him, I introduced once or twice a piece of sponge, tied on whalebone, into the upper part of the esophagus. His real disease, violent sub-acute laryngitis with bronchitis, accompanied by a full, hard, and rather frequent pulse, was removed by repeated venesection, leeching the throat, cups on the chest, and free purging. The subject in this case was young, of a full habit, robust frame, and a full liver. He was one of the choir in a church, and his singing talent no doubt had been often put in requisition in the social circle. Difficulty is sometimes experienced in swallowing, and a part of the food or drink is returned through the nose, at the same time SYMPTOMS OF CHRONIC LARYNGITIS. 151 that the patient coughs violently, and is in danger of suffocation. These symptoms are generally attributed to loss of substance of the epiglottis, or excessive rigidity through inflammation, by which it ceases to cover the larynx during deglutition. In the disease before us, there are cases in which the patients are able to swallow, although the epiglottis was far from covering the glotteal aperture; and again deglutition was almost impossible, although the epiglottis was entire; but the tongue was enormously tumefied, as was the epiglottis, which was erect and stiff at the same time. 'lhe voice is almost always altered in its tone, and this change is one of the earliest symptoms of the disease. At first it is merely weak ; but more frequently hoarse ; and sometimes entirely extinct. The hoarseness is sometimes continual; and at other times comes on only when the larynx is fatigued, or the patient is exposed to a temperature which differs much from that in which he habitually lives. If the individual suffer from severe hunger, the hoarseness is much increased, but disappears after a meal. Immediately before menstruation, as well as after venereal indulgences, the hoarseness becomes greater. Dividing the duration of the disease into three periods, it will be found that, during the first the hoarse- ness is intermittent, during the second it becomes continued, and may so remain to the end, though more frequently complete aphonia supervenes during the second stage. Inequality of the voice is a common symptom in chronic laryngitis; more, indeed, than is sus- pected by the patient himself. When the larynx is diseased, the volume of the emitted sound is lessened ; and, in general, the emis- sion of air is proportioned to the intensity of the voice. Hence discordant and unequal intonation is avoided. But the voice becomes discordant and squeaking in those who attempt to give it the full development which it possessed before. This has been observed in several singers and pleaders, and in clergymen who persist in the performance of their clerical duties when their voice has lost its accustomed pitch. Aphonia may be intermittent or continued. In the former case the voice is lost at night, while in the morning, or after a meal, it is merely hoarse. Continued aphonia is a bad symptom. That which comes on suddenly in the acute form of disease of the larynx, and continues when the disease has passed into the chronic form, is not nearly so alarming as that which advances progressively. That which succeeds mucous or catarrhal hoarseness is not so bad as that which follows the stridulous; which last is believed to depend on ulcerations or vegetations in the larynx. Alone aphonia is not of such bad import. I have had it to last some weeks in one of my patients who was subsequently restored to full health. The cough is a constant accompaniment to chronic laryngitis, which cannot always be said of disease of the lower parts of the respiratory apparatus. It is hoarse, and even croupal, when there is tumefaction of the mucous membrane; and generally dry, or at 152 DISEASES OF THE RESPIRATORY APPARATUS. most partially relieved by puriform mucus and sputa mixed with blood. Sometimes pure blood is expectorated : at other times false membrane is expelled once daily for some months, and a more than usually copious discharge has been followed by convalescence and restoration to health. Mixed with purulent or sanguinolent mucus, are occasionally seen the remains of carious cartilages of the larynx. In those affected with aphonia or slridulous hoarse- ness the cough is very peculiar: it has been called eructation by MM. Trousseau and Belloc—the latest and most careful describers of the disease. The frequency of the cough is not, however, a measure of the state of the larynx ; nor is it nearly so unfavourable a symp- tom as hoarseness and the change in the volume of the voice. Some persons on whom there has been found great lesion of this part have hardly coughed at all; whilst others have been teased with an incessant cough,in whom both the lungs and the larynx were sound. The breathing is not much affected in the milder forms and early stage of chronic laryngitis; that is, when there is no diminution of the common diameter of the glottis. After the second stage of the disease is reached, anhelation is marked and goes on increasing until death takes place. This anhelation may proceed from two causes ; muscular debility, the result of general weakness, or nar- rowness of the orifice of the larynx. In the latter case it takes the following course : at first the patient feels himself liable to what he calls fits of asthma, which most frequently come on at night; at a later period the severity of the paroxysm is increased, and the op- pression is permanent. The patient cannot breathe on his bed, unless supported with pillows, and then the inspiration is habitually sibilant, and the expiration loud and prolonged. Paroxysms of true orthopnoea soon supervene, during which there is extreme anxiety and threatened suffocation; and, generally, in fifteen or twenty days from this time the patient dies suffocated. These noc- turnal fits of asthma in chronic laryngitis are not always of such bad import. I have found them sometimes readily relieved by tincture of belladonna and sub-carbonate of potassa, or liquor potassa, in a sufficient quantity of fluid, with sugar or syrup. Of this mixture, a single dose at early bed-time will suffice to ward off the paroxysm. When there is anasmia at the same time, a mild chalybeate in the morning more effectually prevents a return of the nocturnal fit. When the ulcerations are situated at the superior orifice of the larynx, deglutition is impeded, giving rise to some uneasi- ness and cough ; but in cases in which the epiglottis is in part in- flamed or removed by ulceration, there is much dysphagia with a return through the nostrils of the drinks taken in by the mouth, and a fixed pain in the superior portion of, or immediately above, the thyroid cartilage. Still, as if to prevent positive conclusions re- specting the effects of evident organic lesions, we learn, from Ma- CHRONIC LARYNGITIS — APHONIA. 153 gendie, that there have been cases in which, notwithstanding the complete destruction of the epiglottis, deglutition was performed without abnormal symptoms. In some cases of chronic laryngitis, pressure on the larynx by grasping it between the finger and thumb produces a crepitation, which is alleged to be caused by caries of the cartilages, and by some it has been regarded as a pathognomonic sign of phthisis laryngea. But renewed experiments showed that this occurs when the organ is perfectly sound. Expectoration, in simple laryngeal phthisis, does not furnish very positive signs. It is commonly purely mucous, transparent, and not very tenacious ; but when there is ulceration, the sputa, with- out losing these characters, are often mixed with little puriform masses and streaks of blood, and are brought up with slight effort, as if to clear the throat. It is important to be aware of the different symptoms in the dif- ferent species of chronic laryngitis or laryngeal phthisis. The pro- gress of syphilitic is not the same as that of simple laryngeal phthisis. The latter generally originates in the larynx and trachea; whereas, the former usually spreads from the pharynx and nasal fossae. It is, we are told, of great practical importance to attend to this, because experience shows that the larynx is usually affected in the same manner with the throat. Thus, when an erythematous syphilitic affection is observed in the throat, the affection of the larynx will not be of an ulcerous nature; and, on the contrary, when the pharynx and velum palati and nasal fosses are deeply ulcerated, we may expect to find the larynx ulcerated or eroded. In every case of chronic laryngitis we should examine the fauces and pharynx, in order to see whether, and to what extent, their mucous membrane is affected. Frequently, there are diseases of these paris and digestive disorder associated with that of the larynx, and although we may not be able to reach this latter by topical remedies, we can exert a salutary effect on it through applications to the fauces and pharynx. I have, after careful and repeated ex- amination, detected in this way ulceration at the lower part of the space between the pillars of the palate adjoining the upper part of the larynx ; on cauterising which, the laryngeal affection was greatly relieved. Elongation of the uvula is of itself a frequent exciting cause of cough and of irritation of the glottis, and through this latter of the whole respiratory apparatus. Its excision is often necessary for a cure, and at times the operation alone will be found sufficient for this end. An inspection of the epiglottis is very de- sirable, since the larynx is seldom severely affected without this part participating in the disease. Sometimes by getting the patients to utter loud cries during the inspection, the epiglottis, carried for- ward at each expiration, may become visible. As yet, little benefit has been derived from the use of speculums invented with a view to our examining the larynx by their means. The trials made to ascertain by the introduction of the finger the state of the epiglottis VOL. II. — 14 154 DISEASES OF THE RESPIRATORY APPARATUS. and upper part of the larynx, must be regarded as hazardous, al- though the practice has been recommended with some emphasis in cases of suspected cedematous laryngitis, in order to allow of our obtaining thereby a satisfactory diagnosis. Believing the title of laryngeal phthisis to be sufficiently compre- hensive, both to express consumption which may result from simple chronic laryngitis, as well as that which has its origin in pulmonary tubercles, and to which the disease of the larynx furnishes some of the chief characteristic symptoms, I do not see the necessity of using the terms tubercular laryngeal phthisis. It is sufficient for us to be aware of the fact, that with organic lesions of the larynx of a chronic nature there is commonly complicated a tuberculous state of the lungs, which is, after a time, converted into true phthisis. In forming, therefore, our diagnosis and prognosis of diseases of the larynx, an examination of the state of the lungs can never be omitted. On this point, the advice of Dr. Stokes should be regu- larly and fully acted on. — (A Treatise on the Diagnosis and Treat- ment of Diseases of the Chest. Part I.) " The first step in the investigation will be to examine accurately into the history of the case ; and in particular to determine whether the laryngeal affection was primary or supervened on an already existing state of the lung. We must examine what were the first symptoms, and whether they were referrible to the larynx or lung. We must inquire into the past and present state of the fauces, and also whether a syphilitic taint exists. Now, should it be found that the first symptoms were those of a laryngeal character, that the voice had been altered from the outset of the disease, or that a syphilitic taint did really exist, we have a good probability, not that the lungs at the time of examination are free, but that the first morbid action was exerted on the larynx. But if, on the other hand, we find that, previous to the occurrence of any hoarseness, or stridor, or dysphagia, there has been cough without the laryn- geal character — particularly if it was at first dry, and afterwards followed by expectoration — if hectic has existed, although the expectoration continued mucous; if there have been haemoptysis, pain in the chest or shoulders ; and lastly, if the patient was emaci- ated previously to the setting in of the laryngeal symptoms — we may be almost certain that tubercle exists, and that the case, so commonly called laryngeal, is in reality pulmonary phthisis; and if it appears that the patient is of a strumous habit, or has already lost brothers or sisters by tubercle, we may form our diagnosis with a melancholy certainty, even though, at the time, we can detect no certain physical sign of pulmonary tubercle." It follows, from these premises, that we must have recourse, in our diagnosis, to the stethoscope, the nature and abundance of the expectoration, and the rapidity of the consumption. But, as Dr. Stokes has stated in the work just quoted, the sounds which would be conveyed to the ear through the stethoscope, and consti- tute the phenomena of respiration, are greatly obscured or masked CAUSES OF CHRONIC LARYNGITIS. 155 by the state of the larynx, when this part is the seat of the disease — a difficulty also mentioned by MM. Trousseau and Belloc. For- tunately, percussion serves us here instead of auscultation, and enables us to determine which lung, and of the diseased one which part is affected. " Under any circumstances," says Dr. Stokes, " the localized dulness points out that there is something more than laryngeal disease; and we know from experience that that some- thing more is, in the great majority of cases, luberculisation of the lung." This present, the disease of the larynx runs its course with greater rapidity. Between laryngitis and tracheitis, either simple as such or asso- ciated with phthisis, it is difficult to distinguish. In.the former we may expect dysphagia, and the voice to be more affected — in its being muffled, hoarse, or wanting—than in the latter. Among the terminations of laryngeal phthisis one of the most severe is swelling of the margins of the glottis. The primitive laryngeal angina {acute cedemalous laryngitis), of which this is an accom- paniment and a symptom, has been already described with requi- site fulness; its inflammatory nature is contended for by the French writers just named. The consecutive is occasioned by organic lesion of the larynx and its connections, and may be either inflam- matory or active, or non-inflammatory and passive. In duration, chronic laryngitis will vary from a few months to many years. For us to augur a favourable termination, the disease should have made but little progress. When it has advanced con- siderably, and the system is weakened by dyspnoea, cough, prolonged abstinence, or marasmus, there is little hope of saving the patient. But as there are on record accounts of several patients in whom the disease had made great progress, and who were nevertheless cured, it shows the propriety, and indeed duty, of persevering in our endeavours to save the patient, so long as there is the slightest shadow of hope. The causes of chronic laryngitis are not always appreciable. Sometimes the disease originates under the influence of atmospheri- cal changes. In such cases we find persons contract a slightly acute laryngitis, which soon passes into a chronic state and never leaves them. The inspiration of irritating particles or gases which escape in various manufacturing processes ; a prolonged mercurial course ; typhoid fevers, and debilitating causes in general; periodical exanthe- mata ; foreign bodies in the larynx, occasionally give rise to it. Of the internal causes, unmeasured and protracted exercise of the voice is one of the most frequent and evident; as we see in the cases of preachers, pleaders at the bar, and other public speakers, and in actors and singers. Even here, obvious as is the exciting cause, we often see so little proportion between its action and the occur- rence of the disease, that we must look to other collateral causes, and perhaps still more to the predisposition of the parties affected, as in a tuberculous and scrofulous constitution. Belonging to this pre- disposition will be general debility from deficient exercise, depraved 156 DISEASES OF THE RESPIRATORY APPARATUS. digestion and nutrition, excess in venereal indulgences, including masturbation and the depressing passions. The local predispo- sition may be found in a want of moderate exercise of the voice in the intervals between the formal and professional exercise and extraordinary strain on it; also, in continued irritation of dry hot air by a person habitually breathing such. Tobacco is a predisposing cause, both of general and local debility; a disturber of the functions of the lungs, stomach, larynx, and pharynx, both by perverting the secretions of the mucous membrane lining these organs, and by at first exciting and afterwards depressing their nervous power. Whatever tends to attract fluids in excess to the larynx, and to derange the circulation in its mucous mem- brane, as well as indirectly to weaken its muscles, which are those of the voice, by enfeebling innervation, must of course contribute to a morbid state of the organ. The use of tobacco may bring on all these derangements of function. But one would suppose from the obstinate perseverance in this filthy and eminently anti-social practice, that it placed the chance all on the side of health, rather than of that of disease and of a compli- cation of unpleasant sensations more annoying to the sufferer than positive pain. The apparent exemption from deleterious effects in a few persons of a robust and phlegmatic habit of body, is no argument against the general rule. The same deceptive reasoning has been attempted to show the innocuousness of free spirituous and vinous potations in general. But how small the number of exempts out of the legions of those whose health and comfort and re- spectability have been ruined, and their lives abbreviated by such practices. Well have these privileged exempts been called the Devil's decoys—seducers of the thoughtless crowd to their undoing. The use of ardent spirits is, particularly in conjunction with expo- sure to vicissitudes of weather, a powerful cause of this disease. Age and sex exert a great influence over the development of chronic laryngitis. Almost all the,patients whose cases are re- corded by different writers were between twenty and fifty years of age; the most of them between thirty and thirty-five. It appears, from the observations of Louis and Serres, that among individuals of the tubercular diathesis at least, the organic alterations in the larynx and trachea are twice as numerous among men as among women. Women are less subject to alterations of the organs of voice than men ; and children, whose constitution is very analogous to that of women, participate in this immunity. Mention has been made already of irritation and phlogosis of the fauces and pharynx being associated with similar states of the larynx, The disease of the latter is commonly in these cases, whether syphilitic or otherwise, consecutive to that of the former. In some cases of chronic gastritis, there is morbid redness and aphthae of the fauces and pharynx, which extend, by continuous sym- pathy, to the glottis and upper part of the larynx, and give rise to alteration in the voice, cough, expectoration of purulent mucus, &c. TREATMENT OF CHRONIC LARYNGITIS. 157 A restoration of the healthy state of the stomach, if accomplished in an early period of the disease, will bring about a removal of the laryngeafsymptoms. In small-pox, we have frequent instances of this extension of inflammation from the fauces and pharynx to the air-passages, and the consequent changes in the voice and respira- tion, already described among the symptoms of chronic laryngitis ; with this difference, that in the secondary laryngitis from small- pox, the disease runs its course with a rapidity which brings it within the stage of acute disease. A slight irritation of any part of even the buccal mucous surface, by establishing an afflux towards the throat, will develop chronic laryngitis; as, for example, a caries of one or more of the teeth. A celebrated singer, Mme. Main- ville Fodor, the syren of the Italian opera, who enraptured the inhabitants of Paris in my time of study there, is said to have lost her voice in this way. LECTURE LXI. DR. BELL. Treatment op Chronic Laryngitis.—Rest of the vocal apparatus,—antiphlo- gistics,-^-counter-irritants,—narcotics, mercurials, iodine, sarsaparilla, balsam of copaiva, blue mass and syrup of sarsaparilla, sulphurous waters—Topical remedies : inhalation of simple and stimulating vapours; caustic to the parts; attention to anginose complication—Syphilitic chronic laryngitis: mercurials, sarsaparilla, iodine—Tracheotomy, when proper—Prevention of the disease- Clergymen,—rules for their guidance—Uniform temperature of air—Jeffray'a Respirator—Change of climate. The treatment of laryngeal phthisis will vary with its stage and the predominance of certain symptoms. In the first stage of the disease, marked by slight hoarseness, a feeling of heat and dryness in the throat, and imperfect expectoration or hawk- ing of muco-serous matter, the-remedies will be the same as for common catarrh. But if the inflammation does not readily yield to the simpler means, including abstinence from all kinds of ex- citement, and if the hoarseness is increased, and accompanied by aphonia and the characteristic cough before described, more ener- getic and systematized measures are required. The first condition for restoration to health is entire rest of the vocal apparatus, as far at least as speaking above a whisper. Provided there be no effort made by the patient to render what he utters more distinct, speak- ing in a whisper is not attended with any evil in the opinion of Drs. Trousseau and Belloc; but even this in conversation with a stranger, when an effort at a certain pitch is made, is sometimes more fatiguing to the patient than his speaking aloud. The indul- gence of whispering is the more allowable, when we reflect on the extreme difficulty of keeping the patient silent for several months in succession. First among the class of antiphlogistic remedies, 11* 158 DISEASES OF THE RESPIRATORY APPARATUS. applicable to the more decidedly inflammatory or incipient stage of the disease, is bloodletting. * The authors just named prefer greatly venesection to leeches, unless these are freely used. But if the disease have made progress, or the patient be enfeebled, leeches are to be preferred ; in which case they should be applied on each side of the larynx and trachea, inside the sterno-mastoid muscles. The feeling of relief expressed by the patient after their use is often very great. Cups to the nape of the neck I have seen to be of marked benefit; although perhaps not equal to the other methods of drawing blood. If there is reason to believe that the disease has arisen from suppression of the menstrual or hemor- rhoidal discharge, or is greatly aggravated by such suppression, leeches ought to be applied, in the former case, to the thighs or the vulva, and in the latter to the anus. Emollients internally may soothe irritation without exerting any material influence over the disease; but their external use, in theform of warm poultices to the neck, will be injurious by increasing the afflux of fluids to the throat. Coinciding with bloodletting, and a useful substitute for this latter, is tartar emetic, given at first to vomit, and afterwards with a view to its contra-stimulant effects, in such doses, three or four times a day, as the stomach will tolerate. In cases of sustained inflamma- tion, the vinous tincture of colchicum may be combined with tha antimony, and occasionally, when the bowels are to be acted on, with Epsom salts. After the disease has been of some duration, revellents, or counter- irritants, will be found to be among the most efficacious of our remedies. They are deemed more beneficial than bloodletting by MM. Trousseau and Belloc. Blisters are advantageous, but only when kept long discharging. They ought to be applied to the nucha, because when placed in front they create too much pain and irritation, especially in men with thick beards. Setons and the potential cautery, applied to the anterior part of the neck, opposite the crico-thyroid space, are, also, very useful. In milder forms of the disease, the eruption produced by rubbing a liniment, composed of croton oil two drachms to an ounce of olive oil, at first twice daily, will have a good effect. Next to this, and on the rising scale of activity, are the tartar emetic and the aminoniacnl ointments, rubbed, as in the former case, over the front and sides of the larynx and trachea, until an eruption is brought out by the former, and a rubefaction or slight vesication by the latter. The antimonial fric- tions should be continued even after the pustules first appear, and until they are confluent, and then renewed when the scab begins to fall; and so on at intervals of perhaps twice a month while the disease lasts, or as long as there is any evidence of relief being ob- tained by the practice. I have used iodine ointment with beneficial results. The writers already quoted direct, as part of a plan of counter-irritation, and we may suppose in cases in which the fric- tions just specified have not been employed, a small piece of caustic potash, to be applied once a week on either side of the larynx and TREATMENT OF CHRONIC LARYNGITIS. 159 trachea. In this way five or six cauterised spots are made to sup- purate at the same time without the necessity of inserting peas to keep them open. Less confidence is to be placed in revulsives when applied at a distance from the diseased organ, unless in the case of suppressed discharge, as of sweat from the feet, hemorrhoids, &c. Narcotics are often of great use in assuaging the pain and cough, in chronic laryngitis. Belladonna, stramonium, and hyosciamus, have been severally recommended : the two former, in the shape of diluted or semi-fluid extracts, by friction to the anterior part of the neck. The salts of morphia, introduced by the endermic method, are, also, a valuable adjuvant to other measures. M. Cruveilhier, with a similar intention, directs the patient to smoke the leaves of stramonium, or of belladonna which had been boiled in a watery solution of opium, and afterwards dried. By calming the cough, and allaying and removing pain, these narcotic remedies abstract causes of irritation and of flux to the larynx, and contribute to the cure. The use of the extract of stramonium in a two-grain pill twice or thrice a day, will have a more uniform effect, as I have ascertained by repeated prescription of this remedy in asthma complicated with laryngeal affection. A mercurial course, that is, the action of mercury on the mu- cous secretors and capillary system—but always short of ptya- lism — even in cases not syphilitic, I have found to be of manifest and permanent benefit; particularly in persons of a sanguine tem- perament and a rather full habit of body, or of active nutrition. In scrofulous subjects we must use mercury with more reserve, if at all; and where tubercular irritation is obvious the medicine must be care- fully abstained from. In these cases, a decoction of senega with nitre; iodine—either a solution of the hydriodate of potassa, three to five grains twice a day ; or Lugol's solution — iodine in water, in which the hydriodate has been previously dissolved,areapplicable. In various chronic affections of the trachea and bronchial mucous membrane, as v\ell as in the present disease, I have used the iodine with much benefit; and especially I have had occasion to be pleased with its effects, when it has been combined with the compound syrup of sarsaparilla. In cases in which the secretion is copious and muco- purulent the balsam of copaiba has done good ; combined with sarsaparilla syrup, I prescribed the balsam on one occasion in what would be called tracheal phthisis, but in which the bronchioe also were affected. The symptoms—consisting of expectoration, more than a quart in twenty-four hours, and accompanied by hectic and night sweats and a rapid pulse—disappeared under treatment of which this last combination was a leading part. The iodine had also been used in the manner already mentioned. When mercury is thought to be proper in chronic laryngitis, the preferable preparation is the blue mass, in doses of five grains every night, with about the same quantity of extract of hyosciamus, made up into pills. In the morning, if the bowels are not free, and the digestive apparatus disordered, some mild saline, or rhubarb and 1 60 DISEASES OF THE RESPIRATORY APPARATUS. magnesia, will be used. This latter difficulty obviated, and a regu- lar and defined course determined on, the blue mass and hyosciamus are to be administered every night, and the syrup of sarsaparilla in the morning. The dose of this latter will be from half an ounce to two ounces, according as it is found to agree with the stomach and bowels, by not oppressing the former nor purging the latter. I do not recommend this treatment as at all of a specific nature, as far as regards this or any other disease, whatever may be thought of its action on particular tissues. In the morbid secretions which accompany chronic inflammations of the mucous tissue, and in ulcerations of this tissue, in the respiratory, digestive, urinary, and genital organs, I do not hesitate to regard the blue mass, iodine, and the syrup of sarsaparilla, and occasionally the balsam of copaiba, as medicines of undoubted efficacy; so far at least as I can be in- fluenced by my own experience, which in this particular entitles me to speak with some confidence. Sulphurous mineral waters, though of secondary importance, are useful adjuvants to the mercurial and iodine course, especially in recent cases of the disease. But without the aid of topical means, the best devised general remedies are inefficient for the cure of chronic laryngitis, as they are of ulcerations and puriform discharges of the throat, nose, eyes, vagina, rectum, &c. These are laid down by MM. Trousseau and Belloc, as either emollient, detergent,or irritating; so as in the latter case sometimes to destroy the morbid surface itself. " They are either pulverulent, liquid, gaseous, in vapour, or salts." These gentlemen think that they have ascertained " a method of bringing medications in form of vapour, powder, or liquid, in contact with the mucous membrane of the larynx, without interrupting respiration." Most frequently the vapour of water was employed, either sim- ple, or charged with emollient, balsamic, or aromatic substances. Sometimes the vapours were dry, as the smoke of tar, resins, hyos- ciamus, tobacco, poppy, &c. The moist vapours have also been charged with chlorine, iodine, hydro-sulphuric acid, and different essential oils, and applied with some effect to the mucous membrane of the air-passages ; as shown by the experience of MM. Bertin, Gannal, Cottereau, Richard, Sir C. Scudamore, and Dr. Murray, most of which is detailed in my work on Baths and Mineral Waters. This kind of medication has been taken up by some phy- sicians lately, as if it were a new thing ; and it has been made an affair of newspaper prescription and popularity. If, which I doubt, any physician gains by such proceedings, the good people at large are certainly sufferers by their being thus tempted to become their own doctors. Various kinds of apparatus have been made for the purpose of inhaling these vapours ; but it is admitted, even by some of their inventors, that a simple teapot is as well adapted as the most complicated machine. MM. Trousseau and Belloc have also caused patients to inspire fumigations of cinnabar, sulphur- ous acid, &c, with various, but not recorded results. All inhala- tion, of whatever nature, is, however, liable to the objection that TREATMENT OF CHRONIC LARYNGITIS. \Q\ the substance inhaled is not confined to the larynx, but comes in contact with the mucous membrane of the lungs, which it may irritate. It is impossible to limit its action, and hence the necessity of restricting ourselves to the employment of emollient, aromatic, balsamic, and narcotic vapours, and such as cannot exercise any sinister influence on the lungs. An objection, or rather a difficulty of more common occurrence, is the small proportion of these medicated vapours which pass through the glottis at all — closed as this is instinctively when any foreign substance in the air reaches it. The liquid medications are much more easily applied, and without risk of injuring the trachea and bronchia. Of these, some are irritat- ing ; others simply astringent. The former are, muriatic acid, solu- tions of nitrate of silver, corrosive sublimate, sulphate of copper, and sub-nitrate of mercury, and the caustic solution of iodine as recommended by Lugol. The solution of the nitrate of silver would seem to be entitled to the greatest confidence, on account of its rapid action, its relative harmlessness, and its known efficacy in so many external ulcerations and other lesions of tissue. The strength of the solution will vary from half a drachm to a drachm in two drachms of water. Various methods have been devised for applying the caustic to the larynx. The simplest is the introduction of a small conical paper bent at its end, and which has been immersed in the solution, into the throat, and down into the larynx, the mouth of course being kept open during the time by the crooked handle of a spoon. A piece of whalebone answers the same purpose, and more conve- niently reaches the part affected. When it is desired to cauterize the pharynx, the base of the tongue, and the top of the larynx at the same lime, MM. Trousseau and Belloc take a piece of whalebone about a sixth of an inch in thickness, and so that it will not bend too readily: this is heated at an inch or more from one end, and when softened sufficiently it is bent at an angle of forty-five de- grees. To the end of this smaller portion a spherical piece of sponge is fastened, half an inch thick, which is moistened with a solution of nitrate of silver, and introduced in the following manner. The mouth open, and the tongue depressed as before, the sponge is passed through the isthmus of the fauces, which gives rise to an effort of deglutition and a consequent elevation of the larynx, and at this moment the sponge is brought somewhat forward, and from the entrance of the esophagus it now passes into the glottis, and by a little pressure against the latter the fluid is squeezed into the larynx. The cough which is produced at this time favours the introduction of the caustic. Vomiting is often excited by the operation. This plan, though not painful, is, according to its proposers, very disagreeable; and many patients refuse to submit to it a second time. These gentlemen have, in such cases, another means of effecting their object. To a small silver syringe, like that of Anel, a canula, at least five inches in length and curved at its free xlremity with a very small opening, is attached. The syringe is 162 DISEASES OF THE RESPIRATORY APPARATUS. filled three-fourths with air, and one-fourth with a solution of nitrate of silver. The canula is then introduced into the posterior fauces, opposite the larynx; and the piston being rapidly advanced, the liquid mixed with the air in the syringe falls in a fine shower on the superior part of the larynx and esophagus. The patient is seized immediately with a convulsive cough and regurgitation, by which he throws off all the solution yet uncombined with the tissues. I have used, as more convenient, a piece of sponge sowed carefully to the end of a small sized gum-elastic catheter, with a rod in, and the end of which has the required curve given to it, so as to allow of a ready application to the opening of the larynx and borders of the epiglottis. The sponge is to be dipped in the solution as just now recommended. The patient is to be made, directly after- wards, to gargle his throat with water acidulated with muriatic acid, or salt water, which decomposes any of the free solution remaining in the pharynx. Another mode of employing caustic solutions mentioned by Dr. Stokes, is that of Mr. Cusack. A brush of lint, of the requisite size, is sewed on the end of the finger of a glove, which is then drawn on the index finger of the right hand. The patient should be made to gargle with warm water, and the lint, being dipped in the solution, can be at once carried to any part of the pharynx, and even to the rima. It has been appropriately observed by the two French writers from whom I have so largely borrowed for the pathology and treat- ment of chronic laryngitis, that one must have practised these cau- terisations, or seen them performed, to have an ideavof their harm- lessness and of the little pain which results. We are very much alarmed at a cautery, for it is exceedingly painful when applied to the skin or mucous opening, though scarcely felt in the pharynx, larynx, or the neck of the uterus. I know that the application of a strong solution of nitrate of silver to the epiglottis and rima glot- tidis has been followed by very little pain, and did not prevent the patient from sitting down to table and eating his meals as usual in half an hour afterwards. These gentlemen in their valuable work* adduce the histories of several cases in proof of the superior efficacy of this topical treatment over any other. It has succeeded after the other means had been tried in vain. Of the probable coexistence of angina pharyngea with chronic laryngitis I have already spoken. Again, I" would remind the practitioner of the importance of being aware of this conjunction, and, of course, of the necessity of examining carefully the lining of the fauces and pharynx, and of applying to it appropriate topical remedies; emollients, if there be inflammation; caustic solution, or pencilling it with caustic, if the affection be chronic, and manifest itself either by a relaxed tissue, or by aphthous spots, or minute ulcerations. The portion of the membrane which in these cases more commonly requires to be treated in this way is that covering * A good translation of this work of MM. Trousseau and Belloc has been made by Dr. Warder, of Cincinnati. TREATMENT OF CHRONIC LARYNGITIS 163 the tonsils and the arch of the palate. For this purpose, we should touch, two or three times a week, the part just mentioned with a pencil of nitrate of silver, or a solution of the same, or a powder composed of six or eight grains of the salt to about a drachm of powdered sugar-candy. In the same way, we employ powdered alum. Sub-nitrate of bismuth may be used pure ; calomel with twelve times its weight of sugar ; red precipitate, sulphates of zinc and copper, with thirty-six times, alum with twice, acetate of lead with seven times, and nitrate of silver with seventy-two, thirty-six, or even twenty-four times its weight of sugar. The apothecary should be directed to prepare these powders on a porphyry slab, otherwise small crystalline asperities remain, which act as irri- tants, and bring on repeated fits of coughing and the expulsion of the powder. The insufflation is best practised by the patient himself, by means of a glass tube two lines in diameter and eight or ten inches long. Three or four grains of the powder are to be put into one end of the tube, and the other is to be introduced as far back into the mouth as possible. After emptying the lungs by a strong expiration, the patient closes his lips upon the tube, and then by a quick effort of the diaphragm draws his breath rapidly. The column of air, in traversing the tube, divides and hurries along the powder towards the pharynx ; but a part suspended in the air penetrates the larynx and upper part of the trachea. We are apprised of its having entered the larynx by fits of coughing, which the patient should repress as much as possible, so as to preserve the medicine in con- tact with the affected tissue. These inspirations will vary in num- ber, according to the sensibility of the larynx and the strength of the powder. A saturated solution of corrosive sublimate, or of sulphate of zinc or of copper, will fulfil the same indication as the powders before mentioned. When chronic laryngitis has a syphilitic origin it will be removed by mercury, and, at times, under circumstances of the most dis- couraging nature, as where the patient had been reduced to the last degree of emaciation, with hectic fever and night sweats. But let us not forget that this result is not certain, even in old cases of syphilitic laryngitis ; and that mercury has in some of these aggra- vated all the symptoms. In these cases, the ptisan of Feltz has brought about a rapid cicatrization of the ulcers—Cruveilhier, Die- tionn. de Med. et de Chir. Prat). The ptisan here referred to is made of a decoction of sarsaparilla, China root, and other vegetable matters of less strength, in which sulphuret of antimony has been previously put, and to which, subsequently, corrosive sublimate has been added. A neater and more pharmaceutical method is to direct a solution of the mercurial salt in water, to which some simple syrup and a little of Hoffman's anodyne have been added; and afterwards, in the course of the day, the compound syrup or a strong decoction of sarsaparilla. In the advanced stages of syphilis, in which the mucous mem- 164 DISEASES OF THE RESPIRATORY APPARATUS. brane of the mouth and throat was the seat of extensive ulcerations, I have derived excellent results from the iodine preparations already mentioned, conjoined with the syrup of sarsaparilla, in cases, too, in which mercury had either failed to relieve or had aggravated the disease. There is, occasionally, an extreme state in this disease short of death, but which, if not relieved, ends in dissolution. I refer now to the imminent danger of suffocation in some cases: a present remedy for which is tracheotomy. But before having recourse to this last trial of our art, we should have given effect to the following appropriate remarks and suggestions of Dr. Stokes: — " In some cases spasmodic exacerbations occur, so severe as to threaten the life of the patient. These are more frequently met with in females, and demand a careful study. The suddenness and vio- lence of attack, the absence of corresponding fever, and of tumefac- tion of the epiglottis, will in general suffice for the diagnosis. I have often seen cases in which the suffering was so severe, as that, at the instant, performance of tracheotomy was advised, yet in which the breathing was restored to its ordinary condition by the following simple treatment: the feet were plunged in warm water, the body enveloped in blankets, and a draught, consisting of camphor mix- ture, ammonia, valerian, ether, and opium,—exhibited, and repeated according to circumstances. Under this treatment symptoms will rapidly subside, which from their character and continuance would seem to demand the knife; and I would advise that, in all cases,pre- vious to the performance of tracheotomy in chronic laryngitis, the question be carefully investigated, as to whether the urgent symp- toms are the result of spasm or of organic obstruction. Let it never be forgotten that, even where organic disease and thickening of the larynx exists, spasm may supervene, and be met by appro- priate treatment. We are not much attached to the doctrine of diseases being necessarily separate, but experience tells us that nothing is more common than to see spasm following organic dis- ease, or organic disease occurring after a purely nervous lesion. " In cases showing this liability to spasm, the belladonna or other anodyne plasters may be usefully employed." Tracheotomy, then, ought not to be performed except when the patient is threatened with suffocation, and all the promptly available medicinal means have been had recourse to. On these conditions, the operation having been performed, the physician, now freed from the fear of seeing his patient die of asphyxia, may proceed to treat the affection of the larynx in a suitable manner; and when the organ is capable of performing its functions, the canula can be withdrawn, and the wound allowed to heal. Even should the dis- ease be of such a nature that the passage of air through the natural canal is afterwards impossible, the canula may remain for an in- definite period, and the life of the patient be lengthened. A case is given by MM. Trousseau and Belloc, of an individual wearing such an instrument, made of silver, for ten years. They state their having performed it seventy-eight times; seventy-three for croup, and five TREATMENT OF CHRONIC LARYNGITIS. 165 for laryngeal phthisis, with the loss in one instance only of life during the operation. They give a number of successful results from tracheotomy. This would be the proper place for indicating the best preventive measures against so formidable, and, of late years, so frequent a dis- ease among us as chronic laryngitis. 'The immediate and exciting cause in most of those members of the different learned professions, law and divinity, who have been sufferers from it, is, no doubt, undue exercise of the voice: but as we meet with the disease in per- sons who are not exposed in this way, and since, as I have already remarked, there is often no proportion between the repeated strain of the voice for a length of time and the frequency and vio- lence of chronic laryngitis, we ought to look out for other causes, as well predisposing as exciting, beyond the one commonly regarded as the chief cause. We are, as yet, wanting in the requisite statistical data for a proper knowledge of the proportions of the members of different professions and callings affected with the disease. So far as medical observation and popular belief guide us in form- ing an opinion, clergymen are most liable to it. As far as they are concerned, then, our investigation should be directed to an inquiry into— 1, the temperament which we may suppose would be most frequently met with in those whose early bias is to seri- ous and religious reflections; 2, the bodily constitution and colle- giate habits of students for the ministry; 3, the kind of labour and exposure either voluntarily entered into by, or exacted from these young men after they have assumed the office and reponsibilities of the ministry. It will be found, I believe, on a review of the facts under their several heads, that a youth of a nervous temperament and feeble constitution, is exposed while at college, or when pursuing his theological studies elsewhere, to the enfeebling influences of de- ficient exercise ; confinement in illy-ventilated halls and dormitories; study beyond measure, and at late hours in the night; anxiety of mind, both as respects his preparation for the solemn part which he is destined to perform, and his worldly success: habits of sensual indulgence, such as the use of tobacco and other means of enfeebling the nervous system. It is easy to see how badly such a person is prepared for the unremitting toil to which, partly from duty, partly from sectarian rivalry, and in no small degree also from the urgent and often unreasonable calls, exactions, in fact, by the inconsider- ately zealous of his congregation, he is subjected, so soon as he accepts a call to a church. Preaching often on Sunday and not sel- dom during the week in close churches, and in the evening too, and in a pitch of voice beyond his natural one, would of itself bring on laryngeal disease in a person already feeble and unable to exercise any organ much without inducing phlogosis and its con- sequences. But when to this cause we add exposure to frequent and sudden transitions from a dry and hot to a moist and cold air, as when leaving his own home to visit the sick, and, still more, vol. n. — 15 166 DISEASES OF THE RESPIRATORY APPARATUS. to attend and officiate bareheaded at funerals, in the midst some- times of a storm of wind and rain, or of snow ; and when he passes from a crowded church, in which he has been perspiring, to the open and chilling air of a cold night, we cease to wonder that the preacher should suffer from diseases of the lungs and air- passages, and especially of that part, the larynx, which has been enfeebled by prolonged and violent exercise, and is, in consequence, peculiarly predisposed to disease. The prophylaxis of chronic laryngitis should consist in an early attention, on the part of the professional student, to all the agencies counteracting to those which bring on the disease. These preven- tive measures should be much exercise in the open air, a regular training of the vocal apparatus by both methodical speech and even song, so as to accustom the voice to every variety of pitch and into- nation; and to husband its strength, if it be naturally weak, by ac- quiring the habit of distinct and expressive articulation and enuncia- tion. By uniting the two kinds of gymnastic exercise—that of the muscles of the body and limbs generally, and that of the muscles of the voice—the student will be both fitted to discharge his subse- quent duties and less liable to catarrhal and anginose affections. He will enter on the duties of his ministry with some bodily vigour, and with habits of exercise, which he will feel a pleasure, as it will be his duty, to continue. When prevented by inclement weather from taking exercise out of doors, he will have recourse to the use of the dumb-bells and the parallel bars at home. Nor should he omit to keep his vocal organs in the proper tone during the week, in order that he may without fatigue, certainly without injury, task them on Sundays. For this purpose he will not only read aloud but declaim, and vary his tone and inflections, so as to give himself.a wide range of vocal utterance, and yet distinctness and power within this range. Deviation from healthy digestion, and particularly if asso- ciated with uneasiness in any part of the throat, should be early at- tended to and corrected; and a relaxation of the tissue lining the fauces and pharynx and investing the soft palate and tonsils, removed by astringents, or even a slight cauterization in the manner already described. Among the hardening measures, is the use of the tepid bath, or sponging the surface of the body, and particularly the sur- face of the chest, daily, with cold salt and'water. The throat should be well gargled at rising, and after every meal, and, at any rate, the whole neck washed in the morning with cold water. No ligature, or tight cravat, or stock should be worn—nothing, in fact, which ex- erts a compression on the neck, or invites more blood to the part. Many of the above hints are applicable to the members of the bar, and to all public speakers who would strengthen their physical powers of utterance, and avoid disease of the vocal apparatus. As any sudden change of temperature of the air which is inhaled is prejudicial to the invalid suffering under chronic laryngitis, he is recommended, when about to pass out from a warm room into the external air, to place a silk handkerchief, or somekind of network before his mouth and nostrils. There has lately been made in TREATMENT OF CHRONIC LARYNGITIS. 167 England an apparatus called. " Jeffray's Respirator," which is preferable to a handkerchief, or any similar contrivance. It con- sists of a number of layers of delicate wire-net, secured on each side by morocco leather, and straps or strings so as to allow of its being tied to the back of the neck, whilst the person breathes through the wire-net; inhaling an air, which by the time it has reached his mouth, and certainly his larynx, is of a suitably elevated tem- perature. I am acquainted with the case of a lady, who, whilst suffering under catarrh, was kept awake half the night with a troublesome cough, which was speedily arrested, and she allowed to sleep undisturbed, after she had put on the respirator at her hus- band's suggestion. Transition from a cold to a hot air is even still more injurious than the onefrom hot to cold; and hence the respirator should be kept on for a while after coming in from the outer air. A more permanent amelioration is obtained by a change of cli- mate. With this view, a residence for a year or more in warmer latitudes, or sometimes during the winter months only, is recom- mended to patients with chronic laryngitis as well as to those with chronic bronchitis. Where circumstances prevent their ab- senting themselves from home, an artificial climate may be pro- cured by keeping up a uniform temperature and moisture in the house; and the patient confining himself to it during the whole of the winter. But before having recourse to a change of climate, the patient should be freed from any inflammation of the air- passages under which he may be labouring at the time; for, without suitable precaution on this score, he will be more likely to be injured than benefited by leaving home, and exposed to the operation of causes in travelling which tend to aggravate the in- flammation. Another important consideration is the state of the digestive organs. There is hardly any morbid association more common than that of irrita-tion of the bronchial and laryngeo-bronchial mem- brane with a similar irritation of the stomach; especially after the middle period of life. In cases of this kind, it is well remarked by Sir James Clark ;" upon tracing the progress of the disease, we shall generally find that the bronchial affection, the liability'to catch cold,' the ' spring cough,' the troublesome morning phlegm, ifcc, did not occur till the patient had suffered for some time, often for years, from symptoms of disordered digestive organs. When this is the case we shall make little progress in the case of laryngeal and tracheal diseases until we have subdued the irritation of the digestive organs; and the hopes of the successful issue of our treatment, must, therefore, rest chiefly on the facility with which this yields to our remedial measures." This remark may be usefully extended to nearly all chronic dis- eases, over which the stomach, in its different conditions, displays so great and, at times, extraordinary an influence, as to induce those who are not patient and attentive in diagnosis, to attribute the constitutional disturbances caused by lesions in other organs, and notably in the lungs, heart, and even brain, to gastric origin. 168 DISEASES OF THE RESPIRATORY APPARATUS. LECTURE LXII. DR. BELL. Bronchitis. — Its complications with other diseases—Catarrh, a prelude to more serious disease—Importance of early attention to it—Outlines of treatment of catarrh—The dry method of Dr. Williams.—Bronchitis,—its divisions—The kind showing itself in young children—Asthenic variety, or peripneumonia notha—Duration of acute bronchitis—Symptoms,—appearance of the sputum —Physical signs—Percussion, indirectly useful—Touch giving a sense of vibration—Auscultation—Modifications of" sound, produced by inflamed and ob- structed bronchia—Division of sounds in respiration, indicating diseases of the lungs—Meaning attached to the terms rhonchus, sibilus, and crepitations— Specification of sound according to the portion of bronchia diseased. Bronchitis.—Acute Mucous Catarrh.—Inflammatory Catarrhal Fever. — This disease has only been separated from inflammation of the lungs of late years. We are indebted to Dr. Badham of Glasgow for being the first to perform this service to the profession and to humanity, and for pointing out its nature and seat, in a small work published by him on bronchial inflammation. After him, Dr. Hastings has since contributed largely to fix attention on the disease, and to introduce it formally under the title of bronchitis. In varying degrees of intensity, inflammation of the bronchial mucous membrane is met with in neglected catarrh; or it comes on primarily after the inhalation of irritating gases or poisons; or as an occasional and always alarming complication in remittent and typhous fevers, in the exanthemalas generally; but more espe- cially in measles and small-pox; also in gout and rheumatism, and in hooping-cough, asthma, pneumonia, phthisis pulmonalis, pleu- risy, and carditis. In sympathetic relation with all the mem- branes of the body, and more particularly with other divisions of mucous membrane, the bronchial portion is liable to inflammation, not only after laryngitis and tracheitis, but after gastritis and gastro- enteritis and diseases of the skin, both acute and chronic. Bron- chitis frequently occurs in an epidemic form, under the popular title of influenza or grippe. In some situations it may be said to prevail endemically, as at the Children's Hospital in Paris. A common cough, catarrh, or cold in the breast, is a mild form of bronchitis. All ages are subject to this disease, which may even be con- genital. Children in our climate are found to be particularly liable to it, and in some seasons are its chief victims. With us, also, the complication of bronchitis with hepatic and gastro-intestinal de- rangement is frequent; more so probably than the union of pneu- monia or of pleurisy with disorder of the liver, designated as bilious pleurisy. Bronchitis is commonly ushered in with catarrh, the precedent of which again is frequently coryza, or cold in the head. The first stage consists in simple irritation of the mucous surface of the eyes CATARRH — BRONCHITIS. 169 and nostrils, which is soon spread to the fauces, and is manifested by an increased secretion, chiefly of a serous fluid; sneezing, and some soreness of the throat. The irritation extending to the trachea and bronchia, there is a tickling cough, with an expectora- tion of mixed serum and mucus. At this stage the disorder some- times ceases, and the individual is said to have soon got over his cold. But, under other circumstances, there is not simply an irri- tation of the mucous membrane and glands of the bronchia, but a positive inflammation of these parts, and a train of associated symptoms which indicate great distress in the respiratory appa- ratus, as they do real danger to the life of the patient. Sometimes the affection of the bronchia shows itself without any prior irrita- tion of the Schneiderian membrane, fauces, and tonsils; and this is more apt to be the case in delicate persons, or in those predisposed to coughs and pulmonary disease. A few remarks on catarrh, or a common cold, as it is familiarly called, will properly precede a notice of bronchitis in its more aggra- vated varieties. If the commonness of a thing were to render men indifferent to its presence, the people of the East ought not to care for the plague, nor those of the West Indies for the yellow fever; but, still, these diseases are avowedly worthy of study, and serious enough to be avoided if possible. I will not say that colds are to the inhabitants of our climate what plague and yellow fever are to those of other countries ; but I can aver confidently that they usher in dis- eases of greater complexity and mortality than these latter. The common accompaniments of a cold, viz., toothache, earache, head- ache, weak and watery eyes, sore throat, rheumatic pains, indiges- tion, and renal disorders, are quite numerous and disagreeable enough to entitle it to a very respectful notice, and much more con- siderate treatment than it usually receives. If to these annoyances we add the danger from bronchitis and pneumonia, which often fol- low in the train of a neglected cold and from phthisis pulmonalis, the tubercular irritation of which is developed by the same cause, we surely have proof and argument enough for attention not only to the preventive means, but also to the curative ones of a disease, which, however mild in its inception, is directly or indirectly pro- ductive of such diversified and alarming results. More particularly should this lesson be impressed on those who, in consequence of prior attacks of bronchitis, or of constitutional tendency to pulmonary consumption, are in the greatest danger from every fresh cold. They, at least, can ill afford to make the hazardous experiments of nursing and sweating themselves one part of the twenty-four hours, and of exposing and chilling themselves during the remainder, as we every now and then find persons with catarrh to do. If time be of value to him, ' who has caught a bad cold,' it is the more incumbent on him to act promptly in the premises, by his sub* mining at once, and with a good grace, to the adoption of suitable measures for his relief. These will be, quiet in an air of an equable and rather warm temperature, abstinence from animal food and ali 15* 170 DISEASES OF THE RESPIRATORY APPARATUS. stimulating drinks whatever, and in their stead a moderate portion of vegetable matters and simple demulcents. Under the head of medicine will come a brisk purgative, mercurial or saline, accord- ing either to the prior experience of the person himself, or to the state of his digestion and the activity of his circulation. If there be indigestion, a foul tongue, and turbid urine, let him have a dose of calomel and jalap, or of calomel and rhubarb; if his habit be plethoric, he should take salts. After evacuation procured by this means, if the cough harass and is aggravated by the thin serous secretion from the trachea and bronchia, an opium pill of one to two grains, or twenty to forty drops of laudanum ; or Dover's pow- der in five-grain doses, repeated two or three times at intervals of four hours ; or laudanum with antimonial wine will come in appro- priately enough, and not unfrequently relieve all the troublesome symptoms, including pains in the limbs. The headache frequently left by the opium is carried off by a dose of magnesia, or eight or ten grains of carbonate of ammonia, or a teaspoonful of spirits of hartshorn in water. When the stomach is in a healthy state and the bowels free, a full dose of opium often cuts short a cold, and will therefore arrest at once a mild bronchitis. If the cough, however, still continues after the above remedies have been used, recourse is generally had to various formulas of cough mixtures, the active basis of which is either ipecacuanha or antimony, and less fre- quently squills, with opium in some form or another. My own ex- perience has taught me, that the simpler these formulas are the better; antimony (tartar emetic) entering in larger proportion, if there be a tendency to inflammatory action, — ipecacuanha if there be gas- tric complication, and opium if the skin is cool, or the tempera- ture of the surface unequal, and the cough is accompanied with thin expectoration, come on in fits, and is readily excited through the nervous system alone. I can add, with great confidence also, my own testimony, in confirmation of the favourable opinion of others, to the value of the alkalies in simple catarrh, as well as in the more advanced stages of confirmed bronchitis. Wine of ipecacuanha, sub-carbonate of potassa and laudanum in suitable proportions, mixed wiih simple syrup and water, make a cough mixture, to which, especially in the cases of children's catarrh, I am not a little attached. In the more asthenic forms, twenty to thirty drops, for an adult, of the aromatic spirit of ammonia will be properly sub- stituted for the carbonates of potassa and soda. The physician who has tried the alkaline remedies will join Dr. Williams in opinion, — that they quiet the cough and promote expectoration far better than the oxymels and acid iinctus, or lozenges, and I would add syrups of squills, that are commonly in use, and which, how- ever they may appear at the time to " cut the phlegm," and cleanse the throat, tend to disorder the digestive organs, and often ultimately increase the cough. Both with a view of keeping up their influence on the secretion from the bronchia, as well as tolheir immediate impression on the glottis and the throat, cough medi- TREATMENT OF CATARRH. 171 cincs should be taken frequently: and during the intervals it is well to sheathe the fauces against irritating secretion, and through continuous sympathy to operate on the upper portion of the air- passages, by having often, if not constantly in the mouth, a piece of gum arabic, or by sipping frequently of thin flaxseed-tea, or some analogous demulcent decoction. In a class of subjects of catarrh, who are said to be of bilious habit, and also those who are dyspeptic, opium, and the common cough mixtures into which antimony and squills enter, are often prejudicial, and increase the gastric disorder by which the cough is accompanied, and not seldom sustained. For these cases other narcotics are thought to be better adapted, such as the hyosciamus and conium, &c.; which certainly less interfere with the digestive process, and, if combined with rhubarb or the compound extract of colocynth, or, better than all, the blue mass, will be found to answer the double indication of modifying beneficially the secretions of the bronchial and the gastro-intestinal mucous membrane. The alkalies are useful adjuncts in the intervals between the times of taking these combinations or the narcotic extracts alone. There is another plan of treating a cold, by what its author, Dr. Williams, calls drying it up. He first practised it on his own per- son. Having observed, on being attacked with one of the colds, to which in early life he had been so subject, that taking a quantity of tea or any other liquid, although very comfortable at the time, was invariably followed in the course of an hour by an increased 'stuffing in the head,' and accompanying flow of scalding, irritating humour from the nose and eyes, he determined to try and prevent such exacerbations "by cutting off the supplies — by ceasing to drink. For twenty-four hours," continues Dr. Williams, " I did not take a drop of liquid of any kind ; and to my agreeable surprise, not only did I escape these occasional aggravations of the complaint, but the stuffing and discharge began to show evident signs of abate- ment, and the handkerchief was in less continual requisition. I persevered for twenty-four hours more, and my cold was gone; there being only now and then a little gelatinous, opaque mucus collected in the nostrils and throat, without any stuffing or irrita- tion, just as it lakes place at the end of a cold. What was of still more consequence, no cough followed; the whole catarrhal disease seemed to have been destroyed." Dr. Williams has been in the habit of acting on this plan of treatment ever since (twelve or four- teen years ago) under similar circumstances, and has recommended it to a great many friends and patients with a successful issue. The physiological principle on which the dry method acts, is by a prompt decrease of the mass of circulating fluids, and a diminu- tion of the partial plethora of the vessels supplying the morbid secretion from the affected membrane, which, no longer irritated by its own secretion, is soon restored to a healthy condition. " If liquid be freely taken too soon, before the membrane have lost its diseased action, the discharge will return, and the complaint will be 172 DISEASES OF THE RESPIRATORY APPARATUS. as bad as ever. But if, after the discharge has been stopped by twenty-four or thirtv-six hours of dry diet, means be taken to keep up the other secretions, as by exercise, with a warm state of the surface, a little liquid may be taken with impunity, the bulk ot the circulating fluid being still below the point at which it can^supply any demands from the irritation in the diseased membrane. Dr. Williams considers it very essential for the success of the dry treatment, that the cold should be in its early irritative stage, when it generally occupies the nasal and pituitary membrane. " If there be any fever, and especially if the state of the bowels requires it, an aperient with an antimonial should be given, for this favours that free state of the secretions on which, as we have seen, the effj- cacy of the dry plan depends, in milder cases, however, this is not necessary. *For the same reason it is expedient that the solid food be not of a too rich or heating kind ; for this, undiluted by liquid, might be apt to disagree. Bread, or any consistent farina- ceous food, with a little butler, vegetables, white fish, and white or gelatinous meats, light puddings and dried fruits, will do very well for a dry diet; and who can call this starving." Sometimes the diet need not be changed in any particular, except on the point of abstinence from liquids; and even in this latter respect, Dr. W. has lately found that a deviation to the amount of taking about a table- spoonful of tea or milk, with breakfast and the evening meal, and a wine-glassful of water on going to bed, does not interfere with the success of the plan, and it certainly adds to one's comfort. A great advantage of this plan is in its not preventing a continuance of one's ordinary pursuits: it needs no nursing or confinement. " In fact, if care be taken to clothe enough to prevent the surface from being chilled, exercise in the open air promotes the success of the plan, by promoting the natural secretions. " On an average, forty-eight hours of abstinence from liquids will be quite enough to effect a cure. The period may be shortened by exercise and warm clothing, or laying warm in bed, or by com- mencing with a purgative, or by any other dry means of increasing the natural secretions" (Lectures on the Physiology and Pathology of the Chest). Bronchitis in its intense and severer forms differs from the milder kind, mainly in the greater extent of the bronchial tubes which the inflammation occupies. It has on this account been studied under the two heads of tubular and vesicular. Tubular bronchitis is inflam- mation of the bronchial membrane lining the larger and middle sized tubes, or wherever it lines tubes, properly so called. Vesicular or pulmonic bronchitis is that variety in which the mucous membrane lining the air-cells of the lun^s is inflamed. Something, also, will depend on the intensity of the phlogosis, even on an equal surface. Like all the phlegmasiae, bronchitis exhibits an acute and a chronic form. The first again is appropriately divided into the sthenic and the asthenic varieties. SYMPTOMS OF BRONCHITIS. 173 Symptoms. — In sthenic bronchitis, inflammatory symptoms are evident from the commencement. After the preliminary stage of simple coryza, already mentioned, or, sometimes, without any notifi- cation of this kind, the patient suffers from pain and a feeling of tight- ness across the sternum, dry hard cough, without expectoration, or with the discharge in this way of glutinous mucus combined with frothy serum, sometimes coloured with blood. The chills, with which these symptoms are ushered in, soon alternate with increased heat and dryness of the skin, and are followed by quickened and some- what laboured breathing and dyspnoea, and sometimes a dull pain at the sternum on coughing; tongue while with red borders; pulse quick andfull, andattimeshard; pain in theforehead, back,and limbs; constipation, and scanty, high-coloured urine. As the disease ad- vances, the cough becomes more troublesome, and in its paroxysms causes redness of the face, watery eyes, and a feeling of pain in the hypochondria along the false ribs, in the back, and at the lower part of the sternum ; in fine, in the course of all the attachments of the diaphragm manifesting extension of the inflammation to the vesicles. The cough is generally excited at each full inspiration ; as, also, by speaking, or the mere act of drinking, or a simple change of posture; and it is sometimes productive of nausea and vomiting. Pain in the course of the trachea and the bronchia, as felt under the sternum, and in what is called soreness of the chest, is not a constant symptom. Sometimes it is slight, and the patient complains of a troublesome heat diffused through the chest, and a tickling in the trachea. There is an aggravation of the symptoms towards night, which is generally sleepless and disturbed. The common posture is on the back; but it is often changed. If there be not relief by expectoration or perspiration, or by prompt remedial measures, bronchitis shows a change of character. Feelings of great depres- sion are complained of; the pulse becomes weak as well as quick; the brain is disturbed in its functions, and the muscular strength is much reduced: the countenance, from being often flushed, becomes anxious and pallid, or partially livid, according to the quantity of blood in the system; the pulmonary congestion becomes evident by a slightly diminished resonance on percussion in the postero-in- ferior regions of the chest. The secretions are scanty and vitia'ted ; the tongue is loaded with a brown fur; the thirst is intense. Cerebral and abdominal congestions may also occur, and dropsical swellings are no unfrequent result. The transition from this stage to death is soon made, especially in those cases which have been neglected from the outset. A remarkable feature in the character of the worst form of bronchitis is, the rapidity with which the collapse and symp- toms of extreme prostration and debility succeed to high fever, and well maiked local excitement. The whole course of these fatal cases is sometimes wonderfully rapid, death ensuing within two davs from the commencement of the attack. They are commonly con- 174 DISEASES OF THE RESPIRATORY APPARATUS. founded with pneumonic inflammation, and are scarcely to be dis- tinguished from it during life, but by the physical signs, lhe severest form of bronchitis is, however, more formidable and rapid in its course than pneumonia itself. Another form of bronchitis than that just described presents itself in young children, to whom it often proves fatal. Its beginning, says Dr. Williams, is very insidious, in its assuming the aspect of a common catarrh with coryza, but without pain, much fever, or de- rangement of the general health. An attentive observation, how- ever, will discover a frequency and wheezing in the breathing which is uncommon, particularly before and after fits of coughing; and the paleness of the countenance and depression of the child's spirits indicate something more than a common cold. The cough is not always present, so that this symptom does not indicate the extent of the disease ; and as children do not expectorate, the thoracic derangements may escape notice, until the coming on of dyspnoea shows the imminency of the danger. At this time the pulse becomes very quick, and the severity of the attack is evinced by the disturb- ance of the respiration and circulation. There may be a remission for a time, in which the child remains in a somnolent slate vyithout much cough or quickness of pulse: but if the breathing still con- tinues quick, the dyspnoea returns after a while with increased severity, accompanied by a greatly quickened pulse ; stupor comes on, the lips become livid, and in this or some similar exacerbation the child dies suffocated. Inflammation of the bronchia may exist in newly-born infants, without producing any well marked symptoms. Billard (Dr. Stewart's Translation, 1839,) states, his having in four instances seen the remote ramifications of the bronchia very red and filled with thickened mucosities in children, in whom, during life, there had not been either rhonchus or cough. In two there was pneu- monia with pulmonary engorgement; in two others the lungs were healthy, and death occurred from intestinal inflammation. When bronchitis supervenes on pneumonia (vesicular bronchitis), the smaller divisions of the bronchia are the parts inflamed. Bron- chial catarrh will sometimes give rise to all the symptoms of suf- focating catarrh, which are regarded as the result of an infiltra- tion of serosity in the pulmonary tissue. The asthenic form of bronchitis bears more analogy to the variety just described than to simple acute or sthenic bronchitis. It has commonly been called Peripneumonia Notha, or spurious inflammation of the lungs, and sometimes bastard pleurisy, and by Laennec, Acute Suffocative Catarrh. One of its earliest and cha- racteristic symptoms is oppression of breathing, and a peculiar wheezing; but it has less of the inflammatory type than the first form. The pulse is small, quick, or irregular, and with little or no increase of heat except at night; the tongue foul and loaded ; urine scanty; extremities cold ; headache; exacerbations of dyspnoea so SYMPTOMS OF BRONCHITIS —PHYSICAL SIGNS. 175 severe as to prevent the patient from lying down, and accompa- nied by extinction of the voice. The expectoration, at first scanty, becomes afterwards very copious and frothy. These are the chief symptoms of the disease as it occurs in the persons who are most liable to its attacks, viz., the aged and infirm, and those weakened by prior diseases and excesses. The duration of this form is commonly longer than that of the other or sthenic, and it has a much greater tendency to pass into the chronic form. Persons liable to pituitous catarrh, or who have habitually a cough with copious thin expectoration, generally suffer in this way when attacked by bronchitis. Acute sthenic bronchitis will vary in its duration from one to two weeks. In favourable cases the disease declines between the fifth and eighth days. The appearance of the sputum, if not the chief characteristic of acute bronchitis, as some regard it, is unquestionably of such im- portance as to require our early and continued attention to its suc- cessive changes. In the early stage the secretion from the bronchia is either wanting, and then the cough is dry and hard, or it is scanty, and consists of a sero-mucous fluid, transparent and viscid. If poured out from one vessel to another, it flows out in one mass of extreme tenacity, — drawing out sometimes like melted glass ; and the de- gree of viscosity is a tolerably accurate measure of the degree of the existing inflammation. Upon the surface of the viscid mucus there is usually more or less froth, the quantity of it depending on the facility or the difficulty with which the sputa are brought up; becoming, as the disease advances, more opaque, more abundant, and less tenacious ; and at the period when the inflammatory fever ceases, and is either succeeded by an apyrexial state, or by a hectic, we ob- serve a remarkable change in its character. It becomes thick, and has considerable consistence; or it may pass into the muco-puriform state, and exhibit masses of a greenish-yellow colour, quite opaque, and, though somewhat viscid, yet flowing altogether. For valuable specifications of the appearances and other characters of expecto- rated matter in bronchitis, I would refer to the comprehensive section on this disease by Dr. Stokes, in his excellent Treatise on the Diagnosis and Treatment of Diseases of the Chest. I will merely give now his divisions of the secretions from the bronchial mucous membrane, when in a state of irritation. These are, 1, Transparent mucous secretions; 2, Opaque mucous or albuminous secretions; this again subdivided into the amorphous, and moulded to the form of the tubes; 3, Muco-puriform secretions; 4, Puriform secretions; 5, Serous secretions. Much light is thrown on the pathology of bronchitis by the physical signs. They are derived, first, from percussion; second, from the touch : third, from auscultation. As regards percussion, it is admitted, very generally, that it fur- nishes no direct sign in the present case; the sound on striking the chest being almost always of a natural clearness. There is but 176 DISEASES OF THE RESPIRATORY APPARATUS. a single case in which simple bronchitis is even attended with decided dulness, and that is, one in which a vast secretion of mucus or muco-purulent fluid exists in the bronchial tubes; but, continues Dr. Stokes, who makes this remark, such a case is extremely rare, for a large proportion of the bronchial tube3 may contain quantities of secretion, and yet the sound on percussion shall continue without any perceptible diminution. When, however, the disease is combined with affections which have their seat in the areolar or parenchymatous structure of the lung, such as oedema, congestion, pneumonia, or tubercle, the results are of course different, the extent and situation of dulness varying according to circumstances. Yet, as Dr. Stokes properly remarks, although percussion gives no direct result in bronchitis, its employment is of importance in the particular diagnosis. Thus, suppose that after the existence for three or four days of fever, cough, hurried and difficult breath- ing, the chest still sounds well, the great probability is, that the disease is bronchitis. The patient has had an acute inflammatory affection of the lung, and but of a few days' standing: this must be either bronchitis, disease of the serous membrane, or of the paren- chymatous tissue itself. Here the absence of dulness guides materially our judgment; for were the case one of pleuritic effusion, or of disease of the substance of the lung, the great probability is, that by this time a degree of dulness would be manifested ; in the one case the lung would be compressed, and its place occupied by liquid effusion ; in another, more or less obliteration of the air-cells would take place, from congestion, or from inflammation. The absence, then, of dulness, with the existence of acute irritation of the lungs, which has continued for several days, forms an important argument that the case is one of uncomplicated bronchitis. From the knowledge of the fact, continues the able writer already quoted, that in simple bronchitis there is nothing to produce a perceptible dulness of sound, we derive a most important assist- ance in the diagnosis of tubercular development, whether in the acute or chronic form. The value of this will be seen when we consider the frequent similarity of symptoms between the disease of tubercular phthisis and bronchitis, a similarity easily understood, when we recollect that in most cases of tubercular development there is a coexisting catarrh. But, as will be shown hereafter, the occurrence of a partial, or general and progressive dulness, in a case presenting the symptoms of bronchial inflammation, is one of the principal circumstances on which the diagnosis of tubercle .depends. The sense of touch guides us in forming a diagnosis in bronchitis, by the transmission of a distinct vibration when the hand is laid on the thorax. This sensation can be detected both durino- inspiration and expiration, but is generally more perceptible in the former than in the latter; and more in the child and female than the adult male. The vibration is much more distinct in the middle and inferior than SYMPTOMS OF BRONCHITIS — PHYSICAL SIGNS. 177 in the upper portions of the lung: it is not met with in simple pleurisy or pneumonia. In pleurisy, however, a sensation of rub- bing may occur; but it is that of two continuous, though roughened surfaces, moving one upon another; whilst the bronchial vibration gives the perception of air passing in many directions through an adhesive fluid. The application of the auscultation test is happily introduced by Dr. Williams (Cyclop, of Pract. Med.) ; and the subject is more fully explained in his Lectures on the Physiology and Diseases of the Chest — Philadelphia Edit. We may premise, that the purring, rattling, or wheezing sound, which accompanies breathing in bron- chitis, may be heard by applying the ear to the patient's mouth. Inflammation of the mucous membrane of the bronchia at first causes tumefaction, and consequently a diminution of the cali- bre of the tubes. This occurring in individual points so modifies the passage of the air through them, that, as in a musical instru- ment, a sound is produced. This sound varies according to the form of the constriction and size of the tube ; but the general effect is, that on applying the ear directly to the chest, or mediately by means of the stethoscope, we find the ordinary respiratory murmur accompanied by various whistling and wheezing sounds. These occasionally present a graver tone, like the prolonged note of a violincello, or the cooing of a dove ; and they indicate that some of the large bronchia are the seat of disease. To such modifica- tions of the respiratory sound, M. Laennec gave the names of sibilant rdle, rhonchus, or rattle, and sonorous rdle or rhonchus. These constitute the dry sounds, and are the symptoms of the earliest stage of bronchitis, and are often perceptible, especially during expiration, before the patient is aware of any suffering in the chest. They prove, moreover, the fact, supposed by Dr. Badham, and doubted by Dr. Hastings, that the dyspnoea of the early stage of bronchitis is caused rather by the state of the mucous membrane than by the redundancy of its secretion. Both the co-arctation of the tubes by which air is scantily admitted, and the general thick- ening of the membrane by which the oxygenation of the blood is interrupted, appear to be the physical or pathological causes of the symptom in question — the rhonchus. This is a generic term, ap- plicable to all those sounds which are produced by an increased re- sistance to the air moving through the lungs. Dr. Williams divides them into the dry and the humid, according as the impediments that produce them are solid or liquid. Of the dry rhonchi there is the sibilant or whistling rhonchus, which is sufficiently described by its name, and may be generally imitated by whistling between the teeth. The sonorous rhonchus is a snoring, humming, or drawing sound, and may vary, in loudness and key, from an acute note like that of a gnat down to the grave tone of a violencello or bassoon. There is another rhonchus which Dr. Williams calls the dry mu- cous, because it is produced by a pellet of tough mucus obstructing a tube, and yielding to the air only in successive jerks, which cause VOL. II. —16 178 DISEASES OF THE RESPIRATORY APPARATUS. a ticking sound, like that of a click-wheel. Dr. Williams very properly adds: " Now, as any of these rhonchi may be produced in only one tube, and yet make a great deal of noise, you are not to suppose that they are important in proportion to the noise they make. It is rather when they are very permanent, or when several of them are heard at once in different parts of the lungs, that they bespeak disorder which may be serious, either from its permanency or its extent." The humid rhonchi all depend on the passage of air, or bubbles, through a liquid in the lungs, and their species are produced by differences in the size of the tubes and the nature and quantity of the liquid which cause varieties in the bubbling sound. The mucous rhonchus may be heard in the large and smaller bronchia down to the size of a crow's-quill, and in these different situations its gurgling or crackling presents different degrees of coarseness. When the bronchial tubes become unnaturally enlarged by disease, or when m6rbid cavities are formed by the destruction of portions of lung, the bubbling of air through liquid in these is of the coarsest kind; it is quite gurgling, and if the liquid be scanty, has a hollow character, and is called the cavernous rhonchus. A roughness added to the ordinary respiratory murmur, or the bubbling or crackling, owing to a little liquid in the smaller bronchia, constitutes the sub-mucous rhonchus. It may result from slight degrees of bronchitis, and owes its importance only to its being per- manently present when such slight inflammation is constantly kept up, by the irritation of adjacent tubercles in an incipient state. More liquid, but not of a viscid kind, in the smallest tubes and terminal cells, gives the rhonchus a still more crepitating character, resembling that heard when the ear is applied near the surface of a liquid slightly effervescing, such as bottled cider or champagne. This is the sub-crepitant rhonchus which is heard in cedema of the lungs, humid bronchitis, and other affections in which liquid and air occupy the extreme tabes, and are forced through each other in the motions of breathing. But the most perfect and equal crepi- tation is that of peripneumony, called the crepitation rhonchus. It exactly resembles the sound which you can produce by rubbing slowly and firmly between your finger and thumb a lock of hair near your ear. I like the way in which Dr. Watson describes the phenomena re- vealed by auscultation,applied to bronchitis; and in place of attempt- ing a mosaic picture, made up of detached parts from different auscul- tators, I shall give you his own representation. I will just premise, however, that he, like Dr. Latham (Lectures on Clinical Medicine, Philad. Edit.), divides the sounds referrible todiseased lungs, whether in breathing, speaking, or coughing, into the two genera, viz., the dry and the moist. The first, or the dry sounds, are represented by the terms rhonchus and sibilus ; and the second, or moist sound's, by the term crepitation. Rhonchus is the larger and hoarse sound, proceeding from the bronchia in their first divisions; sibilus the SYMPTOMS OF BRONCHITIS — PHYSICAL SIGNS. 179 smaller and shriller, caused by the minute bronchial ramifications or the vesicular structure of the lungs. Crepitations in this disease correspond with the moist rhonchi and their species, or other divi- sions which, you will remember, included also different crepita- tions. " When you listen, I repeat, to the breathing of a healthy person, you hear, as the breath goes in and out, but especially as it goes in, a smooth and gentle rustle — the respiratory murmur, or the vesicular breathing. But when the inner surface of the bronchial tubes, and of their ramifications, is preternaturally dry, and tumid, this sound is altered : you hear a hissing, or wheezing, or whistling, as the breath goes in and out; and this is technically called sibilus: or you hear a deeper note, a snoring noise, as the patient inspires or expires—a sound like the cooing of a pigeon, or the bass note of a violin, or the droning hum of an insect in its flight; and this is called rhonchus. These two, in their various modifications, con- stitute the dry sounds of respiration ; and it will be worth while, once for all, to reflect upon their cause and nature, and the manner in which they are combined, and what they denote. You are aware that when air is propelled through a cylindrical tube of a certain size, and when that tube is narrowed in a particular way at one or more points, a musical note is produced. Now this is what often happens in the larger bronchi; this is what always happens in them when rhonchus is present. Rhonchus belongs to the larger divisions of the bronchi exclusively ; and as these are often, for a time, exclusively affected, so rhonchus may exist alone. It will be graVe or deep in proportion to the length and diameter of the tube in which it is produced. When the sound is grave and deep, the hand placed upon the chest may frequently perceive a trembling or thrill communicated to its parietes. I believe that rhonchus is mostly occasioned by portions of viscid, half-solid mucus, which adhere to the membrane, and cause a virtual constriction of the air-tubes, and act as vibrating tongues while the air passes by them. I conclude such to be the case, because it seldom happens that the rhonchus cannot be got rid of by a vigorous cough. It will soon begin again, perhaps, or it will commence in some other part, but the effort of coughing, which detaches and removes the adher- ing tough mucus, dislodges also, for the time, the rhonchus. Yet, rhonchus in a given spot may be permanent: a tumour, or a tuber- cle, may flatten one of the air-tubes, and convert it into a musical instrument. For the most part, you will find what I have told you holds true: you may suspend the rhonchus by getting the patient to make a hearty cough. Now in the natural state of the chest, we do not, except in particular spots, hear the transit of the air through the larger bronchi. Whatever sound it makes is damped by the spongy lung, or covered by the vesicular breathing. But rhonchus, in its turn, may overpower the vesicular murmur, and render it inaudible. It does not prevent it, but it outroars it, as it were. Yet this is seldom the case: you hear the rhonchus, and, if you 180 DISEASES OF THE RESPIRATORY APPARATUS. listen attentively, you may in general hear, mingling with it, the vesicular murmur also. Recollect, then, that rhonchus belongs to the larger divisions of the air-tubes; that it denotes their partial narrowing ; that it is a dry sound ; and that the condition of which it is expressive implies usually no danger : there is no material obstacle to the passage of the air through these larger tubes to the vesicular structure beyond them. "I must further admonish you, that in your earlier essays in auscultation you will be apt to deceive yourselves in respect to the exact place in the lung in which the rhonchus which you hear is produced. It is so loud a sound, that when it proceeds from a single bronchial tube it may be plainly audible over the whole of that side of the chest; and sometimes, more obscurely, over the other side too. " When air is driven with a certain degree of velocity through a small pipe, it gives rise to a hissing noise. It is by forcing air through a cylinder perforated by a slender tube, that Professor Wheatstone obtains the sound of the letter S in the talking machine which he has constructed, after Kempelin's model. Precisely this condition we have in the smaller bronchial ramifications, when the inflammation in catarrh or bronchitis has reached them, and ren- dered the membrane lining them tumid. And sibilus is the result of this change. Now sibilus, like rhonchus, may exist alone; and, inasmuch as the sibilus proceeds from the smaller air-tubes, adja- cent to the pulmonary vesicles, it abolishes the natural respiratory murmur. It does not, like simple rhonchus, merely drown it, but it takes its place. If you do hear the respiratory murmur mingling with sibilus, you may be sure that some of the lesser air-tubes are narrowed, and some free: you cannot have both sounds at once from the same ramifications of the bronchi. Sibilus is a sound of more serious import, therefore, than rhonchus; it bespeaks a condi- tion of greater danger. It belongs to the smaller air-tubes and vesicles, and denotes that they are in the first stage of inflamma- tion, which has diminished their natural calibre, by rendering the membrane tumid. It is a dry sound, but you cannot cough it away. " I say rhonchus may occur alone, and sibilus may occur alone; but very often indeed they both occur together ; and may be heard in various parts in different degrees: causing a strange medley of groaning, and cooing, and chirping, and whistling, and hissing, mixed, it may be, here and there, with the natural respiratory murmur. When you hear sibilus over the entire surface of the chest, the mucous membrane is universally affected, and the case is a severe one, and attended with considerable hazard. " It is just possible that a sibilant sound may proceed from a large air-tube, when its bore has been narrowed to a very minute slit or orifice; but this possibility does not interfere with the gene- ral distinctions that I have been endeavouring to point out. " Now, in these cases we neither obtain nor require any informa- SYMPTOMS OF BRONCHITIS — PHYSICAL SIGNS. 181 tion from percussion, except of a negative kind. Supposing the inflammation confined to the mucous membrane, the resonance on percussion will not be sensibly diminished; the lung is everywhere spongy still, and air reaches every part of it, though not with the usual freedom. " There is one exception to this. Occasionally, though rarely, a piece of tough phlegm may seal up, as it were, the very entrance of one of the principal bronchial tubes, and so prevent the air from passing to or from the portion of lung to which that tube conducts. When this happens, it is very likely to puzzle the auscultator for a time. There is air in the sealed up portion of lung, therefore per- cussion gives a natural sound ; but the air is at rest, therefore no sound of respiration is audible. An effort of coughing unstops, perhaps, the bronchial tube; and then the air is again heard to enter and to depart from that portion of lung. I shall advert to this sort of accident again. " Finally, I may remark, that these dry sounds, rhonchus and sibilus, are heard during the breathing; they have no relation to the voice or to the cough. " After a while the inflamed membrane begins again to pour out fluid ; but it is not the thin, bland, moderate exhalation of health ; it is a glairy, saltish, transparent liquid, like white of egg somewhat; and if it be expectorated only after much coughing, it will be frothy also, i. e., it will contain many bubbles of air entangled in it. It is a stringy, tenacious fluid, and the more so in proportion to the inten- sity of the inflammation. With this new condition of the membrane, we have new sounds — sounds which result from the passage of air through a liquid ; sounds which are occasioned by the forma- tion and bursting, in rapid succession, of numerous little air-bubbles. These sounds are called crepitations. This process may take place in the larger air-tubes, or it may take place in the smaller, or in both. In the larger tubes the bubbles will be larger, and the ear can readily distinguish this; we have large crepitation. In the smaller air-tubes we have, in the same way, small crepitation. There is no difference between these sounds except in degree; and they graduate insensibly into each other. But there is a consider- able difference in the nature of the intimations which their well- marked varieties convey. If there be merely large crepitation, without any other morbid sound, it is produced in the larger tubes. Air passes, notwithstanding, into the vesicular structure beyond the accumulated liquid ; and vesicular breathing exists, though perhaps it cannot be heard, on account of the crepitation. But the state of the patient is not a state of peril. On the other hand, small crepitation has its seat in the smaller air-tubes and cells; it super- sedes the vesicular breathing, and, if extensive, it bespeaks consider- able danger. " Rhonchus and large crepitation are respectively the dry and moist sounds that belong to the larger bronchi; sibilus and small crepitation the dry and moist sounds of the smaller branches 16* 182 DISEASES OF THE RESPIRATORY APPARATUS. When the latter sounds are heard over a considerable part of the chest, there is, I say, usually a good deal of distress, dyspnoea, and cough ; and the fever which attends the local inflammation is at its height. By and by, the expectoration becomes opaque, and more consistent, and of a greenish or yellowish colour; it is brought up with more ease; the crepitation, great and small, diminishes; per- haps rhonchus reappears: but at last the parts return to their origi- nal condition ; and the natural, smooth, equable rustle of the breath- ing is again everywhere audible. " These are all the morbid sounds to which active and recent inflammation of the mucous membrane of the air-passages ever gives rise: rhonchus and sibilus; large and small crepitation. Having once described their nature and causes, I need not repeat the description if we find them accompanying other diseases; but their import may be different. I may mention here, that as crepi- tation results from the passage of air amongst and through liquid, from the rupture of the little air-bubbles so produced, the kind of liquid may vary. If the air, in going and returning, meets with serum, or with pus, or with blood, it will occasion exactly the same bubbling noise. Hence the French term for what I have been call- ing crepitation, viz., mucous rattle, is very objectionable.. From the sound itself, we cannot tell whether it proceeds from mucus or from some other liquid present in the air-passages; and from this objection the word crepitation, whatever exception may be taken against it on other accounts, is free."— (Lectures on the Principles and Practice of Physic.) LECTURE LXIII. DR. BELL. Morbid Anatomy of Bronchitis.— Treatment—Venesection, not to be pushed far—Purgatives—Emetics, of doubtful value in acute bronchitis—Tartar emetic, as a counter-stimulant—Rules for its use—Immediate effects various—Case— The warm bath—pediluvium—Blisters and other counter-irritants to the chest —Calomel in bronchitis complicated with abdominal disease; to which are added opium and ipecacuanha—Second stage of bronchitis, with symptoms ofdebility— Stimulating expectorants useful; carbonate of ammonia, wine whey, senega,ace- tate of ammonia—Calomel and a few cups, with simulants, for congestion of a part of the lung—Diaphoresis without diaphoretics—Diuretics as antiphlogistics sometimes useful—Secondary or Symptomatic Bronchitis—Complication of bronchitis with various diseases, especially eruptive fevers—Treatment by local depletion, counter-irritants, and moderate stimulation—Dr. Copland's plan of external cutaneous revulsion—Emetics—Bronchitis succeeding laryngitis, — Active depletion in.—Hooping-cough—Its connexion with bronchitis—Outlines of treatment—Remittent fever with bronchitis; in the tyyhoid stage—Cooling remedies useful—Depletion and stimulation sometimes necessary at once—In- halation of watery vapour—Change of posture—Quinia and laudanum, for excessive bronchial secretion—Dr. Graves's practice—Sugar of lead. Morbid Anatomy of Bronchitis. — More frequently the morbid changes in the bronchia have been found in the bodies of those who MORBID ANATOMY OF BRONCHITIS. 183 have died of other diseases, during the attack of which they had suffered at the same time from bronchitis. In the mild and recent form of this latter, there is found some redness in a circumscribed portion of the mucous membrane, particularly at the termination of the trachea and the first divisions of the bronchia. If the inflam- mation has been more intense, the redness extends to a greater number of tubes, tand more so in the smaller ramifications. It is often, says M. Andral, that the redness is exactly limited to the bronchia of one tube, and commonly it is the upper one which is more peculiarly disposed to inflammation. The fine injection on which the red colour depends, seems to exist simultaneously both in the mucous membrane and in the sub-mucous cellular tissue. Sometimes the redness diminishes progressively from the large bronchia towards the small ones; at other times the reverse is met with. Often the redness presents itself in patches, constituting, as it were, so many circumscribed inflammations, between which the mucous membrane is white and healthy — a state of parts simi- lar to that which is so frequently found in the intestines. On opening the thorax the lungs do not in general collapse, the escape of air being prevented by the obstructions of the bronchia. These in most instances contain a quantity of frothy liquid, of the quality of the matter expectorated before death. Not unfrequently it is mixed with bloody serum ; but as this is not perceived in the matter expectorated, it is probably an exudation from the distended blood- vessels at the moment after death. Purulent matter is, also, some- times observed, and mostly in very acute cases, which have proved fatal within four or five days. When the inflammation has been chronic, the bronchial mucous membrane generally loses its bright redness, and presents a livid, purple, or brownish tint. For this change of colour from a deep red or rosy hue we are prepared. But we should hardly, h priori, have said that there would be cases in which the mucous mem- brane of the air-passages was white through its whole extent. Both Bayle and Andral, however, cite such cases ; and I have witnessed such myself in persons dead of small-pox, in whom, too, the ulcerated spots were distinctly seen extending from the larynx into the bronchia, and the intermediate spaces of a natural colour. These appearances were seen in the bodies of persons who had died in an advanced stage of the disease, after the third week. It should not, as M. Andral justly remarks, be inferred that inflamma- tion did not exist, because the membrane is thus found white. Analogous appearances are presented in other inflamed tissues. Thus, serous cavities filled with pus and lined with false membranes, frequently present no change of colour, no appreciable alteration in their texture. The intestinal mucous membrane, though traversed with numerous ulcerations, often presents a remarkable paleness, either in the very place where these ulcerations exist, or in their intervals. More than once, in individuals whose urine was for a 184 DISEASES OF THE RESPIRATORY APPARATUS. long time purulent, the mucous membrane of the calyces and pelvis of the kidney has been found very white; in these different affec- tions of mucous tissues an inflammatory process could not be called in question; but whether, by reason of its long standing, or in conse- quence of general debility, the inflammation appears to have left no other traces in the organ which was the seat of it than a change in its secretion: thence very often result new therapeutic indica- tions. (Andral's Clinique Medicale.) Treatment. — The advantage of the physical signs of bronchitis, is to inform us with certainty of the first coming on of an inflam- matory affection of this character. When, with the febrile state before described, whether the functional disorder be permanent or not, we find extensive rhonchi in every part of the chest, especially if they extend to the inferior parts, and there be little respiratory murmur audible, we should not hesitate to resort at once to deple- tory measures admissible in the individual case. These will con- sist of bloodletting, by venesection, or by cupping or leeching, and the exhibition of antimonials and mercurials. In acute bronchitis, both in children over a year old, and in adults, if the pulse be hard and frequent, and the respiration de- ranged in the manner already described, the lancet should be had recourse to at once. The physician will remember, however, that, in inflammations of the mucous tissue generally, and the dis- ease under consideration forms no exception to the remark, he must not expect by bloodletting to make that decided and permanent impression which he does in phlogosis of the parenchyma of an organ, or of its serous membrane. Hence, whilst he bleeds so far as to relieve decidedly the existing oppression, he will not urge it to the producing of syncope. His aim must be to bring down the in- flammation to the secreting point, for expectoration, but not to sink the excitement and depress the strength of the body below this point. The inflammation still persisting, or originally occurring in persons in advanced life, or of a weakened and cachectic habit, and the pulse exhibiting little hardness, local depletion is entitled to a preference over venesection; and that procured by cups is pre- ferable to leeching. In severe cases, the patient should be cupped over the part which auscultation had proved to be most affected. If no selection be made on this score, the cups should be placed under the clavicles, or between the scapulas. The opinion first clearly pointed out by Broussais, of the greater advantage from local depletion exercised over the upper than over the lower parts of the chest, must find confirmation from every observing practi- tioner. Even at an advanced stage of the disease, local bloodletting may be resorted to, if the expectoration have become suppressed, and there is coincident fever and irritation, and increase of dys- pnoea not caused by over secretion — a point this ascertained by auscultation. Next to the remedy just mentioned, a free evacuation of the bowels TREATMENT OF BRONCHITIS. 185 will often give the greatest relief. There is no disease of the tho- racic contents in which free and early purging is so beneficial as in bronchitis; I have been most sensible of this fact in the epi- demic form of the disease, or in influenza, in which, be it said, also, there is frequently a complication of gastric and intestinal disorder. Emetics have been strongly recommended in bronchitis; and in the stage in which there is excess of secretion, and filling up of the tubes from this cause, and consequent oppression of breathing, par- ticularly in children, they are decidedly efficacious. But in the first and more violently acute stage, in which there is no secretion, or it is sero-mucous and thin, tartar emetic in contrastimulant or sedative doses is entitled to a preference. This remedy will either follow bloodletting as an adjuvant, or take its place in cases in which, although the dyspnoea and fever be considerable, we are afraid for other considerations to abstract blood. The vomiting which follows repeated doses of the tartar emetic is more ser- viceable, because implying a solution, however temporary, of the disease, than that which is brought on at once by a large dose. From an eighth to a fourth of a grain, according to the age of the subject, may be administered every hour until a decided abatement of the symptoms follows. This simple prescription is preferable greatly to common expectorant mixtures, which often only irritate and tease the stomach, and just serve to increasethe secretion without either adequately abating or modifying the inflamed condition of the bronchial mucous surface. We have in the former case, that in which tartar emetic is used, a definite object to be accomplished by a modus operandi which we can measure and appreciate; in the latter we wait for, we know not what, results, and with an expendi- ture of time, which, in acute disease, can never be afforded to doubtful measures or timid expectancy. The considerations which should guide us in the exhibition of tartar emetic in bronchitis are well defined by Dr. Stokes, seemingly the more so to me because they correspond with my 6wn experi- ence, which has been considerable with this remedy in thoracic affections, ever since my visit to Italy and acquaintance with the new Italian medical doctrine of counterstimulus. Even now, after so much has been written on the subject, 1 may refer you to my paper, one of the first in order of time, on Counterstimulus, in Dr. Chapman's Medical and Physical Journal, vol. iii. Thus, the more robust the patient, the more acute the disease, the more bloodletting has been indicated, the better it has been borne, the more inflammatory the blood, the earlier the period at which the disease has been met by treatment, and last, though not least, the more simple and uncomplicated the affection, particularly with abdominal diseases, the greater will be the certainty of tartar emetic exerting that singularly sanative action which has justly obtained for it the name of heroic. On the other hand, where the disease lias occurred in a debilitated constitution, where the pulse 136 DISEASES OF THE RESPIRATORY APPARATUS. has not been strong, nor the skin very hot, where the teeth are coated with sordes, and the tongue red or dry and chapped, where the abdomen is swelled, and tender in the epigastric and ileo-coecal region, where there have been diarrhoea or vomiting, and pain in the abdomen ; in such a case or cases, the tartar emetic will either not be borne at all, or, if retained on the stomach, will exert com- paratively little influence on the pulmonary disease, and too often increase the gastric symptoms. Laennec recommends an aromatic and opiate to be combined with the antimony, as in the following solution : — R. Tart, antim., gy. vi. Aq. cinnam., 2jvi. Tinct. opii acet., gtt. xii. M. Of this solution half an ounce, a table-spoonful is to be given every hour or second hour, so that, if possible, the whole of the six grains may be consumed in the course of twenty-four hours. For many years I was in the habit of giving the tartar emetic simply in com- bination with cream of tartar, either in the form of powder or solu- tion as recommended by Rasori,—with the occasional addition, as circumstances seemed to warrant, of opium or laudanum. Of late years, however, I have prescribed the medicines in question with camphor water, and a little laudanum. The immediate effects of the antimonial practice are various. In a few cases, particularly where the stomach had been foul, free vomiting is produced, and, less seldom, purging: but after repeating the remedy two or three times, it fails either to vomit or purge until the morbid excitement is reduced, and then the toleration of the sys- tem to the medicine having ceased, nausea, vomiting, and prostration are produced, and would be perilously increased by its continuance. In a majority of cases, however, in which there is decided phlogosis of any of the thoracic viscera, tartar emetic barely causes nausea, and this chiefly when the patients moves. In evidenceof the tolerance by the system tofulland repeated doses of tartar emetic, I would refer to the case of a person labouring under bronchitis complicated with pneumonia, which was attended by Dr. Otto of this city and myself about five years ago. The patient became delirious, and would not take any medicine which was prescribed for him. Both on account, therefore, of its relative want of taste, and of its being ad.ipted to the stage, which was the second one of the disease, we prescribed tartar emetic dissolved in some simple drink slightly sweetened. The dose of the medicine was increased from half a grain to two grains every two hours, so that in one twenty-four hours more than twenty grains were taken. This practice was continued for four or five days, gradually re- ducing the dose of tartar emetic, and with the best effects: the delirium was removed; the expectoration became loose and free, TREATMENT OF BRONCHITIS. 187 the matter being thick and opaque; and the pulse was abated of its great frequency. In some instances so little apparent effect is produced, so far as regards its action on the stomach, bowels, skin, and kidneys, that the remedy might be considered as inert, were it not for the disappearance of the symptoms and signs of pulmonary disease. Dr. Stokes relates his having frequently seen patients who were using from six to ten grains of tartar emetic daily, yet who had a good appetite for their food. An advantage is attributed by this gentleman to the use of tartar emetic, even when it fails to bring about the restoration of the disease. It is this ; stimulants and tonics will have now a better effect after we desist from the use of the medicine in question. This advantage occurs in all cases in which depletion has been freely and timely practised. Stimulating remedies, which, even in the second stage of this dis- ease, have only increased the indirect debility caused by continued and unchecked excitement, will now kindly restore the feeble powers of life, and reanimate the exhausted functions. After the employment of the tartar emetic, or in conjunction with it, the hot bath will frequently be of decided benefit, but it should be confined to the lower limbs, or the lower portion of the body at most, by immersion of the pelvis and legs. In this way a salutary derivative effect may be obtained. The heat of the water when this half bath is used should be from 98° to 102°; and the time of immersion about ten minutes. The period of inflammatory excitement having passed, and the respiratory distress, with the diffused rhonchus still continuing, coun- ter-irritants should be had recourse to. A blister is to be applied so as to cover the anterior part of the chest; or, that which is pre- ferred by some practitioners, tartar emetic is to be rubbed on until a free eruption is induced. To insure its prompt action, the chest should be first well rubbed with a brush or a piece of course flannel ; or the skin may be still farther excited by applying a warm hand wetted with camphorated spirits, or by a short application of a mustard poultice. The tartar emetic should then be immediately rubbed in, either in the form of a warm saturated solution, or an oint- ment composed of one part of tartar emetic to two of spermaceti ointment. With these precautions, adds Dr. Williams, who gives this formula, we shall rarely fail to excite a full pustular inflam- mation in as short a time as that required for the rising of a blister, with far less irritation to the system, and with decided relief to the pectoral symptoms. Partial as I am to the use of tartar emetic in this way in many diseases, I "still prefer a blister in the one now under consideration : the counter-irritation produced by it, in the capillary injection and inflammation, and in the effusion of serum on the cutis, is more complete than that caused by tartar emetic; and the subsequent pain is, judging from my own feelings, certainly less than that from the latter. A blister should not be allowed to re- main on a child for more than three or four hours, or until its action 138 DISEASES OF THE RESPIRATORY APPARATUS. has been distinctly felt by the patient. It is to be then taken off, and the part dressed ; after which vesication takes place. It is advisable, also, as recommended by Bretonneau, to cover the blister with a leaf of fine paper. An emollient poultice, applied after the venesection is induced, I have often found to be of great service. In the cases in which disease of the abdominal viscera is com- plicated with bronchitis, and in subjects not robust and easily depressed by remedies, and in whom there is more evidence of congestion than of excitement of the circulation, calomel combined with ipecacuanha will be preferred to the tartar emetic. I have, every now and then, seen ipecacuanha, in small doses particularly, to have rather an irritating effect than otherwise in inflammatory affections, and certainly, except in coughs of gastric origin, it has no beneficial one that I have witnessed. Hence, if the combina- tion just mentioned does not soon relieve the bronchial distress, or apparently increases it, we must not give up the calomel, but administer it alone, or with very minute doses of Dover's powder, in which the opium is the active ingredient. In more than one epidemic bronchitis among children, I have found, in common with others of my professional brethren, calomel to be the remedy of the greatest efficacy, given with a freedom, too, which at other times would be hazardous. Should the bowels be irritable, a few grains of prepared chalk may be usefully added to the calomel. The plan of treatment now laid down will often suffice to arrest bronchitis, and bring it to a satisfactory termination. But if they fail to do so, the disease passes into a second stage, which I will not qualify with the epithet of collapse, as some writers have done. It is one in which general debility predominates, whilst the morbid local action is still going on. The skin is cold, it may be clammy; the pulse small and frequent, or soft and compressible; tongue foul and moist; renal secretion small; whilst the accumulation of mucus in the bronchia is increasing, with evidently less power of throwing it off by expectoration. An emetic will often give relief at this time: it should be of ipecacuanha, since our object is merely to evacuate, by a moderate effort, the bronchia, without depressing the general system. For this reason, in asthenic bronchitis, as a general rule, ipecacuanha is preferable to tartar emetic as a vomit. It is now that the classof expectorants, which in the first stage would have been for the most part mischievous, may be advantageously en- listed in the treatment: those of the stimulating class being preferred. At this time, also, the alkalies may be had recourse to, united with some stimulant. Carbonate of ammonia, mixed with lac assafce- tida, answers admirably, and enables the child, or the old person, to throw off the mucus with comparative ease. Aiding to the same end, a tea-spoonful of wine-whey now and then for a child; and in proportionately large doses for an adult should be tried; its con- tinuance to be regulated, of course, by the pulse and the state of TREATMENT OF BRONCHITIS. 1SD the skin. So long as the first is weak and the latter cold, we may persevere with good effect. Preferable still to the remedies just mentioned in the minds of many practitioners, is a decoction of the polygala senega, with the addition of the liquor ammoniae acetatis, or the carbonate of ammonia. If, apart from the symptoms of general debility and difficult expectoration, we find evidence of congestion or inflammatory engorgement of portion of a lung, the use of calomel in minute doses may still be continued, during the period in which stimulants are administered. Even a scarifying cup or two over the diseased portion is sometimes admissible. Of diaphoresis I have said nothing, believing that remedies specially given with a view to produce it will either be misplaced by their character or by their interference with others already mentioned. Tepid drinks, moderately warm bed-clothes, an equable air of the chamber, and the occasional use of the warm semi- cupium or half-bath, will generally keep up a moist state of the skin, whilst they contribute to give effect to the more active plan of treatment already indicated. I would dismiss diuretics in as summary a manner as diaphore- tics, if the former could only be administered with sole reference to their action on the kidneys, and not in harmony with the state of the circulation, in bronchitis. But there are certain remedies, such as nitre, digitalis, and colchicum, which are both sedatives and diure- tics, and all of which have been recommended in the disease under notice, especially with a view to prevent effusion. Without pre- tending to specify the precise time when they are had recourse to, we can very well infer, from a knowledge of their general effects on the animal economy, that they will prove most useful in the early stage of the disease : they assist to keep down febrile excitement, and relieve the inflammation of the bronchia, by means of deri- vation by the kidneys. When given with a view to their anti- phlogistic operation, tartar emetic is combined with one or other. If you prescribe such a combination, you should be aware that it is one of the most active in the materia medica, and you will be required in consequence to watch vigilantly the first evidences of sedative operation, and either to desist from the medicine, or to diminish the dose, or prolong its administration, before prostration is induced, which, as in certain cases in children and in old persons, cannot be supported nor always readily recovered from. Secondary or Symptomatic Acute Bronchitis. — Our treatment of various diseases will be readily modified by the extent to which bronchitis is associated with then, either as a primary symptom or one of secondary occurrence. In measl3s,thechicf danger, both in the first or acute stage, as well as after the disappearance of the erup- tion, is from bronchitis, the degree of intensity of which will guide us very much in the use of the lancet or analogous depletory agents. We must be prepared, however, at the same time, to see a complication, in the case ol eruptive fevers generally, of asthenia with inflammation, which will prevent our carrying out in all its VOL. II.— 17 190 DISEASES OF THE RESPIRATORY APPARATUS. simplicity the antiphlogistic treatment. More especially is this caution requisite in bronchitis with scarlatina. Now and then the complication is increased by the addition of cerebral disease. In such cases our reliance will be on local depletion, at the same time that we husband the strength of the general system, and even administer camphor and ammonia in alternation with calomel and ipecacuanha, and apply revulsives to the skin. Bronchitis is a frequent secondary occurrence in small-pox. During the epidemic visitation of this disease in 1823 and 1824, I frequently found my patients, more especially those in the hospital, sink under bronchi- tis and pleuropneumony after the eruptive febrile stage had been gone through, and the desquamation of the skin nearly completed. In some instances the bronchial disease was coeval with the pustu- lar eruption, which appeared on the trachea and its ramifications at the same time with that on the skin; in others we had reason to believe that the inflammation of the bronchia was secondary, and consequent on the morbid impression of cold on an exquisitely sensitive skin not yet furnished with a new epidermis. In the regular secondary bronchitis of small-pox and scarlet fever, accompanied with accumulated mucus in the bronchia, which oppresses respiration and interferes with the decarbonization of the blood, emetics should be had recourse to. In some extreme cases of depression and stuffing up of the bronchia, Dr. Copland recommends the following process, which, he says, he has employed with marked benefit. It consists in applying, over the epigastrium and lower part of the chest, a flannel wrung out of hot water and immediately afterwards soaked in spirits of turpentine, and allowing it to remain on until severe burning heat of the skin is produced by it. Internally camphor and ammonia, together with a hot decoc- tion of the polygala senega should be used at the same time. Small doses of ol. terebinth, also might be given by the mouth, or in alterna- tion with the remedies last mentioned. As a general rule, emetics are useful in'those cases of bronchitis complicated with scarlet fever, measles, and small-pox, in which a state analogous to diphtheritis is apt to occur. If sore throat and dysphagia be complained of, purgatives in full doses ought to be administered. Bronchitis succeeding to acute laryngitis or tracheitis requires full and active depletion, in the manner already pointed out when speaking of laryngitis. Hooping-cough.—One of the most common complications is of bronchitis with hooping-cough. I believe that, for useful practical purposes, we shall err least by regarding hooping-cough as chiefly a bronchitis, with some nervous and gastric disorder conjoined; and in treating it accordingly : and hence, in the incipient stage of the cough, I usually draw blood from the arm, and afterwards, if the violence and-quick succession of the paroxysms indicate it, use cups or leeches to the chest; purge freely, and then have recourse to antimonials, the alkalies, and camphor and assafoetida. Revulsives HOOPING-COUGH —REMITTENT FEVER. jgi to the skin in the form of blisters, or of tartar emetic ointment, will come in as part of the treatment. An early recourse to ex- pectorant or cough mixtures, is to the full as reprehensible in hooping-cough as in distinctly recognised bronchitis. In reverting to local depletion I may add, that I have never seen speedier and more complete relief afforded in violent disease than from the ap- plication of cups, and detraction of blood by their means, to the chest of a little child which was tormented, with scarcely any re- mission, by a succession of paroxysms of hooping-cough. If we begin by appropriate remedies in the first stage, we shall have little occasion for trials of the various antispasmodics, narcotics, and tonics, which, in combination or succession, are recorded and re- commended in the second and advanced stages of the disease. Of the narcotic tribe, tincture of belladonna is the best; of the tonic, the sub-carbonate of iron ; and, in obstinate cases, the arsenite of potassa — Fowler's solution. Whether we admit the cerebral origin of or complication with hooping-cough or not, I can speak con- fidently of the effects of leeches behind the ears, or cups to the nucha. It is quite common for remittent fever, especially the autumnal, to be ushered in with, among other symptoms, a slight bronchitis, which, as the fever advances, may either disappear, or, a no un- usual thing, be augmented, and thus complicate not a little the disease, in addition to the other phenomena of fever, we find the patient exhibits lividity of countenance, cough, hurried breath- ing, and expectoration. If, at the beginning, under the impres- sion that, as we have to deal with both inflammatory irritation, perhaps positive inflammation in the chest, and a similar state in the abdomen, as in gastro-enteritis or gastro-hepatitis, we bleed freely, we shall give the patient the best chance in our power, both by abating the febrile disturbances and concomitant phlegmasia,and by keeping up the susceptibility of the system to other remedies, of whatever class they may be. But if, dissatisfied at the bronchial irritation still remaining, and the abdomen still continuing tender, with a show of gastro-enteritis, we bleed again, we do wrong; the more so, too, if we bleed largely, and with the expectation that we can strangle, as it were, the disease, We can do no such thing, but we may greatly and dangerously weaken the patient. It must be our aim now to ascertain the hold which the associated bronchitis still has on the system, and having done this, to try and remove it by local depletion and purgatives, provided these latter be not contra-indicated by the state of the stomach at the time. The disease in some in- stances predominates in the respiratory, in others in the digestivesys- tcm; and we can, not unfrequently, observe a remarkable alternation of the predominance of disease, now in the thoracic and then in the abdominal viscera. More commonly, if there be disease of the re- spiratory mucous surface, there is an associated disease of that of the gastro-intestinal: the reversedoes not prevail with the same frequency. But as it is not my intention here to discuss the pathology and 1,92 DISEASES OF THE RESPIRATORY APPARATUS. treatment of remittent fever, except in connection with bron- chitis, I shall pass on to another and more advanced stage of the fever, in which it has assumed a typhoid form. We are now pretty well assured that the morbid condition of the mucous surface of the gums and tongue, by which they become incrusted with sordes and dark matter, prevails lower down, and has even ex- tended to the bronchia, so as obviously to interfere with the regu- larity and completeness of respiration. The blood is not changed as completely as it ought to be in its passage from the pulmonary artery to the pulmonary vein, owing to the inspired air not being able to reach it through the secreted coat of mucus which covers the bronchial mucous membrane. What shall we do at this junc- ture, when probably the brain is disordered at the same time, either in consequence of inflammation of its arachnoid membrane, or of the flow into it of thecarbonated blood, which has not been purified in the lungs before it reached the left side of the heart. If this collection of symptoms, of which the stomach and intestines furnish a full share which I do not now enumerate, have followed originally associated bronchitis, we can have the less difficulty in framing our treatment, with a view to its probable persistence at this time, even though we should not make our diagnosis clearer by percussion and aus- cultation. The brain, the pulmonary apparatus, and the abdo- minal viscera, are now all suffering, perhaps all more or less phlo- gosed; but the organ, the partially suspended function of which is most prejudicial, is thelungs. It is now no longer a question,however, whether venesection is to be practised or not. This might have been debated during the first stage. All that is left for us is, to discuss the propriety of local depletion. Were we to be influenced by the general symptoms, even this would seem to be inadmissible; but morbid anatomy has revealed to us the condition of the bronchial mucous membrane at this period, It is red almost universally, and the bronchia are filled with mucus. We attempt, therefore, the relief of this morbid state of the bronchia by cupping between the shoulders, or on both sides of the chest; and the depletions, says Dr. Stokes, are afterwards repeated in different situations, according to the stethoscopic signs of predominance of disease. The respiration will also be greatly relieved by the use of terebinthinate and assa- foetida enemata. Following the cups come blisters, which long experience declares should be between the shoulders rather than in front of the chest; and if this be difficult, on account of the posture, on the back, and extreme prostration, they should be applied to the sides of the thorax. Contradictory as it may seem, there are cases in which, whilst we deplete, to relieve the congested lung, nutri- tive and diffusible stimulants are called for to keep uplhe general strength, unless we are prohibited from using them by the excessive tenderness of the stomach, the morbid heat of the epigastrium, and a dry, red, and shining tongue, and compelled to be spectators, waiting and watching anxiously for every fair indication to act. One of these is to apply a few leeches over the epigastrium. TREATMENT OF SECONDARY ACUTE BRONCHITIS. 193 Whilst we attend to the state of the skin and endeavour to preserve it of an equable warmth, by directing flannel to be worn, and thus to promote.insensible perspiration, we are not, I think, precluded from the admission of cool as well as fresh air into the apartment of the patient. I have known patients to be tossing about from side to side, complaining of a sense of heat and oppression at the chest, and unable to sleep, who, on the introduction of fresh and cool air into the room by the opening of a window, became composed, and soon fell into a tranquil and refreshing slumber. The inflamed state of the bronchia, the impediment to the access of air to the lungs, and the consequent imperfect hematosis, would all seem to indicate the advantage of the freest supply of air ta the lungs, at the very time that we envelop the skin in warm clothing. Dr. Armstrong was fully impressed with, perhaps even somewhat exaggerated, the dangers from the bronchitis secondary to typhous fever, or, as he called it, special bronchitis. While in the primary and common form of the disease, the danger is chiefly from the quantity of mucus secreted exceeding that which is expectorated, our apprehensions are excited in the secondary form by the quality of the secretion. It is, in this latter, more sticky, like varnish smeared over the bronchial lining, so as far more effectually to ex- clude the air from contact with the blood, than is the case with the less sticky but more copious secretion in common bronchitis. And all those fevers, continues Dr. A. (Lectures on the Morbid Anatomy and Treatment of Diseases), which are called typhous, typhoid, putrid, low, or malignant fevers, owe their characters to this special bronchitis. If, without too much fatiguing the patient, he could be made to inhale the simple vapour of water, alternately with one of the more stimulating gases, as chlorine, the effect would probably be useful towards a solution of this varnish and adherent mucus;" and a not ill-timed excitement of the bronchial vessels, to enable them to throw out a modified and more fluid secretion. Change of posture is desirable in this variety of secondary bron- chitis, as it is in every form of congestion of the lungs. The patient should be turned on one or other side, or at least made to incline in that direction, by being propped with soft pads or air-cushions to his back. A decided predominance of disease in either lung will be an indication of the necessity of his lying or being turned on the one opposite to that affected. In the very last stage of this secondary bronchitis, or that with typhoid fever, when hope is on the point of forsaking us, the patient lying on his back nearly insensible, the mucus having choked up the bronchia, with its rattle in his throat, temporary, but immediate, and even sometimes, though more rarely, permanent relief, has been procured by an emetic, to be repeated at intervals, if a re- newal of the symptoms calls for it. Dr. Graves has recommended a new, and, in his hands, success- ful means of arresting the excessive bronchial secretion, the con- 17* 194 DISEASES OF THE RESPIRATORY APPARATUS. tinuance of which to this extent is always harassing to the patient, and often hazards his life. This gentleman proposed the employ- ment of a combination of quinine ten grains, and of laudanum twenty drops, in the form of enema. He gives the details of three cases in which the patients were moribund, but in whom life was clearly saved by this treatment. Justice to the author requires that we should give his own ideas as to the discernment to be exercised by the practitioner in the selection of cases for the administration of the above remedies. "An accumulation of mucous secretions in the air-passages," remarks Dr. Graves, "producing the rattles, forms the closing scene of almost all diseases however different in their nature. To exhibit remedies for this would be ridiculous: it is only when this accumulation is the direct consequence of actual disease attacking the air-passages themselves, that we can hope for its removal. In such cases, we must try everything that expe- rience has proved to be even occasionally useful, and must care- fully watch the effect of each new medicine; for it must not be concealed, that very different results are obtained from the same remedies under circumstances apparently similar. The injection of sulphate of quinine and laudanum possesses, as appears from the cases I have detailed, very great powers, and for that very reason must be used with circumspection; for if exhibited at an improper period of the disease, or in cases where expectoration is at all scanty and difficult, it may produce dangerous consequences." Sugar of lead has been given under these circumstances of dis- ease with a very happy effect. LECTURE LXIV. DR. bell. Chronic Bronchitis. — Description of—Expectorated matter—pus with hectic fever—Difficulty of diagnosis of chronic bronchitis with purulent expectoration —Ulcerations of bronchia are rare—Causes,—primary irritation of the lungs,— and secondary in other diseases—Bronchitis after gastric irritation—Stomachic cough—Its diagnosis—Bronchitis with intestinal irritation,—with other morbid states,—gout, syphilis, &e.—Treatment, modified by cause—Venesection not often required—Local bloodletting preferable—Purgatives,—Antimonials— Calomel or blue mass, with ipecacuanha and hyosciamus—Colchicum and digi- talis—Hydriodate of potassa—Tonics with the balsams—Compound syrup of sarsaparilla with iodine or iodide of iron—Counter-irritants to the chest—In- halation of various vapours—Modification of treatment in complicated chronic bronchitis—Visits to mineral springs—Change of air and climate—Prevention of chronic bronchitis. Chrontc Bronchitis. — It has been well said, and the remark is one of great practical value, that chronic bronchitis is not separated by any distinct line from the acute form of the disease. The two pass by insensible gradations into each other, and are often con- joined, for, although acute bronchitis frequently exists alone, chronic CHRONIC BRONCHITIS. 195 bronchitis is rarely free from occasional admixture of acute inflam- mation supervening on it, in consequence of the exposure of the in- valid who is labouring under the former to the causes which brought on the disease primarily, such as sudden mutations of temperature,. or errors in clothing, &c. If we would be sure that we have to do with a chronic inflammation, the knowledge must be acquired by an observation of the symptoms derived from the pathology of the mucous membrane itself, and not simply from the duration of the disease. We every now and then see acute bronchitis in which attack succeeds to attack during many weeks, with a retention, all the lime, of its original character. So long as the expectorated matter remains glairy and viscid, uniting in mass and without opacity, the inflammation is acute. Towards the termination of an attack of this kind the sputa become opaque and are expectorated in distinct masses, which, although consistent, are not very adhesive or glutinous. Sometimes, instead of being diminished and more consistent, as when the disease is about to terminate, they remain in this state, or increase and become diffluent and heterogeneous in quality without sensible increase of fever, and they then indicate inflammation of the chronic kind. Doctor Williams describes the disease with such clearness, that I shall adopt his language. Chronic bronchitis in its slightest form manifests itself only by habitual cough and expectoration, which are increased by certain changes of weather, and gene- rally prevail most in winter and spring. It is more common in advanced life, and, in fact, very few old persons are perfectly free from it. In its severe forms it is accompanied with dyspnoea, occasional, pain in the chest and about the prsecordia, and some febrile symptoms, especially towards evening, palpitation, and disor- der of the digestive functions. The cough is sometimes very severe, especially at night, and the expectoration copious; and if these persist long, they seldom fail to waste the body and reduce the strength. To this description it may be added, that even with considerable emaciation the appetite is often good, and the digestion regular. Chronic bronchitis will, if not restrained, end fatally; but more generally when this result takes place the disease is complicated with tubercular phthisis, which on these occasions it would seem to have developed. The appearance of the expectorated matter in chronic bronchitis is various. Sometimes it is precisely similar to that in the latter stage of the acute form ; but most commonly it is less glutinous, more opaque, and nearly puriform. Occasionally, it is of a dirty-grayish or greenish hue, from, as Laennec thinks, an admixture of the pulmonary matter; and in this state it cannot be distinguished from the expectoration of phthisis. In some cases it is real pus, and presents all the varieties that are seen in pus from other sources; in its being inodorous, as from a recent wound, or, again, having the strong odour of the contents of a large abscess, and occasionally 196 DISEASES OF THE RESPIRATORY APPARATUS. approaching the gangrenous fetor. After a period, this bad smell disappears, but it may return perhaps several times in the course of the year. When the secretion is obviously of pus, there are not unfrequently a quick pulse and signs of hectic, and a tendency of the disease to a fatal termination, with night sweats, emaciation, diarrhoea, and all the common symptoms of pulmonary consump- tion. The following case, related by M. Andral (Clinique Medicale), is an example of this variety of chronic bronchitis, in which also the tracheo-bronchial mucous membrane was white. A locksmith, twenty-seven years of age, entered La Charite Hos- pital during the month of December, 1821. For the two years pre- ceding, this man has been tormented with a constant cough: he had never spit blood. When we saw him, he was in a state of marasmus : he expectorated sputa, formed of greenish, round patches, separated from each other, and floating in an abundant serum : these sputa were inodorous, and appeared to the patient to have a saccharine taste. The respiration was a little short; he could lie down in all postures; the chest when percussed resounded equally well in all parts ; some mucous rdle was heard in different points; there was no appearance of pectoriloquy; the pulse was not frequent in the morning, but became so towards evening; every night the patient perspired a little. The digestive functions pre- sented nothing remarkable. What diagnosis, continues M. Andral, could be given here? Auscultation informed us, to be sure, that there was no tubercular cavity; but the aggregate of the other symptoms seemed to an- nounce, that numerous tubercles, beginning to soften, existed in the lungs. The marasmus and debility increasing, and diarrhoea also super- vening, together with disturbance of the intellect, the patient died in a half comatose state. Post mortem examination revealed the following particulars: — A sero-purulent infiltration of the sub-arachnoid cellular tissue of the convexity of the hemispheres; lateral ventricles distended with tur- bid serum. Pulmonary parenchyma sound, but slightly engorged. The internal surface of the larynx, trachea, and bronchia, traced as far as their smaller divisions, presented everywhere great paleness; the mucous membrane (of the air-passages) exhibited no other appre- ciable alteration; white fibrinous concretions distended the right cavities of the heart. The digestive canal, opened to its entire ex- tent, presented no other lesion but a bright redness, scattered in patches over the great intestines. Here we have a case which presented all the rational symptoms of phthisis, although the lungs were sound, and evidences of decided lesion of the bronchial mucous membrane, which, notwithstanding, was in a state that would have been declared sound, had we been ignorant of the patient's condition before death. This case serves also to apprise us of the difficulty of distinguishing a simple chronic bronchitis from a tubercular degenerescence of the lungs. What, DIFFICULTY OF DIAGNOSIS IN CHRONIC BRONCHITIS. 197 as M. Andral asks, can auscultation tell us in this case, except that there are no cavities ? Let us, he continues, draw from it this con- clusion ; that so long as the existence of tubercles shall not be ascer- tained by the stethoscope, the return to health should not be deemed impossible, by the cessation of the bronchitis, which occasioned all the symptoms. It is against such an inflammation of the mucous membrane of the air-passages, that a great number of hygienic and therapeutic means have often succeeded, which, if directed against real phthisis, would certainly have failed, or at most would merely have retarded for a little the progress of the evil. 'Much stress is sometimes laid, but without reason, on the large quantity of expectorated matter in a doubtful disease of the pul- monary organs. The quantity in chronic bronchitis varies from day to day, but it is almost always greater in the acute disease; not unfrequently amounting to one or two pints in the twenty-four hours. It is increased by every attack of cold ; or rather the mu- cous secretion is at first less, with more watery discharge ; and then, after a few days, becomes more copious. In some rare cases it becomes all at once, and usually without obvious cause, so very abundant and puriform, as to lead to the suspicion of a vomica being opened into the bronchia ; a mistake which is more likely to happen on account of the oppression which usually precedes and accompanies this state. The oppression, however, is owing merely to a great increase of the morbid secretion,— which may itself accumulate to such a degree in a weakened subject as to cause suffocation and death. A remarkable case (No. 17) of this nature is given by M. Andral in his work frequently quoted by me in this lecture. It is headed—Acute bronchial flux producing death by asphyxia in an individual affected with pneumonia and chronic bronchitis. Ulcerations of the bronchia are rare, as are softening of their mucous membranes. The frequency of ulcerations decreases from above downwards in the different portions of the mucous mem- brane of the air-passages. Thus, in chronic laryngitis they are common enough. It is not rare to find a part of the chordae vocales stripped of mucous membrane, the thyro-arytenoid muscles and the cartilages exposed to a greater or less extent, in persons who, af- fected with simple chronic bronchitis or pulmonary tubercles, had their voice for a long time hoarse or entirely destroyed. The remarkable feature in such cases is, that in a great majority of them, these ulcerations exist only when there is at the same time inflam- mation of the lower parts of the mucous membrane of the air-pas- sages. In the trachea, ulcerations become less frequent than in the larynx: they are generally small, and are not at all numerous — seldom extending beyond the mucous tissue proper. Auscultation, although it cannot apprise us positively of the exact condition of the bronchia in all their morbid changes, is still a valuable adjunct towards our obtaining a correct diagnosis in 198 DISEASES OF THE RESPIRATORY APPARATUS. chronic as it was shown to be in acute bronchitis. The respiration and cough are heard with various rhonchi — mucous, sonorous, sibi- lant, and clicking, which are continually shifting and changing. There is no bronchial or cavernous respiration, and, it is added by writers commonly, there is no permanent absence of respiration in a part, no unusual resonance of the voice: and in spite of the con- tinuance of the copious and puriform respiration, on listening, day after day, we still find no signs of a cavity, no cavernous rhonchus,or pectoriloquy. But the assertion, that there is no permanent absence of respiratiojt in a part, must be received with some qualification, as we every now and then find a case like that (No. 2) recorded by M. Andral, headed—Chronic bronchitis—narrowing of the prin- cipal branches of the upper lobe of the right lung ; and almost en- tire absence of the respiratory murmur in this lobe. Chronic bronchitis is often a very obstinate, as it is a harassing and fatal disease, especially to those of weakly frames. Death results either from the disease itself, or the complications to which it gives rise in the altered structure of the bronchial tubes and of the lungs. The causes of chronic bronchitis are the same with those of the acute form, except that the secondary chronic, or that supervening on other diseases, more commonly follows these than appears, like the acute, either simultaneously with them or soon afler their incep- tion. The habitual inhalation of dust or fine metallic particles, detached in various processes on the arts, is a cause of a distinct variety of chronic bronchitis. Stone-cutters, needle-pointers, they who powder and sift the ma- terials for making china, and leather-dressers, are particularly liable to the disease. The first and most marked symptom in these cases is dyspnoea, which may continue, however, for a considerable time without the disease declaring itself. But in the course of a few months the dyspnoea is increased, and is accompanied by severe cough and a copious expectoration, sometimes mixed with pus and blood. Not unfrequently the cough brings on a profuse haemoptysis. At this time the constitution generally suffers much,—the pulse be- comes quick; thirst and fever attend; the tongue is loaded ; and the aggravation of dyspnoea occasions lividity of the countenance. Unless, continues Dr. Williams, whose description I am now repeat- ing, these symptoms are relieved by remedies, and a total abandon- ment of the unhealthy occupation, they become worse; the expec- toration increases to a great extent, and becomes more purulent; hectic with night sweats succeeds ; and the patient dies with most of the symptoms of tubercular phthisis. In early life, chronic, which in such cases might be called also secondary bronchitis, occurs after hooping-cough, measles, small- pox, or some cutaneous eruption. Farther examples of the occurrence of secondary bronchitis are furnished in the irritation of the lung supervening on abdominal dis- ease, and particularly of irritation of the stomach, constituting what p DIAGNOSIS OF CHRONIC BRONCHITIS. 199 is often called sympathetic or gastric cough. The following are the symptoms, as given by Broussais in his Phlegmasies Chroniques (translated by Drs. Griffith and Hays). It comes on with violent shocks, which occur at each inspiration, but without swelling and lividity of the countenance, as in hooping-cough. The expectora- tion will be proportionate to the degree of bronchial-irritation ; sometimes it is wanting, at other times present; but the excretion may be suspended by means calculated to relieve gastritis, and this suspension is favourable to the patient. This secondary or stomachic cough is no new discovery; it is associated with either acute or chronic disease of thd gastro-intestinal mucous surface ; being in the first case marked by more violence, and more likely from the exist- ence of fever to become complicated with pulmonary inflamma- tion. In reference to an accurate discrimination of these kind of cases from primary chronic bronchitis, we may say that when there is a want of proportion between the physical signs and functional de- rangement, we are led at once to the correct principle of diagnosis. This is laid down by Dr. Stokes to be— That when distressing pec- toral symptoms exist, the morbid physical signs being either absent, or, if present, yet revealing an amount of disease too slight to account for the symptoms, we may make the diagnosis of sympathetic irrita- tion. If a patient has had fever, cough, and hurried breathing, for three or four days, and no commensurate signs exist, we may be tolerably sure that there is no actual or progressive inflammation ; for, if there were, it would have by that time fully manifested itself. I the more willingly introduce here the valuable details on this head furnished by Dr. Stokes, because the diagnosis is of great practical moment in a complication of maladies, which is, I know, of frequent occurrence, and the treatment of which is subject to fluc- tuations injurious if not perilous to the patient. Thus, persons labouring under gastritis, or gastro-enteritis, have been largely bled, and thrown into a typhoid state; or the abdominal inflammation has been exasperated by the use of remedies intended to relieve the pulmonary irritation. In making this diagnosis, the following are the principal points which must be attended to in order to avoid error : — First. Whether the symptoms or signs of incipient tubercle are absent. Second. Whether there is reason to suspect disease of the larynx or trachea. Third. Whether the uvula be or be not relaxed. Fourth. Whether the patient (if a female) be subject to hysteria. If the result of an investigation is against the existence of any of these causes, we may safely infer the abdominal origin of the cough; and it will not be difficult to decide between gastritis and worms. Thus enlightened, we shall succeed in curing readily pro- tracted gastric cough, which had proved intractable to general de- pletion on the one hand, and various stimulating expectorants on the other, simply by a removal of the gastritis. For this purpose, 200 DISEASES OF THE RESPIRATORY APPARATUS leeches to the epigastrium, iced water, and a bland diet, will often suffice. The association of bronchial with intestinal irritation, though of less frequent occurrence than bronchitis with gastritis, merits notice here. Without considerable attention to the diagnosis, a physician may be so far deceived as to take, for remittent pulmonary irritation of the lung, a case of intestinal worms with sympathetic cough and fever. I had, some years ago, a case of this kind occurring in a young girl about seven years of age, in which the pulmonary symp- toms with remittent fever were well marked: but the state of the abdomen, the appearance of the tongue, and the commemora- tive history, persuaded me that the patient laboured under worms. By prescribing accordingly, she was entirely relieved after a week's suffering, during which the cough was frequent and harassing. I did not avail to the full extent of the signs furnished by auscultation, " but I was not a little influenced in my opinion by the entire remis- sion from day to day of the bronchial irritation. There are other varieties of chronic bronchitis, also of a secondary nature, but depending on slower constitutional diseases than those mentioned. It would be more correct language were we to say, that in the progress of certain chronic diseases the bronchial mu- cous membrane is sometimes violently affected, and that this bron* chitis is cured by the same class of remedies which are adapted to and successful in the original disease. I cannot concur in the ideas conveyed by the expression, " that the gouty, scrofulous, syphilitic, and scorbutic contaminations, may, and no doubt do, produce their specific forms of bronchial inflammation." The fact of bronchitis preceding, alternating with, or following an attack of the gout, is not to my mind evidence of the specific or arthritic character of the former. Having explained myself on this score, when discussing pro- fessedly the nature and mutations of gout, I shall not return to the subject here. A more enlarged view and experience of the opera- tion on the different organic systems of different active medicines, will show that the cure of a particular affection by a remedy which has been successful in gout, for example, cannot be received as evi- dence that the former was also a modification of gout. This kind of argument was at one time common ; as, for example, when a cough or a pain in the head was removed by colchicum, it was forthwith inferred that these disorders were of an arthritic character. Now, we know, from extended trials with this remedy, that it is adapted to a great variety of diseases which, in the nosological catalogue, have no affinity to each other. I have frequently prescribed it in bronchitis with manifestly good effect, in cases, including my own, in which no suspicion of gout could be entertained. These remarks are not meant to apply to another variety of chronic bronchitis consequent upon syphilitic irritation. Syphilis, unlike gout, attacks, in its successive stages, a certain order of parts, viz., the sero-mucous membranes, skin, fibrinous membranes, and bones. That in its progress the respiratory mucous mem- TREATMENT OF CHRONIC BRONCHITIS. 201 branes and the digestive ones should suffer, is not incompatible with our existing knowledge of its organic seats. The upper part of the digestive canal, or the palate, tonsils, and pharynx, are parts commonly enough assailed by secondary syphilis, as is the larynx or upper part of the air-passages. Participation of the bronchia in this modification of laryngeal disease, or independent syphilitic bronchitis, has not probably engaged attention so much as it deserves. In this country, happily, a satisfactory reason exists, in our so seldom seeing bad and protracted cases of syphilis out of the hospitals. The bronchial disease of syphilitic origin is spoken of by Dr. Stokes, as either an acute or a chronic affection. In the first, he thinks it analogous to the bronchial irritations of the exanthemata, of which he has seen a few interesting examples ; whilst in (he second, there is a chronic irritation which, when combined with the syphilitic hectic and with periostosis of the chest, closely resembles true pulmonary phthisis. In the first of these cases he has observed that, after a period of time from the first contamination, the dura- tion of which has not been determined, the patient falls into a fever- ish state, and presents the symptoms and signs of an irritation of the bronchial mucous membrane. These having continued for a few days, a copious eruption, of a brownish-red colour, makes its appearance on the skin, and the internal affection either alto- gether subsides, or becomes singularly lessened. Dr. Byrne, physi- cian to the Lock Hospital in Dublin, is quoted by Dr. S. as corrobo- rating by his experience these views. The former gentleman states that he has in many instances seen patients, who had been formerly diseased, and who had come into the hospital either on account of new sores or of gonorrhoea, attacked with intense bronchitis and fever. The attack would come on suddenly, and the distress was so great that bleeding had to be performed, the effect of which was that, soon after, a copious eruption, often combining the lichenous and squamous forms, made its appearance with complete relief of the chest. In some of these patients, on the day before the eruption, the stethoscopic signs had been those of the most intense mucous irritation; and yet, when the skin disease appeared, the respiration became either perfectly pure, or only mixed with an occasional rhonchus in the large tubes. The same gentleman has observed the reverse of this; as when a syphilitic eruption has been repressed, the bronchial membrane became much affected, and the patient suf- fered from general febrile symptoms. These phenomena subsided after bleeding and mild diaphoretics, which had the effect of restor- ing the cutaneous eruption. The more chronic forms of syphilitic bronchitis with which pneu- monia is sometimes combined has been more fully described by Dr. Graves. Debility, night sweats, emaciation, nervous irritability, and cough and broken rest at night, associated with syphilitic disease, such as periostosis, sore throat, and eruption on the skin, indicate that the patient is labouring under a syphilitic cachexy VOL. II. — 18 202 DISEASES OF THE RESPIRATORY APPARATUS. affecting the lungs as well as other parts. A cautious use of mer- cury in such cases will soon improve the patient, w hose amended looks are ultimately followed by a removal of lues, the cough, and pectoral affection at the same time. We cannot, however, be too careful in our attempts to establish a correct diagnosis before we begin the mercurial course, remembering, as we must, how preju- dicial this treatment would be in a scrofulous habit with tuberculous predisposition or incipient irritation of pulmonary tubercles. Treatment. — The preceding description of the causes of chronic bronchitis, which to some may seem to be rather prolix, will serve not a little to guide us in our views of the proper treatment of this disease. This, it must be obvious, will vary with the nature of the case, as modified by cause, duration, and intensity of the symptoms. If these latter indicate that acute has supervened on chronic bron- chitis, recourse must be had at once to the remedies called for, and already specified as applicable to the former. Commonly, however, venesection is not required in the chronic form of bronchitis, un- less the patient be of a full and robust habit, and greatly jarred by the cough. Nor is local bloodletting, although a safer remedy than general in most chronic local maladies, necessarily required, unless to relieve a temporary but distressing exacerbation or evident congestion. When called for, it is best done by leeches under the clavicles, or cups between the shoulders. In case of doubt, I con- sider it the safest practice to draw blood rather than to abstain. There are cases, of course, such as of delicate lymphatic women, and puny children of scrofulous habit, who are frequently subject to bronchitis, whom it would be clearly improper to bleed. But that other large class, viz., of labouring men in town and country, who have had abundant nutriment and used spirituous and malt liquors, and of young persons of both sexes ' who have neglected their colds,' will be materially benefited by the abstraction of blood in the manner last prescribed ; or if the means for this are not at hand, by a small bleeding from the arm. The circulation is thereby equalized by the abatement, if not removal, of the congestion, and the suscep- tibility to the other remedies is thus more completely awakened. These are, in the first place, purgatives, and then antimony or mer- cury with opium, according to the degree of excitement. Chronic bronchitis is so often associated, at least in our climate, with gastro- hepatic derangement, and a torpid or irregular state of the large bowels, that purging may well precede the alterative and tonic course with which, in conjunction with counter-irritants, the treatment is usually completed. Calomel and jalap, or calomel followed by the compound powder of jalap; pills of the compound extract of coly- cynth and calomel, sulphate of magnesia with wine of colchicum, will represent the purgatives more immediately required. After this, I have been in the habit commonly of prescribing the blue mass with hyosciamus, or with ipecacuanha, in pills twice or ihrice a day, according to the trouble which the cough gives — attention being paid to keep the bowels open, and to suspend the prescription TREATMENT OF CHRONIC BRONCHITIS. 203 if there is any evidence of the mouth becoming touched. I have seldom seen benefit from salivation, or any approach to it in chronic bronchitis, except in one, and that a somewhat peculiar case, in which three grains of the blue mass, united to hyosciamus, caused copious salivation, and cured the patient. She had given me notice of her peculiar liability to the sialogogue operation of mercury. In milder cases a single pill of the blue mass, three grains with half a grain or a grain of ipecacuanha at night, and a teaspoonful of salts in the morn- ing, will exert a salutary effect in removing the cough, and giving the secretion a healthy character. Where the disease is more parox- ysmal, the fits of coughing being violent, and febrile irritation mani- festing itself every evening, calomel and tartar emetic; one or two grains of the former and a sixth of the latter three times a day, with the addition of opium, if the bowels are loose or irritable, will sometimes be required. If relief is not procured in a few days by this course, we must substitute for it the use of colchicum and digitalis, provided that the disease be still accompanied with febrile symptoms, and a feeling of tightness of the chest, and difficult ex- pectoration. Camphor mixture will form a convenient and appro- priate medium for the administration of the colchicum wine, which will be given in doses of half a drachm to an adult twice a day; or thirty drops, if combined with tincture of digitalis, in a dose of four drops given at the same time. In walking cases, wine of colchicum seeds, in doses of ten to twenty drops, three times a day, with, in the evening, five to ten*drops of laudanum, is one of the best remedies with which I am acquainted. It serves, in addition to its direct effect on the bronchia, to relieve these indirectly by keeping the bowels in a soluble state. After the regulation of the digestive system, our attention should be directed to the renal secre- tion, which is at all times not a little influenced by the function of the lungs, as it, in its turn, modifies this latter. I have found a three- grain pill of the blue mass at night, and a moderate dose of the vinous tincture of colchicum on the following morning, and both repeated for some days, to have a very good effect. Where we anti- cipate a salutary operation through the kidneys, the hydriodate of potassa will be serviceable, and should the more readily be enlisted in the treatment, if the habit of body of the patient be strumous, and he exhibits any evidence of tubercular predisposition, which should indispose us from prescribing mercury. If, in despite of these remedies, the disease still persists, with an absence of all the remains of acute disease or of febrile irritation, and exhibits a purely chronic character, with profuse perspiration, cool skin, soft and rather feeble pulse, and a moist or slightly loaded tongue, the treatment should be changed to one of a tonic kind, and the use of the balsams. Calumba and cascarilla, with nitric acid or sul- phate of quinia, sarsaparilla,and taraxacum extract,are useful. The balsam of copaiba is recommended by Dr. Armstrong, in very warm terms, in those cases of profuse expectoration without much vascu- lar excitement. Other practitioners and writers of authority and 204 DISEASES OF THE RESPIRATORY APPARATUS. experience do not sanction his praises. Like my friend, Dr. La Roche (North American Med. and Surg. Journ.), I have found it in some instances of marked efficacy. In others it offends the stomach, and has little or no influence. It is best given with some spirits of nitre, and occasionally I add the bicarbonate of soda; and, from my own experience, I should add, as when I spoke of its use in chronic laryngitis, with the addition of compound syrup of sarsaparilla and a minuteportion of iodide of potassium. In purely asthenic cases, in which there is a languor of the functions of diges- tion and circulation, the iodide of iron serves a good purpose. But at the very outset, or at least after bloodletting, if this be thought advisable, and purging, counter-irritants should be employed in conjunction with the remedies already indicated. It may happen, in fact, that, owing to a weakness of stomach and intolerance of al- most any kind of internal medicine, or to the peculiar circumstancesin regard to the occupation of the patient, or tender age, as in children, our main reliance must be on external or counter-irritation to the skin. To carry this out successfully we may direct friction of the chest with an oily liniment, containing various proportions of tartar emetic, tincture of cantharides, the essential oils, ammonia, acetic acid, or a diluted mineral acid, according to the degree of effect desired. This combination will represent the liniments which quack physicians and medical quacks laud in books and news- papers as their own discovery, and as endowed with peculiar and specific powers. A succession of small blisters applied in the French fashion, or as flying blisters, may be substituted for the liniment. In milder cases, again, a warming plaster, composed of pitch sprinkled over with a little powdered cantharides, or even a mercurial plaster will answer. Auxiliary to other treatment is the inhalation of various vapours, simple and medicated, and of gases, in chronic bronchitis. Having ascertained that the larynx and glottis are free from any inflamma- tory irritation, it maybe occasionally worth while to have recourse to the inhalation of balsamic and stimulating vapours, in cases par- ticularly of a phlegmatic habit, and in which the bronchial profluvia is considerable. Gases, and substances of a more decidedly irritat- ing nature, are better diffused with watery vapour through the air of an apartment, or small closet even for the purpose. In this way iodine, and even chlorine, might be used with benefit; a few grains of the former, or a solution of the chloride of soda or of lime being placed in a saucer floating on hot water. As relates to all the kinds of vapour and modes of applying it, the physician will watch if there be increase of cough or acceleration of pulse in consequence, and regulate the continuance of the remedy accordingly. I may refer to my remarks on this subject in a preceding lecture on chronic laryngitis, and to my work on Baths and Mineral Waters. A knowledge of the peculiar circumstances under which chronic bronchitis has come on, will of course modify our treatment; as where it has a syphilitic origin, or appears in a gouty diathesis, or TREATMENT OF CHRONIC BRONCHITIS. 205 is associated with chronic gastritis. Of this conjunction I have already spoken in such a way as to indicate the appropriate reme- dies. If bronchitis be one of the sequences of syphilis, we may shape our treatment accordingly, even though we have not recourse to mercury. In cases in which the habit of the patient is scrofulous, and the predisposition to pulmonary tubercles obvious, iodine and sarsaparilla, and the narcotics, should take the place of mercury. The simple bitters and quinia, or some chalybeate, will advanta- geously complete the remedial course, part of which should consist of the tepid and warm bath, according to the degree of excitement prevailing at the time. The diet in chronic bronchitis will be regulated very much by the state of the stomach. If this organ be in a state of irritation, or of actual phlogosis, the food will be of the simplest and blandest kind. On the other hand, where the tongue is moist, the stomach free from disease and the bronchia from congestion, the cough, will not forbid a stronger diet — particularly in old persons, whose powers of digestion may be habitually good. There are instances in which a moderate repast of solid food has allayed the cough, which had been aggravated by an empty stomach. In the case of infants, it is desirable that they should be able to procure at once milk from the breast, either of the mother or a good wet nurse. Farinaceous and milky food, commonly recommended to adults in the chronic stage of pectoral affections, is not equally well adapted to all. There are some whose stomach is so constituted that they cannot, without much inconvenience,indicated by weight at the epigastrium, foul and white tongue, and headache, use a milk diet. Others with whom it agrees, and by whom it is readily digested, are with difficulty persuaded that, in conjunction with farinaceous matters and vegetables, it can furnish ample nutriment to their frame. Such persons regard milk in the light of a ptisan, perhaps a panacea, which is to eradicate their disease; and at table as meant to be an introduction to more substantial and sapid food, of animal kind. They obey the doctor's injunction, to take milk at breakfast and at dinner; but they do not understand him to meaner breakfast and dinner; and hence they contrive to finish off with coffee, and hot bread and butter, perhaps cakes also, at the former meal; and fish with wine sauce, calves head, and other made dishes, at dinner. I do not now sketch from fancy, but from sober observation. The inference to be drawn for our immediate instruction is, that, in every case, the dietetic directions should be precise and definite, so as to leave nothing to conjecture and misinterpretation. Often by a review of the food taken at the preceding meal, aggravated cough some hours afterwards will be prevented for the next day. The origin of an evening paroxysm is often of this nature. At all times it will be found that a patient who wishes to pass a tranquil night, must avoid either a heavy or a late, even though a light, supper. There are some persons so constituted that the common functional excitement of digestion will affect the 18* 206 DISEASES OF THE RESPIRATORY APPARATUS. bronchia, and give rise to a sensation of heat and altered secretion with cough : they ought, consequently, to have chymosis at least completed before they retire to rest for the night. Completeness and regularity of the digestiondemands our attention in chronic bronchitis, and hence the function of the lower bowels must be carefully watched. In fact, from the beginning of the treatment of the acute form of the disease to the termination of the chronic, and during convalescence, this is one of the prime indications of cure and health. If the bowels are tardy in their peristaltic action in, this latter period, we endeavour to quicken and give tone to them by the combination of purgatives and bitters; one of the best and most convenient of which is aloes and quinia ; or extract of gentian and rhubarb. Ripe and dried fruits often answer the double purpose of affording, in conjunction with bread, a light and wholesome nutriment, and of keeping the bowels in a soluble state. The cure de raisins, ripe grapes eaten in considerable quantity for several weeks, together with good wheat bread, and nearly the sole diet, is a popular remedy on the continent of Europe in many disor- ders. To the one before us it is well adapted, particularly in pa- tients who labour under a slight febrile excitement or an irritability which precludes as yet either tonics or stimulating food. The more protracted and obstinate cases of bronchial inflamma- tion will often be either entirely cured or materially relieved by the use of certain mineral waters—a selection of the kind of which will depend very much on the complications of the diseases of other organs with those of the bronchia. If the skin has been long affected, and the irritationhas disappeared, orthe eruption dried up; if the liver and bowels have been torpid, the stronger sulphur water will be preferred — such as the White Sulphur Spring of Virginia. Dr. Graves speaks in high terms of sulphur in chronic bronchitis. (Graves and Gerhard's Clinical Lectures, 1842.) Mere acidity and irritation of the stomach being the accompaniments, the water of the Sweet Spring will suffice. Cough with febrile excite- ment and evening paroxysms, and a greatly accelerated pulse, has been often completely and speedily removed by a course of the waters of the Salt Sulphur. One or other of these waters, and the tepid or warm bath, and inhaling the pure mountain air of the region of Virginia, in which they are situated, have restored many invalids in the advanced stages of bronchitis, whose cases were supposed to be of pulmonary consumption. (Bell, op. cit.) In mentioning pure mountain air as one of the restorative agents in chronic bronchitis, I would not be understood to recommend it in all cases. So far from such a recommendation holding good, there are varieties of the disease in which a reduced air, such as that of low grounds, and charged with moisture, is of paramount importance as a curative agent. In the dry tracheal and bron- chial affections this kind of a iris most serviceable ; and to breathe it habitually patients resort, as a winter residence, to Pisa and Rome in Italy; or to Norfolk, Savannah, and Augusta, in our own country. Those patients who are annoyed by copious expectora- PREVENTION OF CHRONIC BRONCHITIS. 207 tion, and whose system is rather torpid than otherwise, will be told to give Naples and Nice, in the old world, and St. Augustine, in the new, the preference. But although different in the hygrometric states of the air, there must be a general resemblance on the score of temperature among the chosen locations for the winter residence of the invalid who suffers from irritation and other diseases of the air-passages. Although cold is most to be deprecated, yet a very high heat is also injurious. Temporary exposure to a cold, or to a cold and moist air, or to currents of air, should be sedulously avoided by the invalid. With this view, as well with that of pro- curing a uniform temperature and moisture of the air, neither of which can be done in our houses heated by fires after the common fashion, it has been proposed to keep the patient, with chronic bron- chitis or incipient phthisis pulmonalis, in apartments warmed by heated air conducted through flues. It is easy, by having large vessels of water in the hot air-chamber, to preserve the requisite moisture of the air which is sent up, after being heated by the fur- nace below, into the rooms above. I am very sure that many persons who are habitual sufferers from catarrhal affections of various degrees for nearly half the year, might entirely escape them by having their houses warmed in the manner just stated. Neither they, nor the more formally recognised and treated invalid, would be precluded from the advantage and enjoyment of exercise in the open air during the winter months; only in the case of the latter this should be taken with a nicer selection of sunny days and noontide hours, and when the southerly wind prevails. The prevention of chronic bronchitis will consist in giving the requisite tone to the skin, in the avoidance of great vicissitudes of temperature, particularly when the body is perspiring freely, and in maintaining a regular digestion. The skin is rendered much less impressible from sudden atmospherical extremes, by sponging the surface daily with salt and water, and friction for some time afterwards with dry towels. A more circumscribed ablution even, as by sponging the chest and neck every morning with vinegar and water, or salt and water, has been found to be a capital preventive, especially when followed by dry rubbing for some time. The undue sensibility of the cutaneous function, by which, in one person, bronchitis, in another rheumatism, is brought on, is greatly diminished by sea-bathing. The precautions and the associated circumstances to be attended to in visiting the sea-shore with this view, have been detailed in my work on Baths and Mineral Waters. At all times the skin should be guarded by an inner garment, of such a texture that it is at the same time a bad conductor of caloric and an absorber of the fluid perspiration. On this ac- count flannel or woollen wove, or silk-jackets, should be worn in winter, and domestic muslin or cotton flannel in summer. There nre many individuals whose liability to fluxions of the bronchia or bowels, or to rheumatism, is such, that they cannot at any season dispense with flannel. In all cases, the inner garment ought to 208 DISEASES OF THE RESPntATORY APPARATUS. be changed night and morning; and the invalid, before putting it on, should use the flesh-brush, or some analogous means of active friction of the skin. In directing the prophylaxis for the benefit of children, we can- not but deplore the exceeding blindness of parents to consequences, and the too general indifference of physicians to the philological law respecting the evolution of animal heat, when we see the fashion of the dress of these little beings. They who have less ability to create animal heat, and whose bodies, in consequence, are less able than adults to resist the morbid impressions of cold and moisture, are cruelly exposed to attacks of croup and bronchitis by their breasts and shoulders, and the greater part of their arms being deprived of all covering in-doors, and often not properly pro- tected when in the open air. But the chief mischief is in the house,— between the different rooms of which there is often as great a contrast in temperature as between summer and winter. Add to exposure, by transitions of this kind, that in entries, and the occasional detention of children at open doors in the arms of nurses and mothers, during all which time the skin of the chest in front, and between the upper part of the shoulders behind, and even of the armpits, is acted on by cold, and by cold and moisture, and we find a cause, the chief cause, of so many attacks of croup and bron- chitis. We need hardly inquire for the often additional ones of cold and damp feet, and chill by detention, without active locomo- tion, in the open air. LECTURE LXV. DR. BELL. Narrowing and Obliteration of the Bronchia.—Dilatation op the Bron- chia.—Organic changes in the tubes and air-cells—Thickening, the first change—Symptoms, difficulty of inspiration—Obliteration of the bronchia with shrunken pulmonary tissue—Dilatation of the bronchia may occur very early in life—Causes, prior diseases—Symptoms analogous often to those of phthisis pulmonalis—Differential diagnosis between these two diseases, its great diffi- culty.— Treatment,—nearly the same as for chronic bronchitis.— Ulcers of the bronchia.—Dilatation of the Air-cells.—Pulmonary or Vesicular Emphy- sema.—Dilatation and rupture of the air-cells—Symptoms equivocal—Disease often begins in early life,—constitutes a variety of asthma.—Dry Catarrh— Asthma.—Bronchial congestion, a preferable term—This with pulmonary emphysema constitutes mainly asthma.— Treatment—Mild aperients, alteratives —The alkalies—Regulation of diet. Narrowing and Obliteration of the Bronchia.—Dilatation of the Bronchia and Enlargement of the Air-cells. — There are other changes in the bronchia resulting from inflammation, than those which occur in the mucous membrane. These are at- tended with opposite symptoms in different cases. As chiefly refer- rible to chronic inflammation of the bronchia, they might have NARROWING, ETC., OF THE BRONCHIA. 209 been described under this latter head, but for the suspension which some of you may think has been already too great by pathological inquiries before I reached the subject of treatment. Considered in relation to bronchitis, the organic changes in the tubes and air-cells are enumerated, by Dr. Stokes, as follows : — 1. Narrowing of the calibre; obliteration. 2. Dilatation of the tubes. 3. Ulceration destructive of the tubes. 4. Enlargement of the air-cells. 5. Atrophy of the lung. The most simple change of structure of the bronchial tubes is a mere thickening of the mucous and the sub-mucous membranes, which generally in some degree accompanies acute inflammation. This is accomplished by an increased seeretion of soft lymph, which, as the inflammation subsides, is eliminated and expectorated with the mucus of the membrane ; or if it have been effused in the cel- lular and parenchymatous tissue, it is after a while absorbed. But it is otherwise when the inflammation recurs frequently, or is of long duration ; for it then causes an effusion of a less absorbable nature, involves the less vital structures, and as the changes induced are slow, so they are more permanent, because they become identified, with the nutritive or reparative functions of these tissues. There will then be produced a degree of hypertrophy of some or all of the various tissues composing the tubes. Nothing, says Dr. Williams, is more common than to see the air-tubes of persons who have long suffered from bronchitis presenting an undue de- velopment of the longitudinal elastic fibres; whilst in other cases the outer cellular coat of the larger bronchia is thick and indurated, and their cartilages are sometimes partially ossified. Any of these changes has the effect of rendering the lungs less easily expansible in respiration ; the first in particular is a common cause of the short breath, which persons frequently affected with bronchitis generally manifest; and although not often serious in itself, yet it may so abridge the sphere of the function of respiration as to make its in- creased exertion on bodily exercise a matter of difficulty and dis- order, and to render it illy able to bear any other attacks of disease, to which the lungs can in general adapt themselves by supplemen- tary effort. Thus, when one portion of a healthy lung is attacked with pneumonia, or compressed by pleuritic effusion, its function is supplied by the increased and quickened movements of the other portions, which, in their natural state, are equal to this augmented task; but if their pliant elasticity be impaired, and their size more fixed by an increased stiffness, they will also be, in proportion, less available for additional exertion, and the body will suffer the more from the crippled state of the function. The chief symptom of hypertrophy of the longitudinal fibres, and of increased rigidity of the tubes generally, is difficulty of inspira- tion, which is short, quick, and performed with an effort, especially on making any exertion; whilst the expiration is comparatively 210 DISEASES OF THE RESPIRATORY APPARATUS. easy; but both acts are often accompanied by wheezing sounds, from irregularities in the calibre of some of the tubes, and frequently from partial congestions or inflammation, from which tubes thus diseased are rarely free. The vesicular murmur is impaired, and the expansion of the whole chest is perceptibly limited. These symptoms resemble those of spasmodic asthma, except that they are permanent, and are not removed as the latter may be for an instant on breathing after holding the breath. As the bronchia cannot be narrowed without the sound caused by the entrance of air into these tubes being also changed, there results a peculiar rhonchus or rattle, on auscultation, which, in consequence of its seat and nature, is called by M. Andral the dry bronchial rattle or rdle, the two principal varieties of which were denominated by Laennec sibilant and stertorous. This rdle is evidently owing to the air in its way to the pulmonary vesicles, traversing tubes which are nar- rower than those which usually give passage to it. In its exit from the vesicles, the air again finds the same obstacles to its free passage, which causes, during expiration, the rdles or rhonchi already mentioned. Sometimes they are only heard during expi- ration. In reference to obliteration of the bronchia, the following con- siderations merit notice. If we follow the bronchial ramifications from their origin to the pleura, we shall observe an approach to transformation from mucous to serous membrane, or at least a decided tendency to it, which increases as we approach their ter- minations. In the larger tubes we find a vascular mucous mem- brane endowed with villosities and glands, but, as we advance into the substance of the lung, this tissue gradually loses its original characters, until, at its ultimate point, if it be not completely serous membrane, it closely approaches to it in appearance and function. It has been remarked by M. Reynaud, as quoted by Dr. Stokes, that we may expect to see the plastic inflammation the more the affected tissue approaches to the white structure; and here is a cause of the greater liability of the minute tubes to obliteration. In all cases except where the tube was extremely minute, it has been found, that, just at the commencement of the obliteration a cul-de-sac existed, beyond which the tube was converted into a solid fibrous cord, furnishing also ramifications which answered to the originally pervious tubes. As might be expected, those parts of the lung to which the obliterated tubes extend, have been found to present a shrunken appearance. In the neighbourhood of the obliterated canals, how- ever, the air-cells were frequently found dilated, while in other in- stances the tissue was dense and impermeable. Obliteration of the bronchia has been met with as a chronic or an acute affection. As a chronic disease it will be frequently found in connexion with tubercle. It is, continues Dr. Stokes, an inter- esting fact, that it occurs much more frequently in the upper than in the inferior portions of the lung, and its connexion with the de- DILATATION OF THE BRONCHIA. 211 velopment and phenomena of tubercle is too obvious to be over- looked. Dr. S. has little doubt that, in many cases of pulmonary disease, the pent-up secretions of the air-cells represent, in some cases, the acute granular tubercle, and in others, where the affec- tion is more general, the suppurative pneumonia. Although we should admit that the minute bronchial tubes or excretory ducts might be plugged up by secretions of the cells, independently of inflammation in the parietes of the tubes or cells, yet we cannot help looking on the obliteration as principally the result of an inflammatory process. Dilatation of the Bronchia.—This state of the bronchial tubes de- serves attention, not only on its own account, but also because it sometimes produces physical signs similar to those of phthisis ; such, for example, as the mucous rattle or rdle, and the gurgling sound similar to those from tuberculous cavities. Auscultation, also, apprises us of pectoriloquy. For the better exhibition of the bronchia in autopsic examinations they should be laid open, from their large to their small branches, with a pair of scissors, Sometimes the dilata- tions are pretty uniform through some length of a tube. In other cases they form irregular roundish cells or pouches, freely communicating with each other, and from which tubes of unchanged size here and there arise. The tissues composing the tubes are, generally at the time, more or less altered. They are least so in the tubular form of dilatation, in which the coats are often quite thin, and the longi- tudinal fibres are distinct, although occasionally enlarged. But in the more globular dilatations, the walls of the tubes are generally much altered. They are irregularly thickened ; the thickening being formed in part by hypertrophy of the mucous or sub-mucous tissues lining the cells, which sometimes form folds of wrinkles around the tubes, and partly by a dense tissue on their outsides, probably consisting of the parenchyma of the lung compressed by the encroaching tube. There is little or no trace of the longitudinal or circular fibres in this form of dilatation, and the lining mem- brane is generally in a softened state, and of a red colour, whilst there may be considerable rigidity in some parts of the tubes. For detailed views of the pathology of dilatation of the bronchia, I must refer to Dr. Williams's and Dr. Stokes's works already so often quoted. This disease may occur at all ages, from two months and up- wards; and,indeed, there is reason to believe that it is sometimes con- genital and a predisposing cause of pulmonary disease. As repects its duration, we may regard it under three different aspects. First, a dilatation may occur to a great extent in a comparatively short time. This has been chiefly observed in young children affected with hooping-cough, in whom the period of two or three months is suffi- cient to produce the fullest development of the disease. In the next class are those cases in which a bronchial irritation has continued for many years in certain cases, indeed for the greater part of the life of the individual, during periods varying from four, five, and six, to 212 DISEASES OF THE RESPIRATORY APPARATUS. twenty, forty-one, and fifty years. Finally, we have this organic change as a common accompaniment of the tuberculous disease of the lung, and of course the period of duration is various. Dr. Williams describes one manner, among others, in which the bronchia become dilated. In the disease called pleuropneumonia the lung is inflamed, and at the same time compressed by an effu- sion in the sac of the pleura. Now, if it remain long in this state, the smaller air-tubes and cells become obliterated by the adhesion of their sides, so that when the liquid is removed from the pleura they will not expand again with the enlargement of the chest: but the large and middle-sized bronchia are not obliterated ; they bear the whole force of the inspired air, and become consequently di- lated by it. This kind of dilatation is usually conjoined with con- traction of the affected side. The symptoms produced by dilatations of the bronchi will be according to the extent of the lesion. Slight degrees of it are met with in the bodies of persons who had not during life manifested any prominent disorder of the respiration; and its simpler forms may exist to a greater extent without producing any other effect than a liability to attacks of bronchitis. But where it affects many tubes, has modified their structure, and has enlarged them to such a degree that they press on and obliterate a considerable extent of the pulmonary parenchyma, it then causes habitual dyspnoea, with more or less cough and muco-purulent expectoration, which is often remarkable for its fetor. There are, generally, present also the ordinary symptoms of severe chronic bronchitis, for which some parts of the affected tubes are scarcely ever free; and the perma- nency of these symptoms, together with a degree of lividity, drop- sical effusions, and cachectic condition, often induced by the crip- pled condition of the lungs, forms the usual general character of the aggravated forms of dilated bronchia. Now, you may say, continues Dr. Williams, whose language I have just been repeating, that these symptoms look very like those of consumptive disease : and so they well may ; for there is injury to the function of respiration, profuse expectoration, hectic fever, and the patient is often slowly wasted away. In their aggravated forms, dilated bronchia are not more tractable than tubercular con- sumption itself; but their tendencies and constitutional effects are different, and merit as much of a distinction as our means of diagnosis can find for them. Unfortunately this is not one of a very marked kind ; in fact it is to be made only by those much experienced in diagnosis; and even they will give it in terms rather of probability than of certainty. Dr. Williams thinks that the situation of the part from which the sounds in auscultation are perceived, will help to guide us in our opinion : in phthisis it is chiefly in the superior parts, but in dilated bronchia in the middle regions of the chest. The character of the sounds in relation to time is of value also ; those in phthisis tending to increase and spread as the excava- tions proceed, whilst those of dilated bronchia remain nearly DILATATION OF THE BRONCHIA. 213 stationary for weeks and months. In the former disease the sound on percussion is more extensively dull, especially under the clavi- cles ; whereas in the latter, if any dulness exists, it is generally in the mammary, lateral, or scapular regions of the chest, and is often ac- companied by a sound of a peculiar kind. This is hollow and tube- like, and from its resemblance to that produced by mediate percus- sion on the trachea, or by tapping with the finger on the mouth of a small vial, Dr. Williams has given it the name of tracheal or am- phoric. A notion of it may be conveyed by filliping on a finger pressed on the larynx or trachea, or on the cheek, when the mouth is opened in the manner of sounding the letter O. This sound de- pends, not essentially on the vibration of the walls, as in the case of the ordinary sounds of striking the chest, but on that of the air in the tubes or cavities, which give a note, according to their length and size, precisely in the manner of a pan-pipe, or of an India rubber bottle. Where the differential diagnosis is so important as that between phthisis and any other disease, I have no hesitation in repeating the very luminous summing up of this subject in the words of Dr. Williams. Finally, says this gentleman, you will be better able to distin- guish dilated bronchi from phthisical cavities, when you become fully acquainted with the signs and general symptoms of the latter; and I shall now only add, by way of recapitulation, when you meet with a case in which long continued cough, with purulent expectoration, dyspnoea, loss of flesh and strength, hectic fever, even with some of the physical signs of cavities in the lungs, be- ware of pronouncing it to be tubercular, if qualified by all or most of the following conditions: — If no proofs of a scrofulous habit can be traced; if the complaint have originated in a long-continued and violent cough, or in an attack of pleuropneumonia, and, consi- dering its duration, emaciation have now proceeded very far; if the purulent expectoration have been fetid and sanious rather than flocculent or caseous; if the bronchial or cavernous respiration, voice, or gingling, be heard rather in the middle than in the upper portions of the chest, and be there spread over a considerable ex- tent of surface; if these middle portions chiefly sound differently on percussion, being dull when the rest of that side sounds pretty well or amphoric when the side is generally dull and contracted ; and if, although the cough and expectoration continue undiminished, these signs remain stationary for many weeks together. After all, however, some of the most skilled auscultators are at a loss what diagnosis to form in certain cases of dilated bronchia. M. Andral presents the outlines of a case of chronic bronchitis with dilatation of several bronchi, pectoriloquy, and ulceration of the sto- mach, in which the diagnosis, according to Laennec, under whose care the patient came, was beyond doubt that of pulmonary phthisis. The nature of the sputa and the pectoriloquy seemed to indicate that cavities were already formed. vol. n. — 19 214 DISEASES OF THE RESPIRATORY APPARATUS. In general terms we may say, with Dr. Stokes, that in phthisis we have first dulness, and then cavity; while in dilated tubes we have first cavity, and then dulness. But, he adds, the bronchial tubes may be sufficiently dilated to give pectoriloquy and broncho- phonia without any dulness ; proof of which he gives in a case fur- nished by M. Louis, who supposed his patient to labour under an organic disease of the abdomen, and a chronic and circumscribed phthisis ; whereas, in fact, the organic lesions were dilated bronchial tubes, in both sides resembling a series of cysts. Of the treatment of dilatation of the bronchial tubes little can be said. We have no remedies of admitted efficacy to control this morbid condition. A useful lesson is derived, however, from this disease, in favour of early and active measures for its prevention. These will be the same as those already indicated for chronic bron- chitis, of which dilated bronchial tubes issometimes one of the effects, and occasionally one of the associated symptoms also. Hence we must go a step farther back, and endeavour to arrest the first inflam- matory attacks, which, if neglected, will end in chronic bronchitis and dilated bronchia. Ulcers of the bronchia seldom occur but in connexion with some peculiar cause which tends to fix inflammation on the bronchial mucous membrane, such as the habitual inhalation of irritating particles of dust, in various trades ; the continued passage of tuber- culous matter in phthisis, and occasionally the specific influence of measles, small-pox, and syphilis. We are ignorant of any symptom by which the presence of ulcers in the bronchia can be distinguished. It is worthy of remark, however, that they rarely exist without a similar affection of the larynx ; in which case the voice is impaired, or lost; but then, again, this happens commonly when the bronchia are not ulcerated, or only so far as to give vent to the matter of vomicae in phthisis. Dilatation of the Air-cells. — Pulmonary or Vesicular Em- physema.— The former of these titles is that given by Dr. Stokes, the latter by M. Laennec, to a morbid state of the air-cells of the lungs, accompanied with enlargement of the viscus and increased quantity of air in the thorax. The anatomical characters of the disease are, according to Laennec, augmentation of size and less uniformity of the air-vesicles. The greater number equal or exceed the size of a millet-seed, while some attain the magnitude of hemp- seed, cherry-stones, or even French beans. The latter are probably produced by the reunion of several of the air-cells through rupture of the intermediate partitions; sometimes, however, they appear to arise from the simple enlargement of a single vesicle. The largest of these dilated cells are often, in no respect, prominent on the surface of the lung; sometimes they form a slight projection. The dilatation is greatest at the base of the lungs and upon the in- ternal surface. So far the air is contained in its proper cavities, which are excessively, permanently, and unnaturally distended; but if the dis- DRY CATARRH —ASTHMA. 215 tension becomes still greater, the air-cells are ruptured in certain points, and we have that other variety of pulmonary emphysema in which the surrounding cellular tissue of the lung is infiltrated with air. The surface of the pulmonary vesicles is in such cases of an irregular form, which is made to vary by pressure on them with the finger. Louis believes the vesicles to be hypertrophied. Sometimes, but comparatively seldom, there is a combination of this last state with a true emphysema of the inter-lobular cellular tissue; but this is generally very slight. Waiving inquiries into the probable causes of dilatation of the air- cells, it is most important for us to know that this disease is, not so often as supposed, a result of bronchitis; but that its prevention, alleviation, and cure, depend on circumstances as yet not fully appreciated. According to Louis, we uniformly find that the extent and degree of the emphysema are always in direct propor- tion to the age of the patients ; or, to what, in an extremely chronic complaint is the same thing, the duration of the disease. Nearly all the subjects of the asthma which Laennec calls dry catarrh, exhibited, on examination after death, a greater or less dilatation of some of the bronchial cells. An occasional cause is worthy of notice : it is a long retention of the breath, as in the case of players on wind instruments, and those who have to overcome unusual resistance by great bodily effort, as in lifting, pushing, and pulling. Both the general and local symptoms of this disease are rather equivocal, at any rate in its slighter forms. Patients labouring under this disease are affected with an habitual dyspnoea, which, in the earlier periods, is often mitigated in summer, to return with violence during the winter: they are, also, liable to repeated attacks of what may be termed congestive bronchitis, during which the difficulty of breathing becomes extreme. The secretions are more frequently scanty, viscid, and unelaborated in the dilatation of the air-cells than in that of the bronchial tubes. Repeated returns of acute catarrhal attacks in this state of the air-cells gives rise to most of the phenomena of dry asthma, the paroxysms of which are accompanied by extreme oppression. In the fixed forms of this disease the physiognomy is almost characteristic. Dr. Stokes, who makes this remark, draws directly afterwards a portrait of a patient affected with it, which is certainly distinguished by remark- able and distinctive traits, although it is too highly charged to be a representation of the majority of persons suffering from dilatation of the air-cells. The complexion is generally of a dusky hue, and the face, although anxious and melancholy in its expression, is preter- naturally full, when contrasted with the rest of the body. The nostrils are dilated, thickened, full, and vascular. The lower lip is enlarged, and its mucous membrane everted and livid, giving a peculiar expression of anxiety, melancholy, and disease to the countenance. The shoulders are elevated and brought forward, and the patient stoops habitually, — a habit contracted in his various fits of orthopncea and cough, by the relief experienced from inclining the 216 DISEASES OF THE RESPIRATORY APPARATUS. body upwards. The apices of the scapulas are remarkably pro- jected; and anteriorly the clavicles are arched and prominent; the sternum has lost its flatness or its relative concavity, and it is thrown forward and even arched both in a longitudinal and trans- verse direction; the intercostal spaces are widened but not dilated, as in empyema. When we examine the sides, however, we see the intercostal spaces deeply marked, and presenting no indications of protrusion; so that, if we compare the diseases of dilatation of the cells and empyema, with respect to the external conformation of the chest, we find that, in the first, the appearance of smoothness and dilatation is most evident superiorly, while in the latter the reverse occurs. The lateral portions of the chest are remarkably deep, and their convexity not at all proportioned to that of the anterior or posterior portions of the thorax. On applying the hand to the inferior sternal region, we generally find that the heart is pulsatory with a violence which we should not expect from the examination of the pulse at the wrist, which is often small and feeble, whilst the impulses of the right ventricle are given with great strength. These phenomena are generally owing to a hy- pertrophied state of the right cavities of the heart which so commonly attends this disease, a slate so frequently accompanied with a violent impulse and a feeble pulse. Two other causes may exist for the production of this symptom without supposing a disease of the heart; and these are displacement of the heart by the dilated lung, and a congested and enlarged state of the liver. This disease begins frequently in infancy, and may continue a great many years. It does not always prevent the subjects of it from attaining an advanced age; although it must be admitted that it will seriously complicate and give additional power to other diseases. Of all the varieties of asthma, it is unquestionably, in the opinionof Laennec,that which affords to the patient the best prospect of longevity. Louis tells us, that it alone never causes death. The physical signs of dilatation of the bronchial cells are a morbidly clear sound on percussion corresponding to the part of the lung affected; and inaudibleness, or nearly so, of the respiratory sound in auscultation. Sometimes, during coughing or violent efforts of respiration, a wheezing or sibilant sound announces that the obstruction is not quite complete: and there will generally be some of the tubes which will give these sounds during common breathing. Dry Catarrh — Asthma. — Intimately connected with dilated bronchial cells, or rather its frequent precursor and cause, is the dry catarrh of Laennec, a few remarks on which will place all the characters of the former disease more completely before us, and will help, also, to enlighten us on the treatment. The anatomical characters of the dry catarrh are swelling, together with an obscure redness or violet hue of the mucous membrane of the lungs. This swelling is most remarkable in the smaller branches, which are indeed sometimes almost completely obstructed by it. They are frequently blocked up by a glutinous kind of matter, of a pitchy DRY CATARRH—ASTHMA. 217 consistence, or somewhat firmer, disposed in globules of the size of hemp or millet-seed. This matter which many persons who do not think they have, expectorate in small quantities every morning. It is called by Laennec pearly expectoration. The physical signs are the same, very nearly, as those of dilatation of the air-cells, which, as already remarked, so generally accompanies this disease. The term dry catarrh involves a contradiction, since the word catarrh itself denotes a flux or discharge; Laennec, who admits this etymological mistake, has chosen, notwithstanding, to designate in this way those inflammations of the bronchia which are attended with little or no expectoration. The coughs called gastric, hepatic, hysteric, &c., are all, according to this writer, examples of the coexistence of dry catarrh with some affection of the particular organs whence their qualification is derived. I should prefer the more pathological name, bronchial congestion, given to this disease by Dr. Williams. The symptoms of this affec- tion are those rather of asthma than of bronchitis. They vary ac- cording to the extent of the affection. In its slightest degree it is presented by those individuals, who, every morning on waking, feel their breath rather short, until they have coughed up a little tough semitransparent mucus. In its severer degrees, that is, when more of the bronchial membrane is affected, the shortness of breathing may amount to a regular fit of asthma, accompanied by cough ; and this may last more or less for hours and even days, and be at last relieved by the expectoration of the scanty, tough mucus just mentioned. There is little or no fever or sign of inflammation present; only sometimes a sense of constriction and heat, or rather of stuffing in the chest; but there is often-much gastric disorder; the tongue is slightly furred; the uvula relaxed; the tonsils congested; digestion imperfect; the liver inactive; the bowels torpid, or liable to extremes; the hemorrhoidal veins swelled ; and the urine turbid. Excesses in diet, the sudden removal of cutaneous eruptions, sup- pressed gout, and sudden checks given to perspiration, or any other free secretion, occasionally excite this affection. These causes, operating on systems not much disposed to inflammatory reaction, such as those of a torpid habit of body, destroy the balance of the capillary system, and occasion an undue distension or congestion of certain parts of it. Of the accuracy, also, and practical value of the following remarks by Dr. Williams, I am fully persuaded, when he says: — "This bron- chial congestion may doubtless originate sometimes in inflamma- tory affections of the same part; but, according to my experience, it is more commonly the result of disorders of the digestive or other organs which tend to injure the tone of some or other part of the capillary system. Thus, these will, in some persons, locate this congestion in the capillaries of the face, harming nothing but their beauty; in others the encephalic vessels suffer, whence habitual headaches of an obstinate character arise ; in others some part of the alimentary canal is the seat, whence indigestion, hemorrhoids, 218 DISEASES OF THE RESPIRATORY APPARATUS. or some disorder of the alvine function ensues. So, too, the urinary or the genital organs may become the place of this congestion; or it may fall on the bronchial membrane,and induce the affection under consideration; and the local determination of the morbid vascular condition is, in individual cases, fixed on particular parts or organs in consequence of prior weakness or tendencies." The treatment of dilatation of the air-cells and that of dry catarrh is to be conducted on similar principles. In both there is congestion of the cells, with imperfect and thick secretion. Both are marked in their course by paroxysms of asthma, often of great violence and frequent recurrence, and disorder of the heart, and occasionally other organs out of the chest. The pathology of pulmonary em- physema, and of its common antecedent, dry catarrh or bronchial congestion, is that of the chief forms of asthma, if we except the simple nervous; and must therefore be steadily held in view if we would properly appreciate the directions for its alleviation or cure. Various exciting causes, among the chief of which are cold and indigestion, will bring on an attack of asthma: but the predis- position depends on the habitual state of the mucous membrane and air-cells of the lungs just now described. To the removal of these latter, therefore, ought our efforts to be directed, rather than to the warding off of a paroxysm of simply spasmodic asthma. It must be confessed that our prognosis, as far as relates to a speedy, or, in some cases, an entire cure, of the diseases under consideration, is not very favourable. Our difficulties, however, will induce us to press on all persons the importance of arresting, as soon as possible, those affections which are so often neglected or trifled with, on account of-their being ' mere coughs,' or * common cold,'—'slight influenza,' &c. Bronchial congestion, although it may have an inflammatory origin, is seldom of such a nature as to require active antiphlogistic measures. Not unfrequently, indeed, I have seen it prevail in per- sons of a lymphatic temperament, disposed to anaemia, and who could illy bear such a treatment. In place, then, of direct depletion by bloodletting, either general or local, we ought to have recourse to derivation by moderate purging, applications to the skin of tartar emetic, &c, and a due regulation of the secretions by mild aperients and alteratives, with which some of the narcotics, such as hyos- ciamus, stramonium, or conium, may be usefully conjoined. I have seen in some cases of dry catarrh decided benefit from the prescrip- tion of colchicum. There is a class of remedies of which Laennec and other practitioners subsequently have made large use, and on which they have bestowed liberal commendations. I refer now to the alkalies. They are supposed to be efficacious by increasing the flow of bronchial secretion, removing the obstructing mucus already secreted, and attenuating or dissolving the tenacious sputa. In this way they tend to unload and reduce the congested mem- brane, and thus to relieve the dyspnoea that arises from tumefac- tion. With Dr. Williams I would say, I am far from wishing to extol chemical medicines in general; but, in the present instance, DRY CATARRH —ASTHMA. 219 we may bring chemistry to our aid, in order to explain the action of alkaline attenuants. We know that we can, by the administra- tion of alkaline medicines, render the urine alkaline, and increase the alkaline qualities of the blood. Now, there is no solvent of mucus more effectual than alkalies, and it is easy to perceive that an alkaline state of the bronchial secretion can scarcely be com- patible with the formation of tough, solid mucus. Dr. W. found these remedies very effectual, and he is in the habit of giving either the liquor potassae (tr\,xx. to xxx.), carbonate of soda (gr. xv. to xx.), or carbonate of ammonia (gr. iij. to vj.), according to the character of the case, three or four times a day, with squill, ipe- cacuanha, or colchicum, and some narcotic, as may be indicated by the general state of the system and the prevalence of particular symptoms. I more commonly myself prescribe the sub-carbonate of potassa, in doses of from three to five grains, with wine of col- chicum, thirty drops, in a simple syrup or mucilage, three or four times a day. I have found, in the catarrh of infants of the most tender age, the carbonate of potassa in minute portions, with a few drops of ipecacuanha wine and camphor water and simple syrup, one of the best combinations for promoting a ready secretion and allaying the cough without offending the stomach. The propriety of the addition of laudanum will be judged of by the circumstances of the case. The preferable plan, it has seemed to me, when we desire to obtain positive and appreciable results by the administra- tion of an alterative, such as the alkali, is to continue it at regular and not long intervals for a protracted period; and even to give it in the drink of the patient. It will, therefore, be better to direct opium or one of its preparations, — laudanum, morphia, &c, separately, once or twice in the twenty-four hours, than add it to the altera- tive; and thereby either interfere with the freedom of administration of this latter, or complicate therapeutical results in such a way as to prevent our telling certainly the effects of the chief article pre- scribed. A due regulation of the diet is, of course, indispensable for a cure. To this end all rich, acid, and irritating articles of food should be avoided. Tonics, the best of which are the sulphate of quinia and the sub-carbonate or the muriated tincture of iron, will be advantageously administered, after the other remedies have been used, to abate or remove the congestion. These will then contribute to preserve the balance between the several organs, and to allay the excessive sensibility, both of the bronchial mucous mem- brane and of the skin. By acting on this latter, we can often more safely remove the irritability of the former surface; and with this view the cold bath has been, not seldom, employed. For adults, whose constitutions are not yet broken down, and in whom conges- tions of the abdominal viscera are not complicated with those of the bronchia, and who are liable to paroxysms of asthma from changes of temperature or slight exposures to cold, the cold bath offers a means of amelioration, if not of positive prevention, of such attacks. It should be used in the morning. 220 DISEASES OF THE RESPIRATORY APPARATUS. LECTURE LXVI. DR. bell. Hemoptysis or Bronchial Hemorrhage;.—May be called bloody secretion- Is idiopathic or secondary; the last variety most common— Causes,—age, in- herited predisposition, certain employments, atmospheric exposures, plethora, compression of the chest—Tubercular diathesis and disease the most frequent cause—Next to this diseases of the heart.—Hemoptysis often vicarious—Apo- plectic congestion of the lungs, an effect rather than a cause—Explanation of its origin—Symptoms—Quantity of blood discharged variable—The physical signs few—Diagnosis, not easy—Prognosis—Organic changes of structure— Treatment—Indications, to arrest the discharge and to prevent its return- Venesection to be freely used at first—Attention to posture—First remedies simple,—cold sponging of the neck and chest—Risk of reaction, unless suitable depletion is practised—Leeches to remote parts,—vulva or anus—Active purg- ing—Peculiarity sometimes following the use of leeches—Sugar of lead— Tartar emetic—Blue mass with laxatives—Astringents—Narcotics and cha- lybeates. Hemoptysis or Bronchial Hemorrhage.—Appropriately does the consideration of bronchial hemorrhage follow bronchitis, the former being in truth but a modification of the latter ; the discharge of blood giving the relief from the inflammatory congestion of the bronchia in one case which the secretion of mucus and pus affords in the other. In hemoptysis the secreting point may be said to be transcended, and blood is exhaled from the bronchial mucous membrane. This disease is either primary or idiopathic, or it is secondary and symptomatic. An attention to these two distinct varieties will not only influence our prognosis, but also guide us in the treatment. The first is often without danger, curable with ease, and when cured will leave the person attacked in good health, and open to the common chances of longevity. The second variety, associated as it often is with tubercles of the lungs, is of bad augury; not so much on account of the disease of the bronchia, as because it indicates a certain degree of advance of phthisis pulmonalis. The bursting of softened tuber- cles into the bronchia is often accompanied with a slight hemorrhage, from the rupture of small vessels, which soon stops spontaneously. But, on the other hand, a rupture of a bloodvessel traversing a tu- berculous excavation may give rise to losses of blood of much more gravity, and which may even prove speedily mortal. It is only in such cases as these that there is any foundation for the once cur- rent pathology of hemoptysis, in making the disease depend on rupture of vessels. For the most part, it is,, as already indicated, a true bloody exhalation or hurried secretion from the capillary, exhalent, and secreting vessels of the mucous tissue. The causes of hemoptysis are numerous and diversified. The period of life which predisposes to it are of youth and adult age, or from 15 and 20 to 30 and 35 years. As regards sex, women are more liable than men, in the proportion, according to Louis, of HEMOPTYSIS OR BRONCHIAL HEMORRHAGE. 221 three to two: their liability is greatest in the period bet ween 40 and 45 years of age. The sanguine and nervous temperaments are the most predisposed. Persons whose parents had suffered from the disease, or were phthisical, or who are threatened with consumption, are in most danger from hemoptysis. This is increased by certain employments, such as of a tailor or shoemaker, which require the body to be much and long bent forward. Sudden variations of tem- perature, and particularly change to a dry, cold air, are enumerated among the causes of spitting of blood, which is, on this account, more frequent in springand autumn thanatotherseasons. The excitement from long exposure to a burning sun has a similar morbid effect in some instances. Maritime exposures, and particularly those to the east winds, is a too frequent cause of hemoptysis, and should be carefully shunned or abandoned by those who are predisposed to its attacks. If elevated regions have contributed to produce the disease, we must attribute the results rather to the cold, and in the case of travellers ascending high mountains, to the great muscular effort and excessively hurried respiration in consequence, than to the rarified atmosphere. Hemoptysis has supervened on protracted mercurial treatment, the use of iodine, the inhalation of irritating gases; also after strong moral emotions, excessive venereal indulgences, and prolonged vigilance. It may be caused by general or local plethora; the latter induced by ardent spirits, loud and protracted speech, the suppres- sion of an habitual hemorrhage, blows on the chest, or compression of this region. Unhappily the examples of the force and frequency of this last cause are multiplied from day to day by the terrific practice of corsetting, so general among women, both gentle and simple, beautiful and ugly ; whether they be attendants on the ball- room or the church, giddy or serious. It is doubtless owing to this cause, that, as M. Andral thinks, consumption is so frequently met with in the other sex. This author gives the following statement as the result of his own observation, in regard to the relative frequency of the several modes of connexion between hemoptysis and consumption. Of the persons whom he had known to die of that disease, one in six never spit blood at all. Three in six (or one-half of the whole number) did not spit blood until the existence of tubercles in the lungs was already made certain by equivocal symptoms. In the remaining two-sixths, the hemoptysis preceded the other symptoms of tubercular disease, and seemed to mark the period of its com- mencement. By this comparative statement you will see how very frequently hemoptysis occurs as one of the symptoms connected with tuber- cular phthisis. Under this physician's observation it happened in five cases out of six. In the experience, however, of Louis, the proportion, though very large, is not quite so great as Andial found it. Among eighty-seven instances of consumption, there were fifty- seven, or four in every six, in which hemoptysis had been present. 222 DISEASES OF THE RESPIRATORY APPARATUS. Next, as Dr. Watson truly says, to tubercular disorganization of the lungs, the most frequent source of pulmonary hemorrhage is to be found in organic disease of the heart. It has been stated by Chomel, Bouillaud, and others, both in this country and abroad, that the disease in these cases is most commonly situated in the right chambers of the heart. But this is certainly a mistake. The error has arisen from arguing upon erroneous analogies, instead of attending to matters of fact. However, the statement is just as little supported by reason as it is by the result of general experience. The only alteration in the right cavities of the heart which we could suppose likely tl priori to cause pulmonary congestions, and thereby hemoptysis, would be increased strength and thickening of their muscular parietes—hypertrophy; a morbid condition which is comparatively rare on that side of the heart, and which, perhaps, would not suffice for the production of hemoptysis, even if it did oftener exist. The direct effect, on the other hand, of any obstacle to the free passage of the blood in the right chambers of the heart, would be to gorge the liver, and the system of the vena porta; and to prevent the lungs from receiving their due proportion of blood. But any material obstruction existing in the left auricle or ventricle will impede the return of the blood from the lungs, lead to its accumulation in those organs, give rise to mechanical conges- tion, and so dispose strongly to pulmonary hemorrhage. Hemoptysis is often vicarious of the menses, and recurs under such circumstances with considerable regularity ; discharges of this kind are not always incompatible with life, since they have been known to take place for a period of thirty, and even forty years, as in the cases stated by Pinel. Laennec thinks that suppression of hemorrhoids more frequently gives rise to pulmonary apoplexy, which is sometimes an immediate and always a serious though far from a necessary cause of bronchial hemorrhage. Pulmonary congestion and the hemorrhage under consideration are not unfre- quently dependent on hypertrophy of the heart, and dilatation also of its cavities. Illustrative of the pathology of the disease and the real origin of the apoplectic congestion, the following remarks of Dr. Watson are quite appropriate: — " In truth, the morbid condition of the lungs which I am now speaking of, has been badly named. The application, by Laennec, of the term apoplexy to the lungs was singularly unfortunate ; for it suggests an analogy between two things", which, though resembling each other in the appearances which they leave behind them in the organ affected, are yet, essentially, unlike. I have shown you, in a previous part of the course, that cerebral hemorrhage depends almost always upon the giving way of a bloodvessel, in conse- quence of the morbid brittleness of its coats ; while what is called pulmonary apoplexy can very seldom indeed be so caused. The notions which I have been led to form upon this subject differ ma- terially from those which you will find expressed in the works of almost every writer on pulmonary apoplexy. The opinions I enter- HEMOPTYSIS OR BRONCHIAL HEMORRHAGE. tain were stated several years ago, in some lectures which I was appointed to deliver before the College of Physicians; and I have constantly been in the habit of mentioning them to the pupils of the Middlesex Hospital, and to my medical friends. It is a matter of satisfaction to me to find that they are esteemed to be correct by so sound a pathologist as Dr. Carswell, who has alluded to them in one of his fasciculi on the Elementary Forms of Disease. Laennec speaks of the pulmonary apoplexy, as if it were the cause of the hemoptysis. But this is surely a very incorrect view of the matter. The partial engorgement, and the hemoptysis, are not mutually connected with each other as cause and effect, but they are concur- rent effects of the same cause ; of that cause which gives rise to the extravasation or exhalation of the blood in the first instance. A part of the blood so extravasated passes outwards by the trachea and mouth ; while a part is forced in the contrary direction, into the ultimate divisions of the bronchi, so as to fill and block up the whole tissue of a single lobule, or of a bunch of contiguous lobules, and thus arises the circumscribed variety. Andral conceives that the sanguine effusion takes place in the ultimate air-cells ; and he applies to this form of disease the term pneumo-hemorrhage, to dis- tinguish it from ordinary hemoptysis, which he calls broncho-he- morrhage ; and this I believe to be the true pathology of the uncir- cumscribed variety. But it seems to be vastly more probable that, in the other form of the complaint, the seat of the effusion is in one or more of the larger branches of the air-tubes; and that the blood, a part of it at least, is driven backwards into certain of the pul- monary lobules, by the convulsive efforts to respire which the patient makes when threatened with suffocation by the copious expulsion of blood, or by a paroxysm of cough and extreme dyspnoea : especially if the blood is poured out from the membrane while the chest is in the state of expiration. It is easy to understand how certain por- tions of the lungs, without undergoing any actual change of texture, may in this manner be so choked up and crammed with blood, which afterwards coagulates, as to preclude any subsequent admis- sion of air." (Led. on the Princip. and Pract. of Physic.) " The principal symptom attending the formation of these masses is hemoptysis; and the principal, though not the only cause, is disease of the heart. The hemorrhage is often severe and copious in the first, or circumscribed form : sometimes slight and scanty, but com- monly slow, oozing, and persistent, in the second or uncircumscribed form. The heart disease is in its left chambers, and very often consists in contraction of the mitral orifice. No example of pulmo- nary apoplexy, or of pulmonary hemorrhage, even apparently de- pendent upon hypertrophy of the right side of the heart, has ever fallen under my notice." Among the curiosities of this disease may be mentioned its originating sometimes from strong sensations; such as the impres- sion of music, above all, on phthisical patients. M. Andral, from whom I freely borrow, just now, relates the case of a young man 224 DISEASES OF THE RESPIRATORY APPARATUS. who spit blood whenever leeches were applied to his chest. Sometimes this discharge has come on in consequence of the application of a sinapism or a blister; means these, in other cases, of arresting the disease. Frank tells us of a person who could not sleep during the day without a spitting of blood resulting; and that he saw another who was seized with hemoptysis whenever he ate honey, and another again after having eaten asparagus. In very nervous subjects the disease has been brought on by strong odours. In the symptoms of bronchial hemorrhage, we note considerable variety. These have been met with in persons who have been attacked, without any precursory or even associated symptoms, and who enjoyed good health afterwards, as they had before. Very generally, however, the disease is ushered in by numerous and marked symptoms. Among these I may mention a feeling of heat and weight, and an inexpressible uneasiness in the chest, or in some part of that cavity; a saltish taste, or that of blood, in the mouth. Soon afterwards the extremities, and sometimes the whole surface of the body is cold, and irregular chills are experienced in the back and loins ; the countenance is changed, the face becoming alter- nately pale and flushed: there is a singing in the ears, lustre and injection of the eyes, headache, and palpitation. The pulse is accelerated, full, hard, and vibrating: pain and uneasiness in the limbs are complained of. The laborious breathing is augmented, and the patient feels a kind of bubbling caused by the passage of air during the movements of inspiration and expiration, and at the bifurcation of the bronchia a sensation of tickling and pricking. Now comes on expectoration, consisting of mucus streaked with blood, or of pure blood, or this fluid is ejected by mouthfuls. It is florid and frothy, unless it has been retained for a time in the bron- chial cells, in which case it is dark, and towards the end of the attack clotted. Sometimes the quantity and rapidity of the discharge is such that one would describe it as a vomiting of blood. After it has ceased the patient commonly experiences relief, especially from the oppres- sion, palpitations, and headache. This absence of disease may be either temporary or permanent. Often, at the expiration of a certain not well-defined period, the same symptoms of congestion, already enumerated, are manifested, and are followed by fresh hemorrhage. In some cases this kind of paroxysm has returned five or six times in the course of the day; its intensity diminishing, however, at each repetition. The quantity of blood discharged is very varia- ble: some persons only giving out a few drops, others many ounces, and even some pounds, in the twenty-four hours. There are hardly any physical signs of bronchial hemorrhage: nothing peculiar is indicated by percussion; the chest being per- fectly sonorous, and auscultation only shows a mucous rattle or rhonchus with unequal bubbles, usually larger than those of catarrh, and formed, one may suppose, of more liquid materials. The rattle is more or less evident according to the quantity of blood effused. HEMOPTYSIS OR BRONCHIAL HEMORRHAGE. 225 These remarks apply to simple bronchial hemorrhage ; but when it is associated with and kept up by that congested and indurated state of a portion of the lung called pulmonary apoplexy, auscultation makes us acquainted with the differential diagnosis. In this case the stethoscope, according to Laennec, furnishes us with two prin- cipal signs, viz., 1, the absence of the sound of respiration over a small, circumscribed space; and, 2, the crepitous rhonchus around this space. This rhonchus, which here indicates the slight infiltration of blood, already described, is always found at the commencement of the disease, but is frequently wanting in its latter stages. When these signs, and the fact is of great importance, coexist with pul- monary hemorrhage, we may be assured that the origin of the dis- charge is in the pulmonary substance, and not in the bronchia simply. If the induration of pulmonary tissue is excessive, the absence of sound, or at least of sonorousness on percussion joined with the signs .already indicated, leaves no doubt of the nature of the disease, and prevents its being confounded with any other ex- cept peripneumony ; and even then only in cases in which the spit- ting of blood is not very considerable. In the spitting of blood which accompanies tubercles of the lungs, we can determine the nature of the cause or combination by the physical signs characteristic of the tuberculous affection, to be hereafter described. Commonly the hemorrhage in this case is bronchial or simple; whilst that connected with pulmonary apo- plexy depends more on hypertrophy and other affections of the heart, and particularly of its right side. The progress of hemoptysis is not by any means uniform. It has been already stated that, in some cases, the attack takes place but once, and with its cessation the person is left in good health. There are individuals, and particularly of the female sex, who spit a little blood every day for months and even years. In some it is readily reproduced by the same causes which brought it on at first; in others it comes on without obvious cause. Appearing for the most part at irregular intervals, bronchial hemorrhage is sometimes periodical: in some women it supplies regularly every month the menses. Moseley and other writers relate cases in which it has corresponded very accurately with lunar epochs, in the male sex. After the cessation of the active discharge there is cough, and the mucus expectorated is usually mixed for some days with dark or clotted blood, which daily diminishes in quantity. The diagnosis is not always easy, particularly between pneu- monia and hemoptysis, if the latter be dependent on pulmonary apoplexy. In pneumonia the sputa are distinct, and, as it were, fused, which is not the case in the other disease. In nasal hemor- rhage the blood sometimes passes into the posterior nares, and thence into the fauces; and is brought up by hawking, sometimes accompanied by cough, but the fluid is dark, and not frothy, like that which comes from the bronchia. In some cases, again, there is a vol. n. — 20 226 DISEASES OF THE RESPIRATORY APPARATUS. slight hemorrhage from the vessels of the pharynx, which, calling the bronchia into sympathetic irritation, may be associated with cough, and mixed with the expectorated matter thus brought up, and impose on the physician as a true hemoptysis. This latter is usually represented as readily distinguishable from hematemesis, by the cough, dyspnoea, vermilion colour of the blood, and its mix- ture with bubbles of air, when the discharge is from the bronchia; while in hemorrhage from the stomach there is nausea, oppression at the epigastrium, mixture of the blood with aliment, and with bile and mucosities. It may happen, however, that the patient is seized with vomiting at the same time there is bronchial hemor- rhage, and then we may expect to see alimentary matter mixed with the blood; nor is the colour of this fluid always so contrasted in the two diseases as is generally represented by systematic writers. Costiveness and tardy digestion may accompany bolh hemoptysis and hematemesis ; but these symptoms are most common in the latter. The pulse is generally fuller and harder in the bronchial than in the gastric hemorrhage. The expectorated blood some- times comes from the rupture of an aneurism of the aorta^in which case there is little time allowed for nicety of diagnosis or recourse to remedies, as the case at once terminates fatally. Our prognosis in bronchial hemorrhage or hemoptysis will be inferred from what has been said in preceding parts of this lecture on the varieties and progress of the disease. M. Andral assures us, that he has ascertained, by autopsic examinations, that more than a fifth of the cases of hemoptysis are not tuberculous, that is, are not dependent on or associated with pulmonary tubercles. In addition to the remarks already made on this point, I may add, that we see individuals in advanced age who in their youth had spitting of blood; some of them valetudinarians, others in robust health. Still, must we not forget the important and melancholy fact, that in a large majority of cases of bronchial hemorrhage this is preceded or followed by pulmonary consumption,. The organic changes of structure produced by, or rather asso- ciated with, and following simple hemoptysis, are not numerous nor well marked. Blood, more or less fluid, has been found in the bronchia; and when coagula are present, they exhibit, at times, fibrinous concretions in the form of polypi. The mucous mem- brane is commonly a little softened and tinged with blood in its entire substance: but in general its alterations are not different from those met with in simple bronchitis. Sometimes, even, it is pale, or at most presents a light rosy tint. A similar state of other mucous membranes which were the seat of hemorrhages has been observed; as those from the intestines, which have been found pale, with slight injection in some points. We may, as M. Andral sug- gests, attribute this want of colour of the mucous membranes, after death from hemorrhage, to the circumstance of the blood having escaped from the vessels in place of remaining in them, and giving rise to the appearance of congestion and inflammation. But in TREATMENT OF BRONCHIAL HEMORRHAGE. 227 hemoptysis dependent on pulmonary apoplexy or pulmonary he- morrhage ; that is to say, when bronchial hemorrhage has suc- ceeded to hemorrhagic effusion into the pulmonary tissue, the organic changes are more evident. Portions, not indeed large, of the substance of the lungs, are found indurated to an extent of the greatest degree of hepatization. The extent of lesion is both small and circumscribed; the pulmonary tissue around being quite sound and crepitous, and has none of that appearance of progressive induration which we find in pneumonia. The indurated portion is of a very dark red, exactly like that of a clot of venous blood, and quite homogeneous ; disclosing nothing of the natural texture of the part, except the bronchial tubes and the larger bloodvessels. In hepatized lung after pneumonia, on the other hand, we can per- ceive, says Laennec, who draws the contrasted picture which I am now copying, the dark pulmonary spots, the bloodvessels, and the fine cellular intersections; all of which give to this morbid state the aspect of certain kinds of granite. M. Andral's description of the appearance of indurated portions of the lungs in hemoptysis with pulmonary apoplexy is nearly similar to that of Laennec's, as will be seen by reference to his Clinique Medicate. The tissue of the lung at the indurated portions, says this writer, was very hard, black, and granular, when cut into ; and there issued out from them a liquid similar to coagulated venous blood by strong pressure. Around this altered tissue the lung was pale, crepitous, and en- gorged with serosity. The description of the mode of this formation, by Dr. Watson, has been given in the beginning of this lecture. The treatment of bronchial hemorrhage resolves itself into, 1, the means of arresting the discharge ; and, 2, those of preventing its return. It consists in diminishing the sanguineous congestion in the lungs, and in relieving the oppression of these organs, and con- sequently the turgescence of the bronchial mucous membrane, by revulsive action of other organs and tissues. Venesection and sedatives are employed to meet the first indication; and purging, sometimes vomiting, tonics, and external counter-irritants, to meet the second. Of the remedial effects of bloodletting, M. Andral is disposed to think more highly than even our own heroic school at home. Those of the latter, who derive their notions of French practice from a perusal of some of the older writers and chance passages in English books, will be surprised to learn that the author just named expresses himself in the following manner, on this subject, in his Cours de Pathologie : We have recourse to emissions of blood either to ward off an attack of this disease, or to arrest it, or to prevent its recurrence. When a patient, continues M. Andral, exhibits all the symptoms which characterise the imminence of hemoptysis, as when he is oppressed and pale, and has rigors through his frame, bleed him at this time, and you will prevent the hemorrhage. Bleed, also, when the hemorrhage is present, and bleed largely if you wish to obtain satisfactory results. If you use leeches, take 22S DISEASES OF THE RESPIRATORY APPARATUS. especial care that they be not applied to the chest, but to the anus, especially when you have to deal with nervous subjects, or with women. As a general rule we should draw blood at once from a vein, in an attack of hemoptysis, and in such quantity as to produce a marked impression on the system, which is measured, not only by a reduction of the pulse, but by a removal of the oppression, heat, and stricture of the chest, and a feeling of relaxation bordering on syncope. But in doing this we must not act empirically, and without an understanding of our true position, determined by a knowledge of the premises. In incipient hemoptysis, and in the first attack, we should bleed more freely than after the hemorrhage has been considerable, or in a case in which it has been of re- peated recurrence. We ought, also, to be aware, that a simple idiopathic bronchial hemorrhage will sometimes be of itself suffi- cient to relieve the congestion, which may have been but tempo- • rary, of the mucous membrane; and that if the discharge do not cease spontaneously, it is readily stopped by means of an easy appli- cation to be hereafter mentioned. When, on the other hand, we are led to believe, from the habit and general appearance of the patient, and from the physical signs, particularly those furnished by auscultation formerly detailed, as well as by the excessive oppression, and sometimes even acute pain of the chest, that the bronchial is associated with pulmonary hemorrhage or apoplexy, then should we not lose a moment's time in having recourse to the lancet, and in procuring a large abstraction of blood. One blood- letting, says Laennec, of twenty to twenty-four ounces on the first or second day, will have more effect in checking the hemorrhage, than several pounds taken away in the course of a fortnight. It is even beneficial, in general, continues this able practitioner and writer, to induce partial syncope by means of the first bleeding. In cases of this kind, the fear of exhausting the patient's strength is without foundation, since we know that the most copious vene- section falls short of the loss of blood sustained from pulmonary hemorrhage, in young and robust subjects, even in the course of a few minutes ; while the debilitating effect of the hemorrhage is in- finitely greater than the loss of blood produced by the lancet (Forbes' Translation). This advice does not assuredly look like tampering with the disease, by trusting its cure to the expectant method, which some persons still believe to be synonymous with French medicine. * Simultaneously with recourse to bloodletting should be the em- ployment of other auxiliary but not unimportant measures. The position of the patient must be semi-erect, or sitting, if the strength will allow of it; or, at any rate, he should be propped up in bed so as to have the chest and shoulders raised ; nor must these parts be enveloped in warm bedding and clothing ; but on the contrary they ought to be exposed to a cool air, and even the chest sponged with cold water and vinegar. The remedies at this time, taken inter- TREATMENT OF BRONCHIAL HEMORRHAGE. 229 nally, may be of a simple and readily obtainable kind; such as vinegar, or common table salt, or mouthfuls of cold and even ice water. The theory of the effects of this refrigerating or sedative practice, is, that the diminished excitement produced on the capil- laries and exhalents of the skin, and the gastric mucous membrane, is participated in by those of the bronchial mucous, which, in con- sequence, refuse to give passage to the blood brought by the larger vessels. But, in advising these remedies, and I think the remark may be extended to the acetate of lead, erroneously called an astringent in place of a sedative, we must be prepared to see after their use a reaction of the capillary tissue, and a renewal of the discharge, if it have depended on pulmonary congestion, strength- ened by general plethora, and perhaps hypertrophy of one of the great cavities of the heart. The occurrence of reaction is not so much an argument, however, against these sedative or refrigerant agents as adjuvants to bloodletting, as against reliance on their sole use, unless in simple bronchial hemorrhage. The inference which I wish to draw from these remarks is, that the indication to be fulfilled, not only in hemoptysis, but in other hemor- rhages, is to remove the cause; as it may be supposed to depend either on increased molimen, or undue determination to the lungs, and congestion of the bronchial mucous membrane. Even if we were possessed of certain means for curing a lesion of the vessels which exhale and secrete blood, their early employment would be of doubtful efficacy at best, and most probably decidedly injurious. This is a question which ought to be presented, from the beginning, to the mind of the physician who has taken charge of a case of hemoptysis, and who may be debating with himself, or with a medi- cal friend, the propriety of trying substitutes for venesection, in order to arrest the hemorrhage. The quantity of blood, and the exaltation of vital phenomena consequent on or associated with its greater afflux at this time to the lungs, must be diminished. The means are depletion and derivation. Venesection in the arm or in the foot carries out both of these objects, but more particularly depletion, and unloading of the vascular system. After this, deriva- tion is easier; and when the hemorrhage originates in the suppres- sion of some other discharge, it is necessary. Thus, if habitual hemorrhoids have disappeared, or the menses have been wanting beyond the customary epoch, leeches to the anus, and a brisk purge of calomel and aloes, or, for more prompt effect, a stimulating enema, as of oil of turpentine even, are called for. Without giving it the importance which I once did, and which perhaps some of my professional brethren are still inclined to do, I cannot but think that the removal of hepatic congestion and of obstruction in the portal circle by active purging, as a revulsive measure, will contribute to relieve the oppression of the lungs in hemoptysis, Nor can we overlook the direct sympathy noticed before between the bronchial and gastro-intestinal mucous membranes, and the 20* 230 DISEASES OF THE RESPIRATORY APPARATUS. benefit received in phlegmasia and congestions of the former by a pouring out of fluids from the latter. In speaking, as I have just done, of the application of leeches, and of the employment of purgatives, as both of them answering the indication for derivatives, I do not mean to affirm that they are either identical or equally beneficial in their operation. Purgatives follow properly and safely in subjects of both sexes after blood- letting ; leeches chiefly, if not only, under the circumstances stated, viz., of suppressed hemorrhoids or menses. Obviously proper as this last would seem to be from analogy, and a knowledge of their generally beneficial derivative action, they are not always safe or useful in hemoptysis, certainly not as a substitute for venesection in the first attack and early periods of the disease. Laennec has noticed the return of the menses and aggravation of menorrhagia during the application of leeches to the epigastrium. The first of these effects I have myself seen from this cause. But still farther, general bleedings, and more particularly those of small extent, have appeared, under the observation of the French writer just quoted, to have a like effect on hemoptysis; and cases of this kind are clearly those in which purgatives should have atrial. On this remark, Doctor, now Sir James Clark, has the following com- ment:— "The fact is not generally known, though it is one of great practical importance. In a plethoric person threatened with apoplexy of the brain or hemoptysis, the application of leeches may, and, I believe, frequently does, decide the very occurrence of the disease it was intended to prevent. I have more than once seen slight hemoptysis follow the application of leeches round the anus, (and have warned patients not to be alarmed at it,) when applied to obviate pulmonary hemorrhage. In one case a severe attack of hemoptysis took place a few hours after the application of the leeches, requiring general bloodletting, &c. A very small bleeding may, as Laennec observes, produce the same effect; but independently of the quantity of blood abstracted, there is a sym- pathetic effect produced on the extreme vessels by the action of the leeches, or the consequent flow of blood from their punctures, which is very desirable and useful when we wish to promote a sanguine secretion, as the menses; but may be injurious when we wish to obviate an effusion of blood from the extreme vessels: a general bleeding is by far the better practice in the cases under consideration." Upon the whole, then, the safer practice is, after venesection, to purge ; and in so doing selection should.be made of those articles which procure abundant evacuations without straining, the bad effects of which in congestion or retarded circulation of the lungs can be readily imagined. I have myself found, that common mercurial purgatives, such as calomel and jalap, calomel followed by the compound powder of jalap, or by rhubarb and magnesia, are preferable to the simple saline; although theory would indicate the superiority of these latter on the ground of the more copious fluid TREATMENT OF BRONCHIAL HEMORRHAGE. 231 discharges and consequent diminutioh of the bulk of the contained blood of the vascular system following their operation. Hemoptysis with febrile reaction may at once be treated, after venesection,or where the hemorrhageisbut slightand its returns have been frequent, without this preliminary, by sugar of lead, sub-acetas plumbi. This medicine has acquired great and in many cases de- served reputation in nearly all the forms of hemorrhage, particularly when administered in conjunction with opium, as in the following formulae: — R. Plumb, suh-acetat., gr. xii. Pulv. opii, gr. i. Sacch. albi, 3ss> M. ft. pulv. vi. Take one every two hours, or until the hemorrhage is arrested. In cases of general plethora and capillary excitement, the opium is not a fit addition; but, on the other hand, where the excitement is unequal and the plethora local, this medicine contributes very much to equalize the circulation ; and, by causing a certain degree of fulness of the capillary circulation in all the organs, to take off the strain upon those of the lungs. Care ought to be used that a simple, and in milder cases a sufficient remedy, in hemoptysis, diluted mineral acid, and especially the sulphuric, be not administered at the time in which you are prescribing the sugar of lead. But, on the other hand, it may be prudent, and will rather aid the refrigerant effects of the salt of lead, to follow the advice of Dr. Thomson, by directing your patient to drink dilute acetic acid, in order to prevent any possibility of the conversion of the acetate into the carbonate, in which last form alone it is specifically inju- rious to the animal economy. My own experience enables me to speak with considerable con- fidence of the powers of the potassio-tartrate of antimony, or tartar emetic, in restraining and arresting pulmonary hemorrhage, and that in the most safe manner, viz., by diminishing the morbid action of the heart, abating the inflammatory congestion, as well as producing a sedative impression on the bleeding capillaries them- selves. But whether you choose to adopt my explanation or not, you may be assured of the fact. I give the tartar emetic in simple watery solution, in the dose of an eighth to a fourth of a grain, every hour or two, according to the urgency of the case and the tolera- tion of the medicine by the stomach, without vomiting being brought on. Even if nausea and retching should ensue, the state of arterial sedation which precedes will prevent any injurious effect, or any increase of hemorrhage, which, without such prior depression, would be readily brought on by this means. In the weeping hemoptysis, or oozing of blood, not much in quantity at a time, but persisting with, at the same time, febrile reaction, yet not enough to justify venesection, I have prescribed the tartar emetic with the best effect. So obvious, indeed, and at the same time so mild is it in its effects, that my patients have at different 232 DISEASES OF THE RESPIRATORY APPARATUS. times asked for a renewal of it, when its use had been temporarily suspended. When hemoptysis assumes a chronic character, and we have symptoms of bronchial congestion, with small but frequent dis- charges of blood, and associated disorder of digestion, you will find the blue mass, in doses of three to five grains, and a grain of ipecacu- anha once or twice a day, and rhubarb and magnesia, or a small dose of salts on the following day, if necessary to procure a full alvine discharge, a good plan of treatment; to becontinued until the tongue is clean and the bleeding arrested, or reduced to a very small quan- tity at prolonged periods. Sometimes a pill, composed of ipecacu- anha and soap, taken two or three times a day, for some days, will suffice under these circumstances. If anaemia be present, or the patient much reduced by the hemorrhage, and the vascular excite- ment be inconsiderable, small doses of the oil of turpentine, as ten to twenty drops in some mucilage three times a day, are found to restrain and check the discharge. It is in cases of this nature, and in scrofulous habits, thatjhe hemorrhage has been called passive, and in which vegetable astringents have been prescribed. Of these pure tannin, galls, or rhatany in moderate doses, will be chosen. In cases of incipient tubercle, the administration of narcotics and some prepa- ration of iron should be tried, under the hope of postponing for a time, at any rate, the development of the symptoms of phthisis. With this view, also, even more than merely to prevent the recur- rence of hemorrhage, a permanent discharge from the inside of the arm by a blister, or from the chest by means of tartar emetic, may be kept up with good effect. All the customary means of giving tone to the general system, without any special strain upon the lungs, should be had recourse to. Of these the chief are, plain nutriment, moderate exercise, especially on horseback, and alternately with that on foot; the tepid and after a while, if the reaction be sufficient, the cold bath, by momentary im- mersion or by shower; frictions, and great attention to preserving the feet warm and dry. Late hoursand nocturnal excess of any kindare to be avoided by the invalid, who is fearful of a return of hemoptysis. LECTURE LXVII. DR. BELL. Pneumonia—The transition slight from bronchitis to pneumonia—Peculiarity of seat of pneumonia—Definition—Stages—Symptoms,—local and general,— The three chief diagnostic ones,—Cough, expectoration, characters of the sputa, dyspnoea, pain, decubitus—Percussion—Auscultation—Crepitation—Ap- pearance of inflamed lung—The several stages of inflammation—General symptoms,—disordered circulation and pungent heat of the skin the most com- mon—Precursory symptoms and complications—Pneumonia succeeding bronchitis and other diseases— Typhoid pneumonia—Dr. Williamsis and Dr. Stokes's descriptions—Progress—Collapse—Duration.—Disease. Pneumonia.—Peripneumony.—Pneumonitis. — Pulmonitis. — The passage from the bronchial tubes, and more especially their vesical STAGES OF PNEUMONIA. 233 terminations, to the adjoining tissue external to them, or the pulmo- nary parenchymals indeed slight; and, as Dr. Stokes aptly re- marks, he who would call pneumonia a bronchitis of the terminal tubes would be hardly guilty of a misnomer. Using also the lan- guage of Dr. Williams on this point, we may ask : But what is this parenchyma, if you take from it the membrane that lines the air-tubes and cells, and the pleura which covers their exterior? See how delicate is the structure of this piece of healthy lung? how thin are the fibres that separate these minute membranous bubbles— this tissue of froth ! How can we distinguish the parenchyma from the investing membrane? We can scarcely do so by anatomy. But physiology and pathology come to our aid, and supply us with a test that enables us to make good the division, long established in practice, of diseases of the lungs, into those of the investing mem- branes and those of the parenchyma. Let us recollect the great purpose of the function of the lungs, and we shall bring to mind the air and the blood that exert across the membranes a mutual influ- ence on each other. We have spoken of the vessels which contain the air, but not of those which contain the blood: these are they that lie between the aerial and pleural tissues of the lung, and with connecting cellular tissue, spread in exceedingly delicate fashion between the cells, but thicker round the tubes and between the lobules; these constitute the proper parenchyma of the lung. In the following lectures on pneumonia, with the works of Laen- nec and Andral before me, I shall most likely be found to make freer use of the admirable compend on this disease by the latter writer, in his Pathologic Interne, at the same time that I borrow freely from Drs. Stokes and Williams, two of the ablest British commentators and imitators of these illustrious Frenchmen. Pneumonia was declared by Broussais to consist in an inflamma- tion of the pulmonary vesicles, and of the cellular tissue interposed between these vesicles. This is the view adopted by MM. Andral and Bouillaud. A more comprehensive definition is given by Dr. Williams (Cyclopedia of Practical Medicine); viz., Fever,with more or less pain in some part of the chest; accelerated and somewhat oppressed breathing, cough with viscid and rusty-coloured expecto- ration ; at first the crepitant rhonchus, afterwards bronchial respira- tion and bronchophony, with dulness of sound on percussion in some part of the thorax. He adds: pathologically, pneumonia consists essentially in an inflammation of the parenchyma of the lung, oc- casionally but not necessarily extending to the pleura investing them; which inflammation, though it usually occasions a certain combination of general symptoms, is not so essentially connected with these symptoms as to receive from them an infallibly patho- gnomonic character. Stages. — Before speaking of the symptoms of pneumonia, let us carry along in our minds the several stages of the disease, which are enumerated as follows by Dr. Stokes (op. cit.):—1st. The lung 234 DISEASES OF THE RESPIRATORY APPARATUS. drier than natural, with intense arterial injection. No effusion of blood into the cells. 2. (Laennec's first.) The cells gorged with blood. No change of structure. 3. (Laennec's second.) Solidity and softening (the red softening of Andral). 4. Interstitial suppura- tion. 5. Abscess. The symptoms are local or genera]: those furnished by the lungs; those by the other organs or organic systems sympathe- tically and secondarily disordered with them. Under the first head we include cough, expectoration, pain, dyspnoea, decubitus, and the signs furnished by percussion and auscultation. Before speaking of these in succession, I may as well at once tell you of the three chief diagnostic marks of pneumonia. They are: 1st, the crepitating sound transmitted when the ear is applied to the chest, or rather to that part in which is contained the diseased lung; 2, the rust colour of the sputa ; 3, the peculiar pungent heat of the skin. Local Symptoms. — Cough is present in a very large majority of cases of pneumonia; but it exhibits no peculiarity, nor are its vio- lence and frequency proportionate to the violence of the disease. The expectoration in the beginning of pneumonia is commonly null, or analogous to that in acute bronchitis. From the second to the third day it assumes its characteristic appearance: the sputa be- come sanguinolent, owing to the intimate mixture of blood with mucus. Their colour varies with the quantity of blood which they contain; and hence, they may be yellow, rusty, or of a decided red; and they may even pass through all these shades in the same day. Their density augments as the disease advances; they be- come viscous, tenacious, transparent, and strongly adherent to each other. So decided, at times, is their gelatiniform consistence, that the vessel containing the sputa may be completely inverted without their being detached from it. This last change is seen when the inflammation passes to the second stage, for so long as it remains in the first, the sputa have not tenacity enough to adhere to the sides of the vessel. A termination of the disease in resolution is indicated by a less heightened colour and viscidity of the sputa; but if, after becoming thinner, they are again tenacious, they indicate that the pneumonia is paroxysmal. Sometimes, even although the sputa have lost all their pneumonitic characters, and exhibit those of the catarrhal state, yet auscultation still apprises us of a crepitation or crepitating rhonchus (rdle) of more or less duration. A suppression of the expectoration may occur from an exasper- ation of the disease; and also from an excessive viscosity of the sputa, or from the weakness of the patient; and in these cases the secreted matter may accumulate in the trachea, and cause death by asphyxia; or this result may be brought about by a suppression of the secretion itself. The expectoration may be also suspended by other diseases com- plicated with pneumonia, by purgatives given early in the disease, by excessive bloodletting or its unseasonable repetition ; and bv all SYMPTOMS OF PNEUMONIA. 235 the causes which aggravate pulmonary inflammation. In some cases of fatal pneumonia the sputa are not suppressed ; but they are smaller in quantity, become changed in their appearance, and are opaque and mottled with dirty, reddish-grey streaks, resembling those seen in the last stage of consumption. When pneumonia terminates by suppuration, the sputa are gray- ish, inodorous, and in a measure purulent: even in the red hepa- tisation or friability they may preserve the same characters; and, finally, they may lose their viscosity, and resemble a liquid of the consistence of gum-water, and of the colour of liquorice or prune decoction. The termination in gangrene is manifested by the ex- pectoration of a greenish matter, which yields after a while a dirty- gray, and exhales an insupportably fetid and characteristic odour. When pneumonia passes into a chronic state, the sputa are like those of pulmonary catarrh. All cases of pneumonia are not cha- racterised by distinct expectoration: some of them slight, some grave, running their course to a happy or fatal termination; and yet the sputa merely resemble those of a simple bronchitis. In inter- current pneumonia particularly, it is common to see the absence of expectoration. The colour of the sputa is attributed generally to the blood, in varying quantity, mixed with them. They are rarely tinged by bile. The dyspnoea is generally in proportion to the extent and seat of the inflammation ; although in this respect there are great differences among different individuals. When the breathing is hurried and laborious, and the feeling of oppression so great that the patient sits up in his bed, complains of a weight in his chest, has the face of a violet-red, or of a livid hue, and pants to such a degree that speech is extremely difficult, if not impossible,— we must augur an unfavourable termination. Dyspnoea may, it is true, remain after the danger is over ; and in such a case it is owing either to the im- perfect resolution of the disease, or to the weakness of the patient. Pain, according to Andral, is never felt in pneumonia, unless there be pleuritis coexisting; but Laennec asserts that simple inflamma- tion of the lung has given rise to pain ; a fact which he had an op- portunity of ascertaining by dissection of the patient after death. Commonly, the pain is felt behind the mamma, or a little below or just above and between it and the clavicle ; or in one or other of the hypochondria. It is increased by coughing, change of posture, pressure on percussion. As to the decubitus, it is not correct that the sick always he on the affected side : the posture is generally that on the back. Percussion does not show any change in the sonorousness of the chest, in the first stage of pneumonia ; and it is rarely until the second or third day that a dull sound is evident. As the disease dis- appears the natural sound of the chest is restored. Percussion can- not be practised when the walls of the thorax are painful, or covered with a vesicated surface, or there is deformity of the chest. In 236 DISEASES OF THE RESPIRATORY APPARATUS. practising percussion, do not forget that the liver on the right side, and the spleen on the left, will cause a dull sound on percussion of the lower part of the thorax. Auscultation, either by applying the ear to the chest, or by the intervention of a stethoscope, enables us to reach generally an accurate diagnosis of pneumonia. The sound heard at this time. if the diseased part be that chosen to which to apply the ear, yields the crepitating rhonchus of Laennec, or ihe fine crepitation, as some others term it, resembling the sound made by projecting small por- tions of salt on live coals, or by rumpling a fine piece of parchment. Another comparison of the kind of sound of crepitation was made, when speaking, in a recent lecture,of thesound sent forth during respi- ration by diseased lungs. This kind of crepitation does not, however, entirely replace the respiratory murmur of health, which is more or less marked on the occasion ; but in proportion to the intensity of the inflammation is the intensity of the crepitation, which, after a time, entirely conceals the respiratory murmur. By some ob- servers (Drs. Gerhard and Rufz), this crepitation is said to be wanting in children between ten and five years old suffering from pneumonia: by others (MM. Rilliet and Barthez), it has been dis- tinctly heard. With the exception of three cases, it has always been blended with bronchial respiration, in the experience of these last mentioned writers. By M. Andral the cause of the crepitation was attributed to the passage of air in small bubbles through serum effused in minute air-tubes and vesicles ; and he supposed that the fine and even character of the crepitation depended on the smallness of the bubbles in the extremest tubes. Dr. Williams, on the other hand, regards this crepitation as distinct in its nature from the other rhonchi. He points out the fact of the narrowness and partial obstruction of the extreme air-tubes and cells in the first stage of peripneumony, by the enlarged vessels distributed between and around them. Now, as the smallest tubes are narrower than the cells in which they terminate, may not, as Dr. W. asks, obstruction become such in them that the air can force itself through the viscid mucus which lines them, only in successive minute bubbles, the crackling of which constitutes the crepitation in question. The crepitating rhonchus, or the minute crepitation, is character- istic of the first degree of pneumonia, or that of turgescence and engorgement, — the second of Dr. Stokes, who believes intense re- spiratory murmur in the affected part and fever to be indicative of the (his) first stage, and precursor of crepitation. In the first stage the pulmonary vessels are so much distended that the whole tissue is of different shades of red. In some cases, a frothy serum exudes when the lung is cut; this is probably the effusion of blood after death, for it is not observed in those cases in which the blood remains in a fluid state. Andral examined an inflamed lun^, after drying and slicing it; and the only difference which he could per- ceive in the structure, was that the coats of the cells were some- SYMPTOMS OF PNEUMONIA. 237 what thicker and redder than natural; but there was not that obliter- ation of the cells that might have been expected if they had been tilled with blood. This last may cease to be heard under two different circumstances ; in the first, crepitation yields to the respi- ratory murmur, and the disease ends in resolution; in the second, it advances from bad to worse, and then no sound is heard, or else crepitation is replaced by another sound ; the phenomena are increased, and the lung becomes hepatised. This change is the result of deposition of lymph in its cellular interstices, and the retention of blood or engorgement in its minute capillaries. Hepa- tised lung is denser and more solid than before; but it is also more friable; more easily crushed and broken. If we take a portion of hepatised lung, and examine the torn surface with a magnifying glass, the pulmonary tissue will appear to be composed of a crowd of small, red granulations, lying close to each other. These are, we may presume, the air-vesicles clogged up, thickened, and made red by the inflammation. The colour of hepatised lung will vary much, according to the quantity of blood left in it; if this be much, it will be red; if little, pinkish-brown, or reddish-gray;' if mixed, the black pulmonary matter. Lung thus diseased does not collapse when the thorax is laid open: the marks of the ribs are frequently visible on the surface. The texture of the lung at this time is some- times so soft that a moderate degree of pressure between the fingers reduces it to a state of pulp. Sometimes the state of organic change just described is confined to certain of the pulmo- nary lobes, and then it is called lobular pneumonia. The deposition of lymph which constitutes hepatization of the lung completes the obstruction of the minute tubes and cells : hence all crepitation ceases, and the only sounds that reach the ear are those of the air and voice in the larger tubes. Instead of the respiration with its prolonged murmur, there is only a short whiffing, as Dr. Williams expresses it, confined to parts only of the respiratory act, and often ending abruptly with a click. This bronchial whiffing is not heard in every case, but only when the hepatisation involves considerable bronchial tubes; and it is most commonly found in the middle portions of the chest. M. Andral designates the sound given out at this time, on applying the ear to the chest, by the term tubular respiration, owing to its resemblance to the sound which would be produced by blowing into a tube close to the ear of the listener. It is a variety of bronchial respiration. The voice is modified at the same time in a peculiar manner, in its passage through the lungs and parietes of the chest, in reaching the ear of the physician applied to the latter. The vocal resonance of the tubes is also transmitted by the condensed lungs to the parietes, as a vibration or fremitus, which may be distinctly felt by the hand placed on the affected side, and which is much stronger than that on the healthy one. This affords an easy mode of distinguishing between a hepatised lung and a pleuritic effusion; for the latter when considerable generally abolishes completely the vocal vibration. vol. n. — 21 238 DISEASES OF THE RESPIRATORY APPARATUS. Often we hear in the same patient and at the same time differ- ent signs furnished by auscultation, which "announce different stages of pneumonia. On the healthy side we hear, by auscultation, the normal respiration, of much more intensity than in health. Some- times auscultation supplies us with negative results. This happens when the fluid accumulated in the bronchia is in quantity enough to cause so strong a bronchial rhonchus as to cover all the other sounds. If the inflammation be very limited, and only occupy a part of the base, centre, or root of the lungs, auscultation, M. Andral thinks, gives no indication to guide us. Auscultation traces the morbid changes in the lung through the stages of engorgement to hepatization. " Can it," says Dr. Watson," trace it any further ? I believe not, with any certainty." But, at last, he adds, — the structure of the lung breaks down, and a portion of it is expecto- rated, and finds its way into the vacant spot, and gives rise to large guggling crepitation. Among the local symptoms should be no- ticed a diminution in the motion of the affected side, in proportion as the air fails to get admittance into the inflamed lung. The third stage of Laennec, to which inflammation brings the lungs, is that of suppuration or yellow hepatization. This consists in the conversion of the semi-solid particles of lymph or blood, which constitutes the solid or red hepatization, into an opaque, light- yellowish, friable matter, and finally into a fluid pus. This suppu- ration is generally diffused in the form of purulent infiltration; but it is very rare to find it assume the character of a distinct abscess. This lastisan uncommon termination of pneumonia. In several hun- dred dissections of persons dead of this disease, made by Laennec during a space of more than twenty years, he only met with five or six collections of- pus in the inflamed lung. Once only did he find a large abscess of that sort. Andral has only once seen a real abscess of the lung form as a consequence of pneumonia. Phlebitic depo- sits of pus and sometimes tubercular vomicae and cavities, may have been taken for genuine abscesses of the lung. Gangrene is an unusual result of pulmonary inflammation; being nearly as uncommon as the formation of an abscess. It seems, however, as remarked by Dr. Williams, to arise pretty generally from the influence of those noxious gases which directly destroy the vitality of the tissue of the lung. The lungs of persons who have died some days after being nearly asphyxiated in sewers, have been found reduced, in parts, to a dark brown, greenish, or livid softening, having a very fetid odour, and being probably the result of the poisonous influence of the gas on a congested lung. General Symptoms. — Among these, the most constant is disor- dered circulation, manifested by a frequent and rather full and sometimes hard pulse, which becomes small when the inflammation is very violent, but acquires volume after bloodletting. We are taught to mistrust acute bronchitis, in the course of which an in- tense febrile disturbance supervenes, even although expectoration and auscultation should not furnish any characteristic signs of GENERAL SYMPTOMS OF PNEUMONIA. 239 pneumonia. A chill is the customary prelude or announcement of the inflammation of the lung, and the fever thenceforwards lasts as long as the disease. A very frequent pulse is a bad sign in pneumonia, as it indicates intense inflammation. Rarely does the case terminate favourably when the pulsations exceed 140 in a minute. Coinciding with this morbid state of the circulation is the frequency of the respiratory movements; and when this correspond- ence is destroyed by the pulse becoming slow, and yet the respi- ration remains much hurried, we have reason to fear a fatal result; in fact, approaching death. Should the pulse be still frequent when the other morbid symptoms have in a great measure disappeared, there are probably some remains of phlogosis. If intermittent, we are to attribute it to some disease of the heart. The belief enter- tained by the old writers, and still accredited by some of the moderns, that the fever precedes the pneumonia which is the effect of the former, is not correct. The febrile suffusion of the cheeks is sometimes more manifest on one side, and this we read is that which corresponds with the side of the affected lung; but in this respect there is no uniformity. The redness of one cheek more than that of the other may depend on the patient's habitually lying on one side. Disorder of the digestive functions is chiefly manifested in anorexia and a white and some- what loaded tongue. There is not much thirst. The cutaneous exhalation differs in different cases ; the skin is often dry from the beginning; at other times bedewed with moisture, which is con- verted into a copious sweat. This last symptom, generally de- scribed as either indicative of a milder disease or of an approaching crisis, I have found, not seldom, to precede a fatal termination ; and hence, unless a free and particularly a viscous sweat be associated with favourable symptoms, indicating an abatement of the inflam- mation, it ought to be regarded with mistrust. If the skin has re- tnained dry through the whole of the period of the disease, and towards the decline of the latter it is covered with sweat, we may regard this as critical and of good augury. Without attaching to it all the importance which it is thought to merit by the gentlemen themselves, I shall repeat in their own lan- guage what Drs. Bright and Addison say respecting pungent heat of the surface, as diagnostic of pneumonia : — Of all the symptoms of pneumonia, the most constant and conclu- sive in a diagnostic point of view is a pungent heat of the surface ; by this symptom alone the first stage of pneumonia may in most instances be readily recognised ; by this symptom alone pneumonia has been repeatedly pronounced to exist, before asking a single question, or making the slightest stethoscopic examination of the chest. The presence of this symptom will seldom mislead even in the most complicated forms of inflammation within the chest. It is by no means contended that it is necessarily present at some period of every case, although that is not probable ; but it may be safely affirmed, that when inflammation is confined to the chest, however 240 DISEASES OF THE RESPIRATORY APPARATUS. varied may be the tissues involved in the inflammatory process, provided this svmptom be present, pneumonia may be confidently pronounced to form a part in nineteen cases out of twenty, and per- haps in a larger proportion. A similar pungent heat of the sur- face is now and then observed in certain forms of renal dropsy; more frequently in continued fever, especially in children; and still more commonly in the eruptive fevers of the exanthemata} and erysi- pelas ; and as such cases may supervene upon already existing disease within the chest, the fact ought to be carefully remembered. —Elements of the Practice of Medicine, p. 241-2. The urine is of a deep red during pneumonia, and deposits a lateritious sediment at its decline. But among the glandular organs, there is no one, the functions of which are so disordered in this dis- ease as those of the liver. Inflammation of the right lung is often attended with hepatic irritation, and the flow of bile is followed by bilious vomiting or stools. In other cases the liver is differently affected: the biliary secretion is impeded, and then predominates what is called the bilious diathesis. This is the bilious pneumonia of Stoll and other writers, and is a complication quite common in our Middle and Southern States. The tongue, eyes, and skin, are yellow; the patient exhales what has been called a bilious odour, and he is tormented with cephalalgia in the lower part of the fore- head, head, or back of the eyes. There is not, often, much disorder of the nervous system in pneumonia. When delirium occurs, we must regard it as the result of cerebral complication rather than a regular symptom of the disease. It is most apt to supervene on the sixth day, or from this to the ninth. At times, however, there is great prostration of force, and from the very outset an adynamic or typhoid state manifests itself. This is most common in old persons. To this complication I shall refer under the title of typhoid pneumonia. The precursory symptoms and diseases on the invasion of pneu- monia are various. Some of its complications will be spoken of at this time. Sometimes the patient has felt, for a few days preceding, discomfort, fatigue, anorexia, disinclination to motion, without either auscultation or percussion indicating pneumonia. Occasionally, a day, or two or three days, before the attack, a slight fever, like that which precedes variola, scarlatina, measles, &c, accompanies the preceding symptoms. This is the inflammatory fever which, in the opinion of some writers, always precedes the local malady. In some cases all the organs are threatened in succession with disease: to-day, the patient complains of gastric symptoms; to-morrow, of a tendency to cerebral congestion; subse- quently, to rheumatic pains; until, finally, the pneumonia discloses itself. M. Andral has seen pulmonary inflammation preceded by two paroxysms of intermittent fever, and during the cold stage of the third a slight cough supervene, pain appear, the sputa of a characteristic nature; and, in fine, all the symptoms of pneumonia evinced. Sometimes pneumonia succeeds bronchitis ; the inflamma- GENERAL SYMPTOMS OF PNEUMONIA. 241 tion, at first limited to the large bronchia, extends to the smaller ones, and finally to the vesicles. Nothing is more common than the union of these two diseases; so much so, indeed, that some have declared that bronchial inflammation exists in every case of pneumonia. In the greater number of cases, however, there are no precursory phenomena, and the patient is all at once seized with a chill, and pain in one or other side. Commonly the chill precedes the stitch; at other times the order is reversed; or, again, there is neither pain nor chill, but cough and fever are the first declaratory symptoms. When pneumonia supervenes on violent fevers, it is preceded by great dyspnoea. Occasionally, I may say not unfrequently, in fever, the pulmonary inflammation is not revealed by any symptom, and its presence is only proved by dissection. Broussais records instances of this in the intermittent fever which attacked the military in the hospital at Bruges; it is far from uncommon in our intermittent fever in the United States, and especially in that marked variety of it called of late years the congestive. I have had occasion when describing the organs affected in epidemic cholera, to mention the congested lung in many fatal cases of that disease. This state was most evident in the stage of reaction. In subjects worn out by cancer and other chronic diseases, Laennec has pointed out the occurrence of pneumonia, which soon ends in coma, tracheal rattle, and death. The bronchial affection of measles sometimes passes into pneumonia, especially if the erup- tion is repressed or disappears suddenly; but in this case the symp- toms are commonly urgent and sufficiently characteristic. Pneu^ monia is sometimes produced in gouty and rheumatic subjects, and this, says Dr. Williams, may occur either vicariously, so that the limbs are relieved, or conjointly with the affections of these. P. Frank has remarked that, in rheumatic subjects, pneumonia some- times terminates without any expectoration, and with a copious dis- charge of clear urine, amounting to twelve pounds and upwards. This curious fact is another evidence of the connexion which sub- sists between rheumatic and gouty affections and a diseased state of the fluids of the body. Several surgical writers have noticed the occurrence of pneumonia after amputation and other great sur- gical operations, and likewise after extensive wounds; and it has been supposed that this disease is frequently the cause of death in these cases. I well remember to have heard Dupuytren frequently speak in his clinical lectures (1820-1), at the Hotel-Dieu, of this always troublesome and not seldom fatal sequence of amputations, particularly in scrofulous subjects; and so impressed was he with the necessity of some preventive measures, that he uniformly directed a blister to be applied, and a discharge established, commonly on the chest or the inside of the arm, before he removed the diseased limb. I revert now to the complications of pneumonia with bronchitis, and particularly of that modification called typhoid pneumonia. I shall first let Dr. Williams speak on the subject, and afterwards introduce the instructive observations of Dr. Stokes. 21* 242 DISEASES OF THE RESPIRATORY APPARATUS. The form of pneumonia that is called typhoid, whether it be secondary to continued fever, or whether it be primary and assume the typhoid type, from a constitution lowered by excesses, or by the depressing influence of foul air or of an unhealthy season, differs remarkably in many of its phenomena from the common pneumonia. The local symptoms are by no means prominent; and although there may be pain, cough, and very imperfect breathing, the obtuse state of the mental faculties prevents attention from being drawn to them. But the general functions are greatly disordered; the pulse is quick, small, and weak; the skin is harsh, dry, and partially hot, or covered with a clammy sweat, and sometimes spotted with petechiae; the tongue is furred, brown, and dry; the alvine excretion dark coloured and otherwise disordered; and the urine is scanty, turbid, and am- moniacal. The lungs in such cases are sometimes found so en- gorged after death, particularly their posterior portions, that they sink in water; the texture is very soft and fragile, and when broken exudes a dark grumous blood: there is only an imperfect approach to hepatization, but the texture in some parts occasionally shows a softening of a lighter colour, which seems to be an imperfect sup- puration. In these cases we find dulness on percussion and ab- sence of the vesicular respiration in the posterior parts of the chest: but no crepitation ; or if it be present, it is of very short duration. In the anterior parts of the chest the breathing may be distinct enough, and accompanied by sibilant and sonorous rhonchi. Now I cannot, says Dr. Williams, help viewing these cases as of a conges- tive rather than of an inflammatory character. By some unknown cause, whether in the condition of the blood or in the affected capil- laries, or in both, the blood stagnates and accumulates in particular viscera; generally to some degree under the influence of gravitation; and the functions of the organs are proportionately impeded or dis- turbed. There is, at the same time, more or less irritation, which may give this congestion somewhat of an inflammatory character; but its products are imperfect and irregular ; and neither in the effusion of lymph nor in the formation of pus is there manifest a true inflam- matory orgasm. We can see why, in the lung, this condition should be unaccompanied by the usual signs of the gradual forma- tion of a crepitating obstruction, because the engorgement is at once produced, and renders a great part of the tissue impervious to air. But this degree of congestion, if it occupy the middle parts of the lung, may give bronchophony and bronchial respiration. Typhoid Pneumonia.—Dr. Stokes, whose description of the disease I shall give without interruption, introduces the subject of typhoid pneumonia by the remark, that — Under this head we may conclude a variety of cases, in which, whether from the low state of the constitution, the complication with other local diseases, or the pulmonary affection being secondary to a general morbid condition, we find a pneumonia often more orless latent and accom- panied by extreme prostration. This disease, so frequent in Dublin, at times, indeed, almost epidemic, has been long noticed under the names of the putrid, SYMPTOMS OF TYPHOID PNEUMONIA. 243 bilious, typhoid, or erysipelatous pneumonia, and various theories as to its nature have been successively formed and abandoned. All this arises from not recognising the fact, that pneumonia may occur as a secondary affection in fever, or other morbid conditions of the whole system, and that its complication, with one or more local inflammations elsewhere situated, may give it a typhoid cha- racter. We cannot say that there is any specific typhoid pneu- monia ; but we find that, under a variety of depressing circum- stances, conditions of the lungs more or less analogous may be induced, presenting the characters of the disease as given by various authors. Among these I may refer you to Huxham on Fevers; Stoll, De Peripneumonia Vera; also Burserius, who has described an erysipelatous pneumonia. In the writings of Good, Williams, Mackintosh, and Andral, the disease is noticed. Louis merely alludes to the occurrence of hepatisation in typhous fever. Recherches sur la Gastro-Enterite. In the earliest editions of the Histoire des Phlegmasies, the statements of Broussais, written before he had formed his theory of fever, may be studied with great ad- vantage. He recognised the secondary and complicated pneu- monia of typhus, the latency of the disease, and its slow resolution. P. Frank has described several varieties of the disease; of these, the nervous peripneumony seems most like the disease as met with here. This disease is seen most frequently in hospital than private practice—a fact strongly illustrative of its connection with the low state of the system. I have observed it in the following cases : — 1st. As a complication with enteritis, or gastro-enteritis. 2d. Complicated with true typhus. 3d. Occurring in cases of bad erysipelas. 4th. Supervening in cases of the diffuse cellular inflammation. 5th. Complicating the delirium tremens from excess. 6th. As a consequence of phlebitis. 7th. As apparently the sole disease. Now, although these cases must be considered different as to their original nature, yet, with respect to the pneumonia, they have a cer- tain agreement; for the affection is more or less latent, presents similar physical signs, and requires that the antiphlogistic treatment should be employed with extreme caution, and in many cases that the free and early use of stimulants should be resorted to. Of the cases above noticed, those complicating typhus fever are most fre- quently observed. Under these circumstances, patients present the general indica- tions of typhus, and frequently the signs of enteric irritation, with the physical indications of pneumonia. I say the physical indica- tions, because the symptoms are often completely absent. A dusky hue of the face, and a trifling cough, with or without expectoration, slight dyspnoea, and acceleration of breathing, may occur; but the patient rarely complains of his chest, even though extensive and fatal disease may exist. This, indeed, is one of the diseases in which the practical utility of auscultation is most frequently seen; and again and again will the stethoscopist detect an inflammation 244 DISEASES OF THE RESPIRATORY APPARATUS. of the lung, which has occurred without cough, pain, dyspnoea, or expectoration. The question, as to how far the existence of a typhoid character implies that the disease is secondary to typhus, or some other morbid state of the system, whether general or local, is still an open one. On this subject my experience is, that, although in most cases we meet with the disease in its complicated forms, yet it may occur as the sole affection: thus I have observed it more than once from contused injuries of the chest. I have seen many cases in which no symptoms whatever of enteritis existed, in which patients recovered under treatment directed solely to the chest; and though I have often found the ileum extensively ulcerated, yet this is not an essential characteristic of the disease, inasmuch as in other cases there was no appearance of gastro-enteritis in any form. These facts show that a complication with abdominal disease is not constant in this affection ; and we must explain its characters on some other principle. Nor does the actual complication with enteric inflammation necessarily imply a typhoid condition; for I have seen a well- marked case of pneumonia with severe enteritis, in which the most active and repeated bleedings alone succeeded in reducing the dis- ease. In the case of complication with enteric disease, we find pneu- monia either secondary to, or coeval with, the abdominal affection; of these, the first is most frequent, but the character of compara- tive latency may be seen in both. There are two reasons why pneumonia of this character should be always more or less latent. First, the general law which regulates the latency of all inflamma- tions occurring in that state of the system where fever and dimin- ished nervous energy exist; and next, the circumstances of its being complicated with disease in other parts. The manifestation of in- flammatory disease is always in proportion to its localisation and sim- plicity. If there happen to be two or three inflammations going on at the same time, a kind of balance is established, and the symp- toms of each are less apparent. As a complication in typhous fever, we may observe this disease in three forms. In the first, a bronchitis exists for several days, and passes ultimately into a pneumonia, the lower part of one side becoming gradually dull, with a humid crepitus. In the second variety, we observe no difference between the mode of invasion or physical signs, and those of the ordinary disease; while the third presents that sudden solidification which has been already described. Of these, the second is by far the most manageable form. In most cases, even where inflammation of the pleura has occurred, the patients feel no pain; the blood is often diffluent and dark-coloured, like that in typhus, though occasionally presenting the buffy crust. Another point of resemblance among them is, that though the disease is generally formed with rapidity, its resolution, as compared with that of the sthenic pneumonia, is extremely slow ; chronic hepatisations, with or without a low hectic fever or a lurk- ing congestion, may continue for many weeks. And although, under PROGRESS OF TYPHOID PNEUMONIA. 245 proper treatment, the disease may be ultimately eradicated, yet atrophy of the lung, with or without ulcerative disease, is often established. But one of the most interesting and least appreciated forms of this disease, is that which occurs in delirium tremens. This com- plication seems essentially to belong to the delirium tremens from excess; I have never seen it in that from the want of stimulants. This disease commonly attacks the left lung, particularly in its lower portion, and is constantly overlooked. In many cases I have found, continues Dr. Stokes, that it was not the only local in- flammation, but that gastritis, and in some instances a low peri- carditis, coexisted. I have no doubt that, in many cases of delirium tremens, the fatal result is owing to this complication of disease, but particularly to the pneumonia, which I have seen to produce suppuration of nearly the whole lung, when its existence was never even suspected. In all these cases the patients had either been treated by stimulants from an early period of the disease, or, which comes to the same thing, had continued-indulging in spirits until a few days before death. And I have seen, says Dr. S., in such cases, the stomach, heart, lung, and brain, simultaneously inflamed. Although we cannot ad- mit with Broussais that delirium tremens is nothing but gastritis, yet the frequency of the latter, in cases of excess, is not to be denied. The other diseases, too, are analogous ; and it remains to be proved whether they are coeval with the gastritis or the result of sympa- thetic irritation. These diseases are always more or less latent; a fact explicable by their mutual influence, and by the severity of the nervous symptoms. The terminations of typhoid pneumonia are various; it may rapidly produce a fatal hepatisation ; it may form gangrenous abscess; or induce a chronic solidity of the lung, passing into the tubercular condition. One of the most interesting circumstances to the practical physi- cian is the extreme slowness of its resolution, as compared with the sthenic pneumonia. Months may elapse before the respiratory murmur is restored, and in many cases this is never completely reestablished. The fact already mentioned, that contraction of the chest has been only met with in these cases, shows the slowness with which the disease is removed. There is, however, one case in which, from conversion, a rapid subsidence of the pulmonary disease occurs. Thus I have seen the signs of pneumonia sub- side in a single day, on the occurrence of a gastritis or enteritis ; and something of this kind may be suspected when there is a sudden and complete resolution of a typhoid pneumonia. — Diagno- sis and Treatment of Diseases of the Chest. The progress of pneumonia is well and tersely described by Andral (op. cit.). From the first to the second day of the disease, pain, chill, impeded respiration, cough without expectoration, cre- pitating rhonchus, resonance of the chest and fever, are the 246 DISEASES OF THE RESPIRATORY APPARATUS. observable phenomena, and those which constitute the first period of the disease. From the second to the third day the expectora- tion is distinctive, by its becoming viscous and variously coloured. The crepitating rhonchus (crepitation) is more evident, the reso- nance of the chest is weaker on the side in which the pneumonia exists ; the pain is less acute than at the beginning, but the dys- pnoea is increased; the patient lies on his back; the fever is violent, skin dry, sometimes moist. If resolution be not effected at the first stage of the disease, or that of engorgement, and the symp- toms be more intense, the second stage is reached ; and then the laborious breathing is increased, the speech is tremulous, the tena- city of the sputa is augmented, as is also the dulness of the chest on percussion; crepitation disappears and yields to bronchophony; the pulse is strong, frequent, and full, or it is either really or apparently feeble. At this stage the pneumonia may terminate suddenly by asphyxia, or its resolution may still be brought about. In this latter case there is an abatement of the symptoms and approach to con- valescence. If the pneumonia reaches the third stage, the expec- toration in the larger number of cases is watery and brown, and more or less like plum-juice. Commonly, also, the face be- comes pale and cadaverous some days before death. There are no definite periods for the several stages of pneumonia to be gone through. Sometimes suppuration takes place at the fifth day; and sometimes the lung is only in a state of red hepatization by the fifteenth and even the twentieth day. Whatever may be the degree and kind of pneumonia, it pursues a uniform course with evening exacerbations. In some cases, after the subsidence of pain and all the unpleasant symptoms of pneumonia, and when the patient is congratulating himself, and praising his physician for the removal of his disease and speedy restoration to health, things take a most unexpected turn. The pulse becomes slow and weak, the skin cool, then cold; sweat oozes from every pore, but to increase the coldness and weakness. If the patient is asked how he feels, his reply is,—"quite comfortable ;" his only complaint is, that he cannot sleep. Uneasy at this new state of things, the physician who had probably already allowed his patient light nutriment, now makes it more stimulating, by substituting animal broths for sago, or arrow-root, panada, and bread and tea. He directs, also, wine and water at intervals, and warm applications to the feet, and frictions of the skin generally. No reaction taking place, and the serous oozing from the skin still continuing, more like that in epidemic cholera than any other morbid state, powerful stimuli are prescribed, — such as volatile alkali, wine whey, hot brandy and water, and opium in small and re- peated doses internally, and sinapisms and blisters externally ; but all without avail. The patient becomes weaker and weaker, and finally expires without pain, and with less pulmonary oppression than is common with the dying. In this brief sketch I have had in view an actual occurrence. It was in the case of a patient of my PROGNOSIS AND TERMINATION OF PNEUMONIA. 247 own who had been bled twice; the first time sixteen, the second twelve ounces, for pneumonia with a severe stitch in the right side. A blister subsequently applied removed this pain; calomel and tartar emetic with a little opium were given; and in the course of four or five days the patient seemed to be out of danger; his pulse good, breathing easy, expectoration free, decubitus natural. In this comfortable state, taking light nourishment and using some mild diaphoretics with opium, he remained two days, after which the symptoms already described began to appear. The period of sink- ing and collapse was of three days duration, during which nothing seemed to arrest the progress towards death ; nor indeed to impart even temporary force to the pulse or warmth to the skin. With so vivid a recollection of the case, made to me more inter- esting by the estimable character of the man who was its subject, I was attracted by the heading of a paper in the Edinburgh Med. and Surg. Journ. (1840), entitled, " Remarks on Collapse occurring during the Treatment of Acute Pneumonic Diseases, by Mr. Kerr, of Paisley." This gentleman gives the outlines of three cases, two of which were fatal, resembling the one which I have just described. He does not speak of their putting on any of the symptoms of typhoid pleurisy or pneumonia. Mine had nothing of that cha- racter at its onset; but, on the contrary, exhibited all the symptoms of well marked acute pneumonia. The mean duration of pneumonia is from twelve to twenty-five days. In some cases it terminates in two or three days; in others, has extended to thirty and even forty days. LECTURE LXVIII. DR. BELL. Prognosis and Termination of Pneumonia.—Critical evacuations and critical days—Age modifies results—The old and young most apt to sink under pneu- monia—Part of the lung most liable to inflammation—Which side most affected __Complication with other diseases increases danger—Morbid Anatomy of Pneu- monia—Varieties of pneumonia—Participation of the pleura with the lungs.— Causes—External and internal—Climates and countriesin which pneumonia pre- vails most—Is a common disease in southern Europe—Winter and first spring months the chief seasons for pneumonia—Immediate or exciting cause—Particular employments less apt to cause the disease than is supposed—Internal causes,— liability of the disease to return in the same person—tuberculous phthisis—Age —young children most liable—Sex—men much more liable than women.— Treatment—Great mortality in pneumonia—Venesection the chief remedy, to be early and freely used—Dr. Stokes's plan of treatment;—not frequent venesection;—local bloodletting preferable ;—wine in conjunction with local bleedings in typhoid pneumonia;—M. Louis's results adverse to bloodlet- ting,—Antimonials and calomel; mode of using tartar emetic, and general advantages of the practice; combination of calomel and tartar emetic; calomel best in hepatization ; posture to be attended to in these cases; seton in pro- tracted cases with dilated bronchia. Prognosis and Termination. — The prognosis in pneumonia is always serious, although physicians are not agreed as to the propor- 248 DISEASES OF THE RESPIRATORY APPARATUS. tionate mortality ; some rating it at one in three, others at only one in twenty; and one in fifty, and even sixty cases. Even of the probable result of cases apparently favourable, as measured by the symptoms, we ought to speak with caution. Our opinion will be modified by the stage of the disease, its duration, and the tendency toacrisis by spontaneousevacuation. Avery frequent pulse.as when it is 120, and hurried respiration, are bad signs; so is an obstinate cough with scanty or difficult expectoration. The character of the expectoration will guide us materially in prognosis. Thus, in simple pneumonia the viscidity and rusty tinge of the sputa are in exact proportion to the intensity of the inflammation, and their increase in quantity and diminution, or tenacity and colour, are the common attendants on resolution. Dirty or watery-brown sputa and those containing pus, import great danger, inasmuch as they indicate the probable supervention of the third stage, and a gangrenous odour generally implies a state of great peril. The sudden suppression of expectoration is generally an unfavourable sign ; for although the disease may be resolved without any increase of the expectora- tion, yet this has always a favourable influence, and contributes greatly to the cure. A dry, harsh state of the skin attends bad cases complicated with gastric disease, exhibited in a loaded or parched tongue, great thirst or sickness, and tenderness of the epigastrium. A moderately perspirable skin is the most favourable state; profuse perspirations, as I have already stated, sometimes occur in fatal cases. The same has been remarked of diarrhoea, yet both these discharges occasionally prove critical. A copious deposit in the urine may be generally viewed as a favourable sign; and the ob- servation of Hippocrates seems to be commonly true, that if, after having been turbid, the urine becomes clear before the fourth day of the inflammation, a fatal result may be anticipated. Delirium is generally considered to be a symptom of great danger; and it is the more so when it is constant and not merely the temporary effect of the nightly febrile exacerbations; but in hysterical females it is of less importance. Equally fearful is a comatose or lethargic state, as it shows that the functionaldisorder has greatly encroached on the strength required for the necessary treatment. Of the evacuations regarded as critical, Laennec believed the lateritious sediment in the urine to be the most common : Frank and Andral describe perspiration as more frequent. Dr. Williams, whose summary of opinions I am now making use of, believes that the two are commonly conjoined; and there seldom occurs in pneu- monia, a perspiration that can be called critical, without, at the same time, a deposit in the urine. A copious expectoration of a critical character does not occur so often as is described by Syden- ham and Cullen, and, indeed, by the older writers generally. Andral, confirming the opinions of Hippocrates and other writers, says that there are certain days in the duration of the disease in which there is a great tendency to amelioration. Of ninety-three cases, he found that twenty-three gave way on the seventh, thirteen on the eleventh, PROGNOSIS OF PNEUMONIA. 249 eleven on the fourteenth, and nine on the twentieth days. The re- coveries in the remaining cases commenced in twelve out of forty- two non-critical days, as many as eleven being ascribed to the tenth day. Thus the recoveries on critical days averaged as high as fourteen, while those on non-critical scarcely exceeded three. The age of the subject will modify our prognosis. In children the inflammation continues for a much longer period in the first stage; after some weeks duration presenting only some hepatised points at the margin of the lung or in isolated lobules. The same peculiarity has been noted by Laennec in certain epidemics. On the other hand, there is a remarkable tendency of pneumonia in old and debilitated subjects to pass rapidly to the state of purulent in- filtration,— even within a period of twenty-four to thirty-six hours after the inception of the disease. Gangrene, though it generally portends death, does not necessarily terminate in this way. A strong constitution and youth have sufficed to triumph over this sinister state of things. The extent of the inflammation modifies greatly the prognosis. Thus a double pneumonia affecting both lungs at once is frequently fatal,even in the first stage; and when- ever the whole of one lung is involved there is much danger of an unfavourable issue. The part of the lung that is inflamed will not be without its influence on our prognosis. It has been a question, disputed by different writers, as to the relative frequency of inflammation of the upper or lower portion of the lung. Andral's statistics on this point are in favour of the predominance of the latter. Of 88 cases of pneumonia, in 47 the inflammation was of the infe- rior lobe, and in 30 of the superior lobe, while in 11 the entire lung was affected. There is, however, a greater risk of fatal result when the upper lobe is the part inflamed. The cause of this, ac- cording to Dr. Williams, appears to be that the disease of the upper portions and root of the lungs obstructs the passage of blood and of air in the larger vessels, so that the peripheral parts unaffected with inflammation do not receive their due supply. From the combined observations of Andral, Chomel, and Lom- bard, Dr. Forbes has shown, that out of a total of 1131 cases, the right lung was affected in 562, the left in 333, and in 236 the dis- ease was double; the general result of which would be, that, out of every ten cases, five would be of the right, three of the left, and two double. This result is probably near the truth, and corresponds pretty closely with Dr. Stokes's experience; but, adds this gentle- man, it will be found that the double pneumonia is more frequent than appears from the above statement. It commonly happens that, notwithstanding a great preponderance of disease in one lung, a careful physical examination will detect more or less of it in the other, even though no local pain or distress exist, which could lead to its detection. The complication of other diseases with pneumonia increases the danger; as in the case of fevers and the exanthemata, and the more vol. n. — 22 250 DISEASES OF THE RESPIRATORY APPARATUS. formidable is the inflammation in these cases because it is often latent. Pneumonia occurring in the course of a phthisical disease is seldom severe in itself, but it has a tendency to accelerate the development and softening of the tubercles. This inflammation is more than usually fatal in pregnancy and the puerperal state. It is especially dangerous at the extremes of life, more particularly in weakly infants and in cachectic old people, and those exhausted by habitual excesses ; and the fatality is much greater among the lower classes than among those well and regularly fed and clothed. Morbid Anatomy of Pneumonia.—Many of the details under this head have been anticipated in my remarks on the different stages of the disease, and the anatomical characters of each. These I shall not repeat. I may advert to the varieties of pneumonia,viz., vesicular, lobular, and lobar, according to the part and extent of the organ affected. Inflammation attacking the vesicles, the paren- chyma remaining intact, is vesicular pneumonia. But in what does this differ from vesicular bronchitis? Or, again, the inflammation may attack not only the separate vesicles, but all the vesicles of a lobule, without the parenchyma being affected. All parts of the lung may suffer in this way; but the lesion is most manifest at the external portions, the root, the inferior lobe, and the central vesicles. This will constitute lobular pneumonia. Finally, the entire lobe of a lung and all the lobes of a lung may be seized with inflammation, constituting lobar inflammation. Lobular pneumonia is most com- mon in children. Inflamed bronchia, so common an accompaniment to pneumonia, are, of course, seen in fatal cases of this latter. The attack is often begun by bronchitis, which may mask the other disease. Some- times bronchitis is consecutive on the pneumonia. Mechanical alteration of the bronchia, sometimes noticed in fatal pneumonia, consists in their obliteration, which always begins in those of a medium calibre. More frequent still are the cases in which the pleura participates in the inflammation of the lung proper. This state is recognised after death in an injection of varying distinct- ness, in albuminous concretions, slight serous, purulent, or bloody effusions. Pleuritic effusion is seldom extensive when pneumonia coexists with the pleurisy. Causes. — The causes of pneumonia may be considered under the two heads,— of those external, and those connected with the individual himself. The first include climate, season, and atmo- spherical exposures in general. Pneumonia is a rare disease in hot latitudes ; but if scarcely known in the East Indies, it is of occasional occurrence in the West Indies. In southern Europe it is far from being uncommon; as we learn that in the Archipelago and Greece there is one case of pneumonia to thirty-eight cases of disease in general. Of the Ionian Islands, Corfu is said to suffer most from this disease. The gradual substitution of pulmonary for hepatic disease is shown in the English troops returning from India losing the latter and becoming subject to the former. In Italy pneumo- CAUSES OF PNEUMONIA. 251 nia is a quite common disease. At Pavia, it appears, from a return made for a period of three years, that in the first year one-seventh of the cases received into the hospitals were of pneumonia ; in the second year, the proportion was a sixth; and in the third year, a quarter. At Padua, the proportion is very variable; being at one time a fifth, at another a sixteenth, then a twenty-third, and even a. fifty-eighth. At Wilna (Russia), the proportion is one in seven to one in eight. Pneumonia is very common in Rome, — a fact long ago pointed out by Baglivi; indeed, there is hardly any difference in this particular between that city and London. There is good reason to believe that inflammation of the lungs is a prevailing malady along the whole European coast of the Mediterranean; in regions and districts, the climate of which has been long supposed to display a sanative influence in all chronic and pulmonary dis- eases, but in a more especial manner on consumption. I shall most probably have time to point out more formally, hereafter, this fallacy. At Nice, Genoa, Pisa, and Florence, the disease prevails greatly, and cuts off many of the inhabitants. The neighbourhood of Naples, or around Mount Vesuvius, is remarkable for this occur- rence. Here it may be called truly endemic, especially by those who attribute it to the noxious exhalation which prevails tfcere. To more recognised climatic influences should we attribute the endemic character of pneumonia in northern Europe generally, in which we must include Great Britain. There is not entire uniformity in the seasons, even- in the same latitudes in which pneumonia is most rife. In general, however, it may be said that the latter winter and first spring months give the largest number of cases in northern and middle Europe, and in the United States. In the West Indies, on the other hand, the maximum of frequency is in summer. In Paris, the chief months are January and April. The immediate and exciting cause of pneumonia is represented to be sudden transition from a warm to a cold medium while the body is heated, and especially in a state of perspiration. Facts justify this explanation in many cases; but in many more, perhaps the majority, it does not apply; and we are fain to suppose a peculiar predis- position by which certain individuals under common exposures contract pneumonia. Still, knowing the seasons and districts in which the disease is most prevalent, we can hardly refuse believing that a sudden and concentrated application of these atmospherical influences, in the manner just described, should count largely in our inquiries into the causation of pneumonia. The epidemic occur- rence of the disease is clearly proved, although even here, again, we shall be at a loss to account for the fact in any known and appre- ciable imitations and combinations of states of the atmosphere. The influence of particular employments, in which those engaged are much exposed to cold and humidity, has been greatly overrated, as we learn from Thackrah, among others. Regularity in other respects, and particularly avoidance of alcoholic stimulation, renders 252 DISEASES OF THE RESPIRATORY APPARATUS. exposures of this nature, and even sudden transitions from high to low temperature, comparatively innocuous. That there are internal causes, a special but not it priori recog- nisable predisposition, by which pneumonia is readily developed and renews its attacks in certain persons more than others, we can hardly doubt. Authors relate cases in which the same person has had the disease repeatedly; Dr. Rush mentions twenty-eight times; M. Andral sixteen times in eleven years; and M. Dezoteu fifteen times. Perhaps the chief predisposing cause, at any rate the one depending on recognised peculiarity of organization, is tubercles of the lungs. Seldom is there a case of tuberculous consumption in which pneumonia is not developed; and often I have seen it near the close of the disease rendering its removal in the then exhausted condition of the patient, who is sinking rapidly into death, a matter of great difficulty. The influence in this case is, however, reciprocal; for pneumonia, though it does not directly cause, yet it develops the production of tubercles. Pneumonia may supervene on chronic bronchitis; and still more readily and frequently on acute pleurisy. It complicates sometimes dothin- enteritis, as also measles, scarlatina, and small-pox, and follows the suppression of any of these eruptions; as indeed it does of less acute ones. Phlebitis is sometimes associated with it Chronic inflam- mation of some other organ singularly predisposes some individuals to pneumonia. One of the most severe cases of the disease which I ever met with, if measured by the structural changes in the lungs, terminated the life of a lady who had for years suffered under chronic gastritis with softening of the mucous membrane of the stomach. Age has an influence on the aetiology of pneumonia. All ages are declared by M. Andral to be subject to pneumonia. It has been known to attack the foetus in utero ; and it is quite common in children, rather less in adult life, and prevalent in old people. Guersent reports the disease to be very common and fatal among children, and that, of the deaths in the hospital of sick children at Paris, before the completion of the first dentition, three-fifths occur from pneumonia which is chiefly latent. Dr. Williams, from his own observations, is inclined to consider young children as more frequently the subjects of pneumonia than adults. Sex displays a modifying influence, in the greater readiness of men to contract pneumonia. Out of ninety-seven cases which oc- curred in the wards La Chariti, under the care of M. Chomel, seventy-three were men, although the number of patients in the hospital wards, of either sex, was nearly the same. Treatment.—If inferences were to be drawn respecting the treat- ment of pneumonia from the proportionate number of fatal cases, we should be greatly at a loss to determine on which side the ad- vantage lies; both owing to the fluctuations at differentfctimes in the same place, and the different results published by two sets of writers of the same cases. The great success of M. Laennec, under TREATMENT OF ACUTE PNEUMONIA. 253 the tartar-emetic treatment, in his only losing two out of fifty- seven cases, has been often quoted in his and its favour; whereas, if we are to believe in the critical accuracy of M. Bouillaud, the deaths were seven in number, leaving at this rate the mortality to be rather less than one in eight. In the Charite, in the years 1825 and 1826, the results of M. Laennec's practice was 12 deaths in 30 cases of pneumonia. M. Chomel very frankly admits, the deaths in his hospital practice were one in four; but M. Louis goes still farther, and rates it at one in three. M. Bouillaud, in summing up the results of the practice which he advocates, early and full bloodletting, reports in 102 cases 12 deaths and 92 cures, which is a mortality of 1 in 8§. M. Lacaze of Montgeron, near Paris, has published, in the Journal Hebdomadaire (1834), a statement of the treatment of 42 cases of pneumonia treated by large bleedings, which shows only one death out of the entire number. In the ques- tion of mortality and of treatment, you must, however, always re- member that, as a general rule, with equal skill, and the same means employed in out-door practice as those enlisted in hospital service, the results will be in favour of the first. The class of persons who, in large numbers, are sent to hospitals, their prior mode of life, poverty, bad feeding, overwork, or excesses of various kinds, and the deteriorating influence of the air of a hospital, are all ad- verse circumstances against the favourable effects from a remedy or plan of treatment. On this account we cannot implicitly follow the practice pursued by hospital physicians, nor receive for our guidance their caution against a full antiphlogistic course of treat- ment in inflammatory diseases. The inability of their patients in the hospital to bear free depletion, ought not to be received as evidence of its inapplicableness to patients of even a similar age and tempera- ment out of doors. I deem it the more important to introduce these cautionary remarks just now, believing that they will apply to the opinion of Dr. Stokes respecting his inculcation of restricted vene- section in pneumonia; and with this reservation I now place his views before you. Treatment of Pneumonia. —I shall here, says Dr. Stokes, consider the treatment of the simple inflammatory and the typhoid pneu- monia. Treatment of the Sthenic Pneumonia. — Of all parenchymatous inflammations, that of the lung seems most under the control of judicious treatment, if this be adopted at an early period ; but if the disease be allowed to run on into its third or fourth stage, its treat- ment becomes much more difficult. I find the bold and repeated use of the lancet to be unnecessary in the great majority of cases, and I am convinced that, in general, a single, or, at the most, two bleedings, will be sufficient. Out of many hundred cases, I have had only one in which it was neces- sary'to bleed more often than twice; in this instance, there was a complication with hypertrophy of the heart. The true principle 254 DISEASES OF THE RESPIRATORY APPARATUS. seems to be, that general bleeding is to be considered only as a pre- parative for other treatment, and not the chief means of removing the disease. I have no doubt that too much has been said as to the necessity and advantage of large or repeated bleedings in pneu- monia, and the mind of the young practitioner has been trained to consider them as his great resource, to the neglect of other neces- sary and important measures, and the consequence has been, that the cure is often purchased at too dear a price, or, what is more frequent, that the disease is only modified, but not removed. It is changed from a manifest to a latent pneumonia, the cough, dys- pnoea, pain, acceleration of bleeding and fever are reduced, and the patient is considered as cured, while his lung remains solidified, or even passing into other disorganisation. I am most anxious to press the importance of local bleeding, in the treatment of pneumonia, for I consider it as the principal remedy. For this purpose, either scarification by cups or leeches may be employed; but if the latter be used, I would, in all cases, recommend that the cupping-glasses should be employed in conjunc- tion with them. In this way, the general fever and arterial excite- ment having been previously reduced by the lancet, we may, directed by the stethoscope, continue day after day to detract blood from the affected part, while the patient's strength can be sup- ported by food, and even wine, if necessary, In the treatment of the typhoid form, the best practice is to use wine, in conjunction with local bleedings. M. Louis has given the results of his experience, drawn from the numerical method, as to the effect of bleeding and other treatment in pneumonia: I shall give his conclusions in his own words: — " 1st. That bleeding has a favourable influence on the progress of pneumonia ; that it shortens its duration ; but that this influence is much less than is commonly believed; so that other things being equal, those patients who have been bled in the four first days of the disease were only cured four or five days sooner than those who have been bled at a later period. " 2dly. That we cannot cut short a pneumonia by venesection, at least during the first days of the disease. And if the contrary has been believed to occur, it is, doubtless, because we have confounded this disease with others, or that in some rare cases the first bleeding causes the general symptoms to subside rapidly, while the local phe- nomena continued for the most part to advance. " 3dly. That age has a great influence on the progress and ter- mination of pueumonia. "4thly. That the tartrate of antimony, in large doses, given in those cases when bleeding has been unsuccessful, has a favourable action, and seems to diminish the mortality of the disease. " 5thly. That blisters have no evident action on the progress of pneumonia ; and that, without any loss, they may be banished from the treatment of those cases of pleurisy and pericarditis which occur in healthy subjects." TREATMENT OF STHENIC PNEUMONIA. 255 On these conclusions a few observations may be offered: It is difficult to explain the results furnished by M. Louis's tables, with respect to bleeding in pneumonia. To find that, with the exception of the first few days, it matters little at what period we bleed, is indeed an unexpected result, and one which is opposed to the experience of all practical men in this country. It may be observed, however, that M. Louis has not separated the sthenic from the asthenic or typhoid pneumonia ; and as we know that the lancet has comparatively little efficacy in the latter form, we must conclude, and without impugning the method or accuracy of M. Louis, that its value in the sthenic pneumonia is greater than what appears from these calculations. In addition, it may be observed, that no mention is made of local bleedings having been employed in connexion with the lancet; had these means been extensively employed, there would, doubtless, have been stronger evidence in favour of bloodletting. It is cer- tainly true that we can seldom cut short a pneumonia by bleeding. In two instances only have I seen this result, but the common effect of general bleeding is to remove or modify the constitutional symp- toms. In some cases the affection is merely converted from a manifest into a latent but progressive disease, while in others the lung continues unresolved, and in a passive condition. In such cases, tubercle, chronic induration and atrophy are commonly the results. Under this treatment, the bowels having been emptied, and all exciting causes removed, the question will arise, whether the patient is to be treated upon the antimonial or mercurial plan. In decid- ing the relative merits of the two remedies, we have a difficulty in limine, from the absence of statistical information; in the want of this we must rest satisfied with those conclusions to which our every-day experience has led us. After ten years' hospital expe- rience, I would state the rule which should guide us, to be the fol- lowing : —- That the success of the antimonial treatment depends on, or is favoured by, the inflammatory character of the fever, the early stage of the disease, the absence of complication with other diseases, the fact of the patient having borne bleeding well, and the firmness of the coagulum ; the more the case presents these characters, the greater will be the likelihood of the tartar emetic acting favourably. But in the typhoid, secondary, and complicated cases, in those where the powers of life have been previously injured, where bleeding can- not be used with boldness, and where stimulants are required, the exhibition of the tartar emetic, in full doses, is very hazardous. The mercurial treatment is to be preferred from its greater safety, and, in this disoase, more than equal efficacy. In the Meath Hospital, we have used the tartar emetic after the manner of Laennec ; but its exhibition has been conducted on a different principle; for while he considers it as his chief remedy, we have always found it secondary to general or local bleeding. 256 DISEASES OF THE RESPIRATORY APPARATUS. The formula used is that already given in a preceding lecture on bronchitis. It is while the crepitating rdle is heard more distinctly, and before a complete solidification has taken place, that the remedy answers best. Indeed, in the advanced stages of the disease, and where the object is to remove a hepatisation, the antimonial is inferior to the mercurial practice; but the mere occurrence of hepatisation does not contraindicate the use of the antimony, if it be in the early stage of the disease, and while the crepitating rdle is advancing in other portions of the lung. We generally begin with the use of from four to six grains on the first day. The dose is increased by one or two grains daily, until ten, twelve, or fifteen grains, are exhibited in the twenty-four hours. I have never gone beyond this dose; but it must be remem- bered that the most careful attention was always paid to local treat- ment. For the reduction of the ordinary inflammations of the lung in this country, our returns show that it is seldom necessary to admi- nister more than from twenty-five to thirty grains of the remedy given in the doses above mentioned. In many cases, however, larger quantities have been employed ; thus, I have often continued the exhibition of the remedy to the amount of fifty grains, and one case, where an acute double pneumonia was superadded to a chronic bronchitis, one hundred and seventy grains were used at the doses of twelve grains daily. The patient's symptoms and appearance daily improved under its use, and, during the latter period of its exhibition, his appetite and digestive powers were excellent. In this case, the recovery was perfect and permanent. In many cases, the first doses produce vomiting, and in some purging; but the effects generally subside after the first twenty-four hours. With respect to the interval of tolerance, I have constantly verified the statements of Laennec, and there is hardly a more interesting cir- cumstance in medicine than to see a patient taken from eight to twelve grains of the remedy daily, without vomiting, purging, or sweating— without any effect, indeed, save the gradual removal of the pneumonia. This treatment is seldom followed by abdominal irritation. In one patient, after the use of eight grains daily for four days, violent vomiting, diarrhoea, and pain in the abdomen, supervened. These symptoms subsided under a sedative treatment, but returned, in two days, with such violence that the lancet had to be employed. In another case, the usual symptoms of poisoning with tartar emetic followed the first dose of the medicine; both these patients recovered without difficulty. In those cases where the remedy has been borne well, it is not advisable to omit its use suddenly. We have seen frequently a severe relapse to follow this practice, but by diminishing the dose at the rate of a grain or two daily, these effects can be avoided. In those cases where the tartar emetic is not borne, or its use seems inadmissible, I have generally recourse to a mercurial treatment; TREATMENT OF STHENIC PNEUMONIA. 257 this is to be conducted both by the internal and external use of mercury. Calomel, combined with blue pill and opium, is to be administered every third hour, and its action assisted by mercurial frictions, and the application of the ointment to blistered surfaces. I have no experience in the treatment by very large doses of calo- mel, as recommended by Dr. Graves and Dr. Hudson. Laennec has been severely censured for his statement, that the gastro-enteritis of fever does not contraindicate the use of the tartar emetic. I apprehend that in this matter he has been scarcely done justice to, for there is every reason to believe that he makes use of the term gastro-enteritis in the conventional mode then so prevalent in Paris, and in which gastro-enteritis and fever were convertible terms. There is no ground for believing that Laennec would give tartar emetic in acute gastritis ; and his statement is reducible to this, that the remedy may be employed in the pneumonia of fever ; and without entering into his reasoning on the subject, we must agree with him, that the contraindications to the use of this, as of all other medicines, ought to be founded on experience alone. It is now proved, that the existence of typhus fever does not contra- indicate the use of tartar emetic, but that, on the contrary, its exhi- bition may be followed by the happiest effects; the gastro-enteritis of Broussais, then, does not contraindicate the use of this remedy. But in conducting the mercurial treatment it must never be for- gotten, that the direct antiphlogistic powers of the remedy are much inferior to those of tartar emetic, and, indeed, that their very exist- ence may be questioned. I have always found that the mercurial action seems rather a result than the cause of the first reduction of disease. While the fever continues high, a complete resistance to mercurial action most commonly exists, and too often is precious time lost in the attempt to salivate, when a direct antiphlogistic treatment would have modified the disease, and induced the ptya- lism. It will always be found that the facility of salivation will be directly as the reduction of the fever. This resistance to mercurial action is less frequently seen in the simple than the complicated cases of pneumonia, in which the curious symptom of vacillating mercurial action may frequently be observed ; thus, in a case where the remedy has been exhibited for the space of thirty-six or forty- eicrht hours, the gums may become spongy and the breath mercu- rial, and everything seems to promise that the desired object will be fulfilled ; but in a few hours all these appearances "cease, the gums become again hard, and the fetor subsides; this is generally accompanied by an aggravation of symptoms, on the subsidence of which another of these attempts at ptyalism may be observed, and in the course of a single case this circumstance may occur three or four times; salivation is almost never established,and the case too often proves fatal. In some cases I have found that the previous exhibition of tartar emetic seems remarkably to facilitate the mercurial action ; and the reverse of this may also occur, and the happiest effects be seen from 25S DISEASES OF THE RESPIRATORY APPARATUS. tartar emetic, in cases where mercury has been previously exhibit ed. In many cases both modes of treatment may be employed. Cases of unresolved hepatisations, in patients either apyrexial or labouring under hectic, are extremely common, as a result of rou- tine practice and neglect of the stethoscope in the early treatment of the disease. In these cases mercury has a better effect than the tartar emetic, and the best treatment consists in its cautious exhibi- tion, combined with repeated local bleedings and counter-irritation. In many cases I have employed the seton with the best effects. I have also used iodine, both 'internally and externally, but without decided advantage. These hepatisations are more common after the typhoid or asthenic pneumonia, and many weeks, or even months, may elapse, before the lung is restored to health : the cure is not unfrequently accompanied by atrophy of the lung and con- traction of the chest, under which circumstances the resolution is pointed out more by the reappearance of the respiratory murmur than the clearness on percussion. But in these cases our efforts will often be nearly unavailing, unless careful attention is paid to the position of the patient, so as to relieve the diseased portion from hypostatic congestion. The patient is to be encouraged to lie on the opposite side, and where the posterior half of the lung is en- gaged lying on the face for a certain time everyday will have the best effect. In many cases, where remedies seemed to have little or no effect, attention to position has been followed by a rapid re- covery. See on this subject a paper by M- Gerdy, published in the Archives Genhales de MSdecine, on the Influence of Position in modifying the Phenomena of Disease. It will also happen, whether in cases treated on the antimonial or mercurial plans, that the lung continues in a congestive state, accompanied with copious bronchial secretion. In this case the treatment recommended for the second stage of bronchitis is to be carried into effect, when the bronchial affection in general yields. In a few cases, however, the tubes become dilated, and though the constitutional symptoms disappear, the respiratory phenomena are not restored to their natural condition. This was well exemplified in the case of a gentleman of strong habit who was attacked with a violent double pneumonia, attended from an early period with a copious expectoration of mucus or muco-purulent matter; his life was long despaired of, but after removal to the country he gradu- ally mended. A seton was inserted, and frequent changes of air had recourse to. In about a year and a half I again examined him; he had recovered his flesh, strength,-and appearance, and only complained of a little dyspnoea on exercise ; the whole chest sounded naturally on percussion, and the respiration over the ante- rior, postero-superior and lateral portions was healthy, while in both infra-scapular regions nothing was audible but an exceedingly large mucous rdle. I again examined him, afler the interval of some months, with the same results; and when we connect the physical signs with the history of the case, there seems little doubt of the correctness of my conclusion. It is obvious, that in a case TREATMENT OF PNEUMONIA. 259 like this, an error may be committed by unavailing attempts at removing these physical signs, and the practitioner must rest satis- fied with curing the constitutional symptoms, and not injure his patient by unavailing treatment. (On the Diagnosis and Treat- ment of Diseases of the Chest.) LECTURE LXIX. DR. BELL. Treatment of Pneumonia, (continued).—Superiority of venesection over all other remedies—Extent of its use and frequency of repetition—Not to be deterred by fear of interfering with critical evacuations—Circumstances which modify bloodletting—Original strength of constitution; complication of pneumonia with other diseases—Purgatives—Revulsives and counter-irritants—Opium and other narcotics—Depression to be met by stimulants and mild tonics—Treatment of complications—bilious pneumonia,—the pneumonia of children—Less deple-. tion required in the cases of children—Tartar emetic in their case—Regimen and drinks in pneumonia.—Convalescence—Cautions requisite in—Treatment of typhoid pneumonia by Dr. Stokes—Depletion less used, and stimulants more freely ; complications to be attended to ;—remedies for hectic with expectora- tion.—Chronic pneumonia—Physical signs of—Caution against much deple- tion in. A few additional remarks including some points of treatment not noticed by Dr. Stokes will find place at this time. As respects vene- section, too cautiously advised by Dr. Stokes, although I would not go as far as the late Dr. Gregory of Edinburgh, who was in the habit of saying in his lectures that, provided he was called early in pneu- monia, he would be contented to dispense with all other aids than those of the lancet and water gruel, yet I cannot help regarding it as the chief remedy, itself superior to all other means, and not to be replaced by any other, or by all others. M. Louis's authority is invoked sometimes against bloodletting in pneumenia, which he says is neither shortened nor materially influenced by the remedy. But here is one of the instances of the fallacy of the numeral method. Without a careful specification of the constitution and habits of the persons whose cases are numbered by M. Louis, his estimates can- not be introduced as contradictory to the experience of both ancients and moderns in favour of free, or we might, as Dr. Watson pro- perly does, say prodigal bloodletting. The abstraction of blood is productive of immediate and direct relief to the suffering organs which are now able to resume in degree their functions at once. To be most effective, venesection ought to be practised at the first in- vasion of the disease; an advantage which may be readily pro- cured in private, but very seldom, if ever, in hospital practice. M. Andral advises free bleeding from a large orifice; but to stop short of bringing on syncope, to prevent which he advises that the patient be bled in a recumbent posture. Leeches and cups, which are of service incases of pleuritic stitch,ought, as this judicious practitioner recommends, to be considered as adjuvants, but not a principal remedy, or substitutes for the lancet. 260 DISEASES OF THE RESPIRATORY APPARATUS. If we can bleed early, within the first twelve or twenty-four hours of the attack, and produce a decided impression just short of syn- cope by this remedy, we may then, as so strenuously recommended by Dr. Armstrong, give at once a full dose of opium, as of two or three grains, with a view of arresting the further progress of the disease. The efficacy of the opium will depend entirely on its early administration; after the first day we cannot hope for much from it, and when hepatisation has begun it will be injurious. How often should the bleeding be repeated? Dr. Stokes has just told us, not more than two; M. Andral says from three to five; and that, if the disease is very violent, blood may be abstracted twice in the same day, once in the morning and once in the evening. Some have bled fifteen to twenty times in a pneumonia. My own observations would induce me to press the use of the lancet without stint, where there is pleurisy associated with pneumonia, until the pain is re- moved and the breathing comparatively easy. It is hardly worth » while to speak of a bloodletting which does not produce a decided impression: short of this it seems to aggravate the sufferings of the patient. On one occasion, a young woman, a dispensary patient, was directed by me to be bled, and she was bled, but not to the ex- tent which 1 wished. I prescribed a repetition of the operation on the morning following the first venesection, but the quantity fell far short of the exigency of the case. In the afternoon of the fifth day of the disease, when I again visited her, I found her still suffering acutely. I now opened a vein myself, and let the blood flow until twenty ounces were abstracted. From that hour she was relieved, and her convalescence may be said to have begun at the same time. We must not be restrained from a bleeding by a fear of its inter- fering with a crisis by expectoration or urine, if the inflammation be still great, and the symptoms urgent as at first. Bloodletting is best on the first day; it is good on the second and the third, and will often save life on the sixth and even the eighth day of the dis- ease. After expectoration is freely established, and the sputa have lost their viscosity and rusty colour, and the breathing is easier, it would be imprudent, under an idea of accelerating the cure, to draw blood. Venesection in pneumonia is a remedy of necessity, not of precaution ; nor is it one of cumulation, an increase merely of re- medial impression for the removal of the disease. Bloodletting cannot be as efficacious in the hepatisation of pneumonia as it is in the primary stage of engorgement; but even here it often produces excellent effects ; even, as M. Andral assures us, after the gray hepa- tisation in the suppurative stage. Not that we bleed in this case for the removal or absorption of the pus, but to relieve other parts of the lung in which hepatisation still prevails. Mere smallness and frequency of pulse will not deter us from using the lancet, if the accompanying symptoms indicate oppression rather than depression or prostration. The pulse in pneumonia, as in most of the phleg- masiag, often rises and acquires volume after bleeding. Copious sweat has been regarded by some as a cause for our withholding TREATMENT OF PNEUMONIA. 261 the use of the lancet; but I have already told you that often a warm sweat even accompanies some of the worst and fatal cases; and hence, that it is not critical, nor can its suppression be attended with deleterious efforts, if this result follows an abatement of the intense phlogosis which, in some cases, seems to keep it up. By some physicians the inflammatory buff and cup of the blood drawn are regarded as a necessary appearance to indicate and justify the repetition of the bloodletting. But on this point there is no uni- formity; for in some of the worst and inflammatory cases of pneu- monia, you will not see any buff in the blood. Returning from this digression, let me conclude my remarks on the circumstances requiring and modifying bloodletting in pneu- monia. In old persons we are too apt to be deterred from this remedy, under an idea that they are weak, and their systems will not react under the temporary depression caused by loss of blood. But this is a mistake, if assumed as a general rule. Original strength or weakness of constitution, prior health or disease, and the habits of the patient, are qualifying circumstances of more importance than those of adult or of advanced life. An old man of seventy, who has been habitually robust, healthy, and temperate, can part with more blood than a young man of twenty-five,of an anaemic or scrofu- lous habit, and weakened by excesses of any kind,— in the same dis- ease. In the complication of pneumonia with eruptive fevers, some physicians are afraid to draw blood, — imposed upon by the small, frequent pulse, and predominance^ nervous symptoms, great weak- ness, and apparent prostration. This is often the critical epoch, when bloodletting is most required to save the patient. It will be more necessary in these cases than in others, to aid in bringing on reaction by moderate stimuli, with small doses of opium and exter- nal warmth and frictions. A similar remark applies to the super- vention of pneumonia on gout. The attack is still pneumonia, by whatever terms we may choose to qualify it; and if it is not removed by active treatment, it will kill the patient. The complication of pneumonia with typhous and typhoid fevers is a very common occurrence, and merits prompt attention. Congestion predominates over inflammation, and we cannot hope to free the lungs by full bleedings; but we may greatly relieve them, and simplify the diagnosis by small bleedings either from the arm, or preferably by cups to the chest, — on the sides, under the clavicle, and between the shoulders. Although bloodletting is the chief, it must not be regarded as the sole available remedy in pneumonia. In the beginning of the dis- ease and towards its decline tolerably active purgatives are administered with good effect. In fixed hepatisation we cannot promise ourselves much service from them. Counter-irritants, in the shape of sinapisms to the extremities and hot pediluvia, are generally and usefully prescribed. As revulsives, leeches to the vulva or the anus, in cases of suppressed menstruation or of hemor- rhoids, shortly before the coming on of the pneumonia, are directed vol. n. — 23 262 DISEASES OF THE RESPIRATORY APPARATUS. in preference to their application to the chest. Blisters, a favour- ite remedy with nearly all writers, are beginning to be regarded with mistrust by some of the most judicious of our practical men. In the acute and febrile stages of the disease they are not to be relied on; and they irritate, often excessively, the patient, especially if he be of a nervous temperament. When prescribed, they ought to be either very early, or, a safer practice, towards the decline of the disease. In children we must trust more to counter-irritation than in adults; and hence, in cases of pneumonia, attacking the former class of subjects, we apply stimulating lini- ments rubbed on the skin, and irritate the lower extremities by liniments or sinapisms, warm bath, and blisters to the chest. Drinks of the demulcent class are always preferred : but we must study variety, so that the patient may not have a distaste, or, in fact, a disgust towards them. We are cautioned against the free use of drinks, in pneumonia, as calculated to injure both by filling the bloodvessels and by inducing dyspnoea, owing to distension of the stomach. I spoke of opium as a medicine which might be usefully given on the accession of the disease, and especially and mainly after a large bleeding. This period over, we ought to be very sparing in the use of opium, which may increase the pulmonary congestion, both by its effects on the circulation, and by dangerously weakening the innervation on the respiratory muscles, and on the lungs themselves through the par vagum. On the subsidence of the pulmonary inflammation and of the violent action of the heart, and the coming on often of nervous symptoms and wakefulness,—Dover's powder, in doses of three grains every two or three hours, will be of much service. When calomel is administered, this fashion of opiate may be usefully combined with it, even in an earlier period of the dis- ease ; and, as Dr. Stokes has already pointed out, the addition of a few drops of laudanum to the tartar emetic solution is both admis- sible and proper. You will find no contradiction between these admis- sions in favour of the occasional use of opium, and the general pro- hibitions precedingly laid down. Opium alone, after the first day, and in such doses as to produce its hypnotic effects, is prejudicial; but opium combined with calomel, or with tartar emetic, or even ipe- cacuanha, serves both as an adjuvant and corrigent, and aids the operation of these medicines without any inconvenient exhibition of its own more distinctive and peculiar powers. In cases of doubt, less objection applies to other narcotics, such as hyosciamus; and as a narcotic diuretic which directly soothes, and indirectly relieves also, by a revulsion on the kidneys, digitalis is entitled to consider- ation. Calomel and digitalis are most useful, particularly the former, in the pneumonia of children. Sometimes sudden depression follows venesection, or comes on in the process of pneumonia, as I stated at the conclusion of my lecture before the last. This requires mild tonics and even stimu- lants. Of the latter I prefer, as prompter in its operation, and less TREATMENT OF PNEUMONIA. 263 hurtful subsequently, carbonate of ammonia, to which small doses of Dover's powder and wine whey are properly added. In the cases in which we are forbidden to repeat venesection, and rely on the calomel, it is no bad practice to give, alternating with this latter, the carbonate of ammonia; and in some instances, where the expec- toration and urine are scanty, small doses of oil of turpentine. In our recourse to tonics we shall be chiefly guided by the state of the stomach and the predominance of gastric debility. Of this class, calumba infusion, with a few drops of nitric acid, will be found to meet our wishes most satisfactorily. The complication of hepatic disorder, or it may be inflammation with pneumonia, ought not to make any difference in the essential points of practice in the latter disease. Venesection cannot be postponed nor preferred in favour of emetics, and purgatives and mercurials which do not purge; but these remedies, and especially purgatives, will very properly follow bloodletting, and contribute not a little towards the cure. In those cases of bilious pneumonia, or, as these are generally designated with us, bilious pleurisy, whether there be pneumonia with pleurisy, pleuro-pneumonia, or pleurisy alone, preference should be given to calomel over tartar emetic after, the lancet has been used. We give calomel at first t6 act on the bowels, aiding its operation in this way by saline purgatives, and afterwards as a direct antiphlogistic; a sedative, in fact, but not as a sialogogue. The presence of the menstrual flux has been supposed to contraindicate bloodletting in pneumonia; but without reason, if the symptoms are violent, and the case is of such a nature that it would otherwise call at once for venesection. In the pneumonia of children we have at first difficulty in esta- blishing a correct diagnosis, latent as the disease is so apt to be in this class of subjects; and, afterwards, a difficulty in carrying out and adopting our views of practice, in reference to their peculiar constitution. Bloodletting is required in infantile pneumonia, but not to the extent nor with the same freedom of repetition as in the case of adults. Could we, with Dr. Gerhard (Am. Jour, of Med. Sciences, vol. xv.), in his valuable paper on the pneumonia of children, suppose that this disease, in subjects from two to five years of age, approaches more to sanguineous congestion from mechanical obstacle to the circulation, than to inflammation, we should feel the less inclined to bleed, and would trust more to revulsion and counter-irritation. But as MM. Rilliet and Barthez pertinently ask (A Treatise on the Pneumonia of Children—Translated by Dr. Parkman of Boston): A rapid progress, formidable symptoms of reaction, evident traces of an inflammation of the lung or its dependencies—are not these sufficient to characterise an inflam- matory affection 1 Whatever shade of pathological opinion on this point we may adopt, the fact is not the less clear that children do not in general require nor bear very copious abstraction of blood. Nutritive life is active in them; and there is great mobility both of the circulatory and nervous system; but their powers of reaction 264 DISEASES OF THE RESPIRATORY APPARATUS. are not great. We are restrained, also, by another consideration in the disease before us. It is seldom idiopathic ; but results from other diseases and ailments, among which bronchitis is one of the principal. Thus gradual in its approach and complicated with other diseases, the pneumonia is not of that open kind that would justify large and repeated bloodletting. The experience of MM. Rilliet and Barthez, and the recorded testimony of other writers which they adduce, are unfavourable to the remedy, which, as they allege, exerts little or no immediate salutary impression, and displays no influence in shortening the duration of the disease. More may be expected from the application of leeches under the clavicles, or cups on each side of the chest, or between the shoulders, than from vene- section ; for unless we produce a stronger effect on the disease than it is in our power to do by the common expectorants, we shall almost certainly lose our patients. Respecting the value of the tartar emetic treatment in the pneumonia of children, my own experience coincides with the conclusions of the French writers just named, viz., " that the tartar emetic may be employed with success in the child; that there is no danger in a somewhat elevated dose; that the tolerance is generally easily established ; that the gastrointes- tinal accidents give little cause of fear; and finally, that this medi- cament appears to act more directly upon the pulse and respiration than upon the hepatisation itself." A remark made by MM. Rilliet and Barthez will not a little diminish our faith in the therapeutic powers of even the most approved remedies in this disease. It is; that the first signs of amelioration appear in nearly all cases at the same period of the disease, from the seventh to the ninth day, what- ever may have been the treatment employed. The regimen in ordinary pneumonia ought to be strictly anti- phlogistic throughout; and hence a restriction to simple drinks, demulcent and diluent. Warm drinks are ihose generally recom- mended; but unless there be some gastric complication forbidding their use, cold ones are not inadmissible. If the counterstimulant plan be adopted, the patient should not be allowed to drink much liquid until toleration to the tartar emetic be established. An exception to the antiphlogistic course in pneumonia is some- times met with, in the cases of old and intemperate persons, to whom, in some instances, wine and even spirits has been allowed. The safer practice will be to give volatile alkali (carbonate of am- monia) in union with opium ; and if farther stimulus be required to sustain the sinking powers of life, wine whey in small quantities at short intervals will answer every purpose. The temperature of the room should be attended to, in connexion with the other parts of the treatment of pneumonia. Hot air and currents of cold air arealike injurious: an average temperature of 60° F. will be the best, but this is to be understood of the air for breathing, and not that to which the skin can be exposed in an uncovered state. I have no doubt of the good effects of occa- sionally allowing the patient to breathe cold air admitted by TREATMENT OF PNEUMONIA. 265 opening the windows; provided there be no current blowing across or over him, and also that his whole body, even his face, with the exception of his mouth and nostrils, be carefully and warmly covered at the time. Posture is of great moment in pneumonia; so that the chest should be raised above the level of the lower part of the body. The best means of doing this is by a bed-chair with a notched rack, which will allow of its being raised to any required angle. Muscular exertion of all kinds, including that in talking, is injurious, and must, except for the necessary acts of defecation, &c, ,be prohibited. Convalescence. — Remembering the tendency to tuberculous dis- ease of the lungs in consequence of pneumonia, we must watch with peculiar care.the state of the pulse and the breathing, and ascertain the state of the lungs by auscultation, so as to be prompt and decided in case of any remains of crepitation, to keep the patient on a restricted regimen, and even to have recourse to leeches and cups, if local or partial (lobular) inflammation remains. Sometimes convalescence may be retarded by a passive cedema of the lungs, as it is termed by M. Andral, which follows inflamma- tion. Tonics are useful in this state; the diagnosis of which is not clear, or rather it must be reached empirically by watching the effects of treatment; for, as we learn from the same high authority just named, dyspnoea and the crepitating rhonchus, to which this form of the disease gives rise, are not sufficient to enlighten us. We are apt to be misled both during the progress of pneumonia and of many other phlegmasiae, by a persistent fulness and tension, or at least vibration of the pulse, which is due to hypertrophy, or sometimes temporary irritation of the left ventricle. *A persistence in bloodletting and analogous depletion is not called for in such a case, or at any rate after the symptoms proper to pneumonia have disappeared. I have found tincture of digitalis in small doses, five drops, or vinous tincture of colchicum, twenty drops, twice a day, with a little sweet spirits of nitre, or cream of tartar in solution, to bring down the pulse, and at the same time meet the other exigen- cies of the case, should there be any remains of pulmonic con- gestion. The means for preventing a relapse are the same as those which are prophylactic against pneumonia. They will consist in a care- ful protection of the skin by suitably warm and, what is best for this purpose, flannel and woollen clothing: nor will these be of much avail unless the chest and the shoulders up to the neck be kept uniformly covered, and the feet be protected by thick and warm shoes from cold and dampness. The neglect of a plain principle of hygiene in this respect will explain in a great degree why women and children are such sufferers from pulmonic disease, It is bad enough for mothers to be such slaves of absurd fashion in their own persons, as to expose their shoulders to the cold in the way in which they commonly do; but it is positive cruelty, whose only 266 DISEASES OF THE RESPIRATORY APPARATUS. excuse is gross ignorance, to subject their infants and other children to similar exposures. Treatment of Typhoid Pneumonia (by Dr. Stokes). — We may enumerate the principal points of difference between the treatment of the typhoid and that of the preceding variety: they are as follows:— 1st. That general bloodletting is to be used with extreme cau- tion. 2d. That the mercurial is in general to be substituted for the antimonial treatment. 3d. That counter-irritation may be employed at an earlier period. 4th. That the vital forces are to be carefully supported. 5th. That as gastro-intestinal disease frequently complicates the pneumonia, close attention must be paid to the abdominal viscera. 6th. That stimulants are to be used with greater boldness and at an earlier period. In this disease the use of the lancet is often inadmissible; I have frequently seen patients faint after the loss of four or five ounces of blood, and this has occurred without any beneficial effect on the disease. In a few cases, where the disease has occurred in the young and otherwise robust individual, I have employed the lancet with caution, but in the feebler constitution its employment seems to be both hazardous and unnecessary. Local bleeding, however, particularly with cupping-glasses, is always beneficial, and may be again and again repeated while the patient is using wine and other stimulants. Blisters should be used from an early period, and while these means are being employed, the system is, if possible, to be brought under the influence of mercury ; the patient should be in general swathed in flannel, and the warmth of his extremities carefully supported. But in many cases we must attend to the abdominal complica- tion ; and it is often advisable to apply leeches to the epigastric or ileo-coecal regions, to use poultices to the belly, emollient or anodyne injections, and, in short, to put the usual treatment of gastro-ente- ritis into full effect. In this affection great caution must be observed in the use of purgative medicines; and should the internal exhibi- tion of mercury induce diarrhoea, it is to be omitted, and inunction substituted. The remedies which I have found to answer best in the advanced stage of the disease, where the patient becomes hectic with a copious expectoration, are the decoction of senega with carbonate of am- monia, and the different preparations of bark. Of these the first has in general answered best. In this condition, however, it would be always advisable that the patient should change his air. I cannot agree (says Dr. Stokes in conclusion) with M. Louis in his opinion as to blisters, though I admit they are often unsuccess- fully and injuriously employed; but when a pneumonia has super- vened on a chronic catarrh, in the sthenic form, when the inflam- matory symptoms have been removed, and in all cases of the typhoid affection, blistering, when properly conducted, has the happiest effects. CHRONIC PNEUMONIA. 267 Chronic Pneumonia. — Considered as an original affection, there can be no doubt, says Dr. Stokes, whose account of the disease is here adopted, that simple chronic pneumonia is a rare dis- ease ; but it is difficult to define the exact meaning of the term chronic pneumonia, or to draw the line of distinction between it and that low irritation of the lung which is followed by the tuber- cular infiltration. It seems not unlikely that there are two forms of the disease: the one producing the iron-grey and indurated lung ; and the other forming, or ultimately passing into, tubercular solidity. The first we may call the simple chronic, and the second the scrofulous pneumonia ; and, perhaps, many cases of the senile phthisis may be referred to the second variety. These forms of disease differ remarkably in their liability to pro- duce suppuration. In the scrofulous affection, suppuration, though slow in its occurrence, is almost sure to supervene; while in the simple form abscess is seldom observed, the termination being in that hard and semi-cartilaginous condition—the " induration gris" of Andral. In two cases, however, I have seen a chronic abscess of the lung, without any evidence of a tubercular condition; to this I have already alluded. We must agree with Dr. Forbes, that although the essentially chronic inflammation of the lung is extremely rare, its occurrence as a sequel of the acute disease imperfectly resolved, or as compli- cating other lesions, is by no means uncommon. On these subjects you may consult the works of Laennec, Brous- sais, Chomel, Andral, Louis, and Forbes. Physical Signs of Chronic Pneumonia. — These signs, though essentially the same as in the acute disease, yet differ from them principally in the greater slowness of their changes, and in the ab- sence of the phenomena of local excitation, whether physical or vital. But it is in the occurrence of atrophy of the lung, and the con- sequent contraction of the chest, that the peculiarity of the signs of this disease is seen. It will not, however, be necessary to repeat what I have already said when describing the physical signs of pneumonia. To this brief notice of chronic pneumonia made by Dr. Stokes, I must add a caution against your having recourse with any free- dom, if at all, to direct depletion, or bloodletting. Kept up as the disease is by and at any rate often associated with phthisis pulmo- nalis, we ought to avoid all the means which would reduce the system, and particularly those which interfere with nutrition ; as they must contribute to a more rapid development of tuberculous disease. The treatment, therefore, in consonance with this view, will consist of alteratives of the narcotic class, with mild tonics, gentle aperients, and counter-irritants to the skin, together with an adherence to the hygienic rules inculcated for the prevention of acute pneumonia. This latter has a tendency to become chronic in young children.— Gerhard (op. cit.). 268 DISEASES OF THE RESPIRATORY APPARATUS. LECTURE LXX. DR. BELL. Pleurisy — Pleuritis.— Ijs forms and complications —Chief symptoms—Fe- ver, pain, difficult breathing, hard and frequent pulse, and decubitus on the back—Even the chief symptoms not always present; and they may be pre- sent without pleurisy—Structure of the pleura—Anatomical lesions—Change in the pleura itself,—in its secretion; immediate effects of this latter—Quality and changes of secreted matters—false membranes,—their characters—tuber- cles and cancerous bodies—Change in the secretion and 6tate of the lung by the effusion—Causes— Identical almost wiih those of pneumonia—Cleg- horn's description of bilious pleurisy—Physical signs;—altered conformation of the thorax, dulness on percussion,—resonance of voice in auscultation,— cegophony ;—friction sounds.—Dr. Stokes's description of dry pleurisy—Dimi- nished vibration of the parietes of the thorax—General symptoms—Fever, state of pulse, buffy and cupped blood—Progress, duration, and termination of pleurisy— Varieties—Complications—Prognosis— Typhoid Pleuritis. Pleurisy — Pleuritis (srAeug/T/s from irxng*., the side ; also the mem- brane that lines the ribs, the pleura). Pleurisy signifies inflammation of the serous membrane which lines the cavity of the chest, and invests the contained organs of respiration. The forms under which pleurisy presents are various and considerable. It may be acute or chronic; it may affect one side of the chest or both sides ; it may be general, involving the whole of one side ; or partial, only part of one side ; it may be simple or complicated: the complications may be either accidental or essential, and in the latter case the pleurisy and its complication stand to each other in the relation of effect and cause. The chief symptoms of pleurisy are, fever after a chill, with pain in the side, which is usually acute, pungent, and lancinating, as if a sharp instrument were driven into the side whenever the patient inspires. With these are associated difficulty of breathing, which is quick, short, and as if jerking ; dry cough, hard and frequent pulse, flushed face, and most generally decubitus on the back or the affected side. A few remarks will be in place on each of these leading symp- toms ; and first on the pain. Commonly pain exists from the very beginning of the disease, but it is often wandering until after the first or second day, when it becomes fixed and permanent, and also cir- cumscribed in one spot. Its seat is on a level with or just below one of the mammae at the part corresponding with the lateral at- tachments of the diaphragm; and it is thus fixed even when the inflammation pervades a much greater space, perhaps the whole of the pleura. Occasionally it is felt in the shoulders; in the hollow of the axilla, beneath the clavicle ; along the sternum, and some- times over the whole of one side of the thorax; or on a line corres- ponding with the borders of the false ribs, or of either hypochon- drium, in the epigastrium, or even in the lumbar region. In most cases the pain, after having been very acute during the first period of the disease, diminishes in violence, becomes obtuse, and may cease SYMPTOMS OF PLEURISY. 269 entirely, even before the termination of the disease. Sometimes, after having thus ceased, it returns with intensity, indicating a re- newal of the inflammation. But we may have the symptoms enumerated, and pain, also, which is one of the most constant features of pleurisy, without this disease being actually present. Sharp pains of a nervous, and still oftener of a rheumatic character, closely imitate those of pleurisy ; and if they happen to be attended with feverish excitement the re- semblance is perfect. On the other hand, even exalted sensibility of the pleura itself is not by any means a necessary accompaniment to its inflammation ; and there are cases in which there had been scarcely a suspicion of disease in the chest, and yet acute inflam- mation and its concomitant, copious effusion, had been for many days or weeks occupying the pleura. The symptoms of oppressed breathing, proceeding from the pressure of the effusion, will be dis- tinct only when the effusion has accumulated very rapidly. In this cause of embarrassment we seek to be enlightened, and gene- rally with success, by the physical signs. The breathing is commonly hurried in pleurisy. If there is no effusion this labour of respiration must proceed from the pain being opposed to the free contraction of the muscles which dilate the thorax. Effusion being present, the dyspnoea is generally propor- tionate to the quantity of the effused fluid. But even to this state of things there are marked exceptions; some persons, as we learn from Andral, with effusions, not only talk readily, but are able to walk about and perform journeys without any inconvenience on the score of respiration. The modifications in the respiratory act will depend mainly on the portion of the pleura inflamed; in costo-pulmonary pleuritis the breathing is chiefly diaphragmatic ; while in inflammation attacking the pleura which lines the dia- phragm, the thorax is chiefly dilated by the intercostal muscles. The cough characteristic of pleurisy is short, catching, as it were, dry, or accompanied with a thin mucous expectoration. The cough is not in this disease, any more than in pneumonia, in frequency or force, proportionate to either the intensity or extent of the inflam- mation. Should the sputa assume more consistence and other dif- ferent appearances, we may suspect complication, as of pneumonia and bronchitis, or, a rare case, the opening of the pleuritic effusion into the bronchia. Nothing very positive can be inferred from the decubitus, which varies in different cases ; for although in some the patient lying on his back with a slight inclination to one side, or lying on one side, may lead to a suspicion of effusion in this side; yet in a large majority of cases we find, as M. Andral has observed, that, whether there be effusion or not, the decubitus is on the back. Before I speak of the physical signs and the anatomical lesions in pleurisy, it is fitting that I should direct your attention to the pleura. The pleura consists of two layers; one distinctly serous, which is always bedewed with a serous fluid, lines the cavity of the 270 DISEASES OF THE RESPERATORY APPARATUS. chest, and forms the outer covering of its organs. The other is clearly fibrous in the costal pleura, and, together with that of the pericardium, seems to be a continuation of the deep-seated cervical fascia. Dr. Stokes has succeeded, after removing the serous coat and a part of the adherent sub-cellular tissue investing the lungs, in demonstrating the transparent though strong fibrous coat beneath. This is in direct apposition with and invests the whole of both lungs, covers a portion of the great vessels, and the pericardium seems to be but its continuation, endowed in that particular situation with a still greater degree of strength for purposes sufficiently obvious. " It covers the diaphragm, where it is more opaque, and, in con- nection with the pleura, lines the ribs, and, turning, forms the medi- astina, which thus are shown to consist of four layers—two serous, and two fibrous. "This description of the investments of the lung is interesting, in a physiological and pathological as well as an anatomical point of view. It establishes an additional analogy between the lung and the parenchymatous and glandular organs of the abdomen, which have their fibrous capsules, and illustrates the general law of the constant association of serous and fibrous membrane, as we see to occur with respect to the arachnoid, pericardium, peritoneum, tunica vaginalis testis, and the synovial capsules. Considered pathologically, it may explain the pain of pleurodyne and pleuritis, and the rarity of perforations of the pleura, so remarkable when considered in connection with the frequency of ulcerations of the lung, which constantly approach so close to the surface as to be bounded by the fibro-serous membrane alone. In pleuritis, with effusion, its existence may assist in explaining the binding down of the lung, and its corrugated appearance after the removal of the effusion ; and, as has been suggested to me, it may be the seat of ossifications of the pleura. " But notwithstanding this structure of the pulmonary tunics, we find that the pleural cavities are capable of great dilatation, and that the mediastinum is not that resisting septum which it has been supposed. On the contrary, we find it to yield rapidly to the pressure of intra-thoracic accumulations, and I have repeatedly observed this to occur long before any yielding of the muscular parietes. Hence it is that, in empyema of the left side, displace- ment of the heart occurs long before the intercostal spaces are obliterated, or the diaphragm depressed ; and that in a case of dila- tation of the cells, as I have already shown, an attack of bronchitis causes the morbid clearness to extend beyond the median line. It is not improbable, however, that the strength of the fibrous tissues varies in different individuals; indeed, with respect to the pericar- dium, the greatest difference of strength exists, for in some subjects we find it dense and opaque, while in others it is nearly transpa- rent. The greater or less extensibility of the pericardium may in- fluence the phenomena which result from sudden effusions into the sac, as in cases of rupture of the heart or aorta." In a case of the MORBID PRODUCTS IN PLEURISY. 271 latter description, with sudden death, Dr. Stokes found the pericar- dium, which had not been previously distended, containing upwards of a pound of blood. The pleura is sussceptible of inflammation of the adhesive kind, which is accompanied merely by pain; and by the pouring out of serum, coagulable lymph, pus, or blood. Anatomical Lesions. —Pleurisy gives rise to textural alterations of the pleura, to alterations in its secreting function, and to modi- fications in the condition of the lungs, such as compression, dis- placement, changes of volume, of situation, and connexions. The pleura seems to be reddened in pleurisy, but this redness isowing to the injection of varying intensity in the sub-serous cellular tissue. If the pleurisy be slight, the membrane itself preserves its transparency, and exhibits no marks of vascular ramification. Inflammation of a more intense kind, continues M. Andral (Pathologie Interne), gives rise to a vascular plexus in the serous membrane, filled with blood, and of more or less closeness and distinctness ; sometimes dotted, at other times striated, or in laminae in sinuous bands; or, a rare occurrence, the whole diseased surface is of a uniform red hue. Whatever may be the colour, or opacity, or transparence of the pleura, it is seldom thickened, softened, or ulcerated. The changes of secretion are more numerous and diversified than all its other abnormal peculiarities. According asthe secreted matter is air, or chiefly serosity or purulent fluid, it is called pneumothorax, hydrothorax, and empyema. As regards quantity, this may vary from an ounce to several pints. In the latter case, the lung is protruded from its place, and occupies less room than common; the diaphragm is pressed downwards, and causes a prominence outwards of the liver to the right and the spleen to the left: the ribs are more widely separated than in health, and the intercostal spaces more prominent; the skin of this side is also preternaturally smooth. The mediastinum is pushed to the side opposite that of the effusion; and when the effusion takes place in the left side, the heart may be pushed to the right, and its apex at the same time brought so near the sternum that its pulsations thenceforward are only heard behind the bone and in the right side of the thorax. The protrusion of the intercostal spaces and diaphragm results from a paralysed state of these expansions — in the opinion of Dr. Stokes. Effusion may take place in a few hours (Hodgkin — Morbid Anatomy of the Serous Membranes). The quality of the pleuritic secretion is various; sometimes colourless, or of a citron hue, limpid, and transparent; at times, in the midst of this limpid serosity float some albuminous flocculi; or these are partly dissolved in the serosity and impair its transparency. In some cases the fluid is turbid, or green, or yellowish-brown, or ash-coloured; sometimes thick, and, as it were, muddy. In other cases the secretion is truly purulent; or resembling on occasions half liquified animal jelly; and it may even consist of blood. 272 DISEASES OF THE RESPIRATORY APPARATUS. These liquid products of secretion from the pleura become concrete in part, and pass into a solid state ; and in this way false membranes are formed, varying, as regards organisation, in their figure, colour, extent, consistence, and thickness. The more immediate material for this membranous formation is coagulable lymph. This is at first soft, of a grayish-white colour, something like paste. It soon acquires an increase of consistence, puts on an albuminous appear- ance, and is gradually organised. Red points show themselves, few in number at first, but after a while increasing, and gradually running into lengthened lines or streaks along the surface of the ef- fused matter. These streaks soon becomedistinctly vascular, and the newly formed vessels inosculate with those of the pleura. The adhe- sions thus madeare of very different forms and sizes; being sometimes merely miliary granulations, separated from each other; atother times large concretions, of a cellular texture, and uniting the two surfaces of the pleura by various bands. The thickness of the newly formed membrane is sometimes no greater than that of the pleura itself; but more commonly it exceeds this latter : the thickness of the new formation is made, however, of several lamina? resting one upon another. Sometimes these false membranes are formed after a few days sickness; and, again, not after a period of three weeks from the invasion of the disease. As a general rule, it may be said, that coagulable or plastic lymph and early adhesion are most to be expected in young, strong, and healthy persons; while curdy and unorganised lymph, or granular deposits with permanent serous effusions, are met with in the old, the feeble, and the scrofulous. These false membranes may pass into a fibrous, cartilaginous, or even osseous tissue. Tubercles are not unfrequently met with in the inflamed pleura: in the midst of the false membrane they are quite numerous, and are evolved with great rapidity. Twice M. Andral has seen the pleura seized with cancerous bodies of considerable size. The lung which is displaced and compressed by the effusion is reduced sometimes to a very small size; and when covered with false membranes we might suppose that it had been entirely de- stroyed. On occasions, it is only a lobe that is thus displaced; and the lung itself may sometimes be pushed towards the side of the thorax backwards or laterally, in place of on the vertebral column. It is never found to crepitate: it is denser than natural, and sinks when put in water. We sometimes meet with pleuritic effusion and inflammation of the pulmonary parenchyma at the same time. The causes of pleurisy are identical for the most part with those of pneumonia; and particularly those which produce a sudden chill and stoppage of perspiration, such as atmospherical vicissitudes, cold drinks in the stomach, or the sudden application of cold to the surface of the body. Organic lesions of the lungs, as pneumonia and tuberculous disease, are frequent causes of pleurisy. But while pneumonia readily produces pleurisy, this latter is not so apt to pro- duce pneumonia. A rupture of the pulmonary vesicles which esta- PHYSICAL SIGNS IS PLEURISY. 273 blishes a communication between the cavity of the pleura and bron- chia sometimes causes partial pleurisy. A parlicular distemperature of the air will give rise to epidemic pleurisy, which generally is of a more asthenic nature than isolated or sporadic cases are. Sometimes the digestive apparatus is much more deranged at the same time, and then we have that which has been denominated bilious pleurisy. The disease described by Cleghorn (Diseases of Minorca) was most probably of this nature, unless we class it under the head of bilious pneumonia. " Those pleurisies began commonly like an ague fit, with shivering and shaking, flying pains all over the body, bilious vomitings and purgings, which were soon succeeded by quick breathing, immo- derate thirst, inward heat, headache, and other feverish symptoms. In a few hours the respiration became more difficult and laborious; the most part of the sick being seized with stitches in their sides, striking upwards to the clavicle and shoulder blade; obliquely downwards along the cartilages of the bastard ribs; or else darting across from the breast-bone to the vertebras of the back ; so that they could neither cough nor make a full inspiration without great pain. Many complained chiefly of a load and oppression in their breast, as if a millstone had been laid upon it; some of a heaviness and fluttering about the heart, which at one time seemed to glow with extraordinary heat, at another to be chilled with cold, as if it had been dipt in ice-water. In a few of the sick those complaints pre- ceded the fever, in others they did not come on till the day after. " In the progress of the disease it was not uncommon for the pains to move about in the thorax from one place to another. Sometimes they would shift from the breast to the limbs, and of a sudden re- turn to the bowels; and I have seen cases wherein, after leaving one side, they have attacked the other unexpectedly, and proved fatal in a very short time. The left side of the thorax was not near so liable to be affected as the other; forty-two out of sixty patients who were seized about the same time having had the disease in the right. But whichsoever side was affected, the sick lay easiest on the opposite; though the generality were obliged to lie upon their backs, or to sit up in bed with their heads erect. Many were drowsy and inclinable to sleep ; but they raved at intervals, or were much disturbed with extravagant dreams. Some laughed in their sleep; others would awake in a fright aud start out of bed, imagin- ing that the house was in flames ; and that those about them were endeavouring to push them over a precipice; to pierce their sides with daggers; to bind them down with cords, or iron hoops, and things of the like nature." Physical Signs. — First among these, as the sign which more obvi- ously meets the eyeof the physician,is the altered conformation of the thorax. The side in which effusion has taken place is full and more prominent than the opposite one ; but as we may be deceived in this particular, by merely looking at the chest, we ought, in order to prevent mistakes, to take the measure of the two sides, by vol. n. — 24 274 DISEASES OF THE RESPIRATORY APPARATUS. means of a ribbon, one end of which is to be held in a spinous process of the dorsal column and the other brought to the middle of the sternum. Dr. Stokes employs a pair of broad steel callipers, with a graduated arc, for the purpose. The enlargement on the diseased side is seldom more than an inch and a half. The ribs and cartilages preserve their relative position, as they would during a very full inspiration ; the intercostal spaces are increased, pro- truded beyond the ribs, and allow of a fluctuation being felt within. But there may be considerable effusion without external dilata- tion,— the space for the fluid in the chest being made at the ex- pense of the lung, which is excessively compressed and reduced to an embryo size and character, and as such is impermeable to air. When, on the other hand, the effusion is absorbed, and the lung is prevented by any cause from resuming its former expansion, the side which was before morbidly dilated is now smaller than natural, and contracted. Percussion indicates the presence of an effusion, however slight, in the thoracic cavity, by a diminished resonance on the side dis- eased. At first the dulness of sound is heard only at the lower part; but afterwards over the whole of the affected side, from the sub- spinous fossa of the scapula and the clavicle to the base of the thorax. In cases of double effusion the proper resonance of the chest is diminished or lost on both sides; and under such circum- stances, as there are no contrasted sounds between the two sides, especially if the effusion be inconsiderable, percussion may seem to indicate only a physiological state. When the effusion is circum- scribed within narrow limits, the dulness is only at one spot, and at other times it is not perceptible at all. It may happen again that, owing to the pain being so acute, percussion cannot be practised. The signs furnished by auscultation in pleurisy are generally of the most satisfactory kind, as regards the aid which they give us in forming our diagnosis. At the outset of the disease, when the pain is still very acute, but before effusion takes place, we discover, either by the ear applied to the chest or through the medium of the stethoscope, that the customary respiratory or vesicular murmur is less thancommon. This dependsonthe patient's instinctively dilating his chest less, and of course expanding less his lungs also, owing to the violence of the pain. So soon asthe effusion takes place, the respi- ratory sound is heard less distinctly than on the affected side; and in proportion as the effusion increases, the respiratory murmur becomes more and more feeble, while on the other side it acquires unusual force. If the effusion is very great, the respiratory sound is lost entirely in every part of the chest. In most cases, the lung being protruded towards the spinal column, the respiratory sound ceases progressively from below upwards, both behind and in front. A different direction given to the lung by the effused fluid, as where it is drawn against the walls of the thorax, will cause an extinction of the sound in front, but allow of its being still heard, but feebly, behind. PHYSICAL SIGNS IN PLEURISY. 075 When the effusion which extinguishes the respiratory murmur is considerable, it sometimes happens that no other sound takes its place ; but, at other times, it is replaced by bronchial respiration. The resonance of the voice is singularly modified in those per- sons whose chests are the seat of pleuritic effusion. The ear applied to the chest on the diseased side, at this time, is sensible of a quality of voice which resembles the bleating of a goat, and which, for this reason, has been called by Laennec oegophony. Often, in place of this bleating, it is a quivering, thrilling, cracked, and discor- dant sound, resembling the voice of Punch ; an apt comparison, for whoever has heard this distinguished character, and whoever has not, will hear it in perfection, be it said parenthetically, on the Mole at Naples. At other times, it seems as if the vpice passed through a tube, or it is muffled, and the articulation of each word seems to be in a peculiar whisper. In many cases these various slides of oegophony are only heard at intervals, and are only perceptible in the enunciation of certain words; even of a monosyllable, as of we, which will serve to illustrate the case referred to by Andral, who only detected this sound when his patient uttered the word oui. CEgophony is not heard when the effusion is inconsiderable; and it ceases after the effusion becomes very great. There are other sounds discovered by M. Reynaud, and further explained by Dr. Stokes, which indicate a moderate degree of lymphatic effusion. They are called the friction sounds, and are represented to be characteristic of dry pleurisy. But on this subject Dr. Stokes shall speak for himself. Dry Pleuritis — Friction Sounds. — " This term has been given to that form in which nothing is effused but lymph. The characters of the case may in general be stated to be, that the constitutional and local distress is comparatively slight, that organisation rapidly advances, that the sound is clear on percussion, — the phenomena of accumulation or displacement wanting, and the friction signs evident. " We meet with dry pleurisy under various circumstances. It may occur as an uncomplicated and original disease, or as secondary to a general morbid state, such as fever, erysipelas, or the diffuse inflammation; it may be combined with, or succeed to any of the affections of the lung, or occur as a complication of cardiac or hepatic disease. " The physical conditions of dry pleurisy, however, may be met with in two stages of the ordinary disease, namely, in the earliest periods before effusion takes place, and in the latter stages when the liquid effusion is absorbed. In the first case the duration of the friction phenomena depends on the rapidity of effusion; in the se- cond, on the vigour of the constitution which influences the process of organisation. "The characters of this friction sound are various, but in all in- stances it conveys the idea of two rough and dry surfaces moving with an interrupted motion upon each other. It accompanies the 276 DISEASES OF THE RESPIRATORY APPARATUS. inspiration and expiration, and may be absent during ordinary breathing, but become manifest on a forced expansion of the lung. In the early period of the disease pain is often felt in the situation corresponding to the phenomenon; but this soon disappears. In many instances the rubbing sensation is perceptible to the patient for a length of time, but we may repeatedly observe the sound to continue long after the patient ceases to perceive the obstruction. " The sound in the early stages of the simple disease, or imme- diately after the absorption of an empyema, is frequently accom- panied by the rubbing sensation, perceptible to the hand. Like the former sign, this may be absent during ordinary breathing, but be- come manifest when the patient inspires deeply. In the progress towards cure, this is the first of the physical signs to subside; it is obviously connected with the most unorganised condition of the effused lymph. " Although these phenomena are precisely analogous with those of the dry pericarditis, their characters are not so variable as in that affection, nor are they so speedily and curiously modified by treatment. The organisation of lymph seems to advance much more rapidly in the pericardium than the pleura. The sound, how- ever, is susceptible of certain modifications: thus, in a case of ab- sorbed empyema in a very emaciated subject, the friction sound, which existed extensively over the side, was similar to that pro- duced by the rubbing of a wet finger on a tambourine ; it was so loud as to be audible for more than a foot from the patient's chest, particularly when he sneezed, coughed, or laughed. A case has been already mentioned in which the friction phenomena existing both in the pleura and pericardium were of a distinctly metallic charac- ter, in consequence of the distension of the stomach and colon with air. (Researches on the Diagnosis of Pericarditis, Dublin Medical Journal, vol. iv.) The creaking sound, bruit de cuir neuf, is rare in pleurisy: I have only observed it in two instances; in both an effusion had been absorbed, but the phenomenon was by no means so characteristic as that in inflammation of the heart or perito- neum. " Until very lately, I had believed and taught that the friction sounds were always accompanied by clearness on percussion, or with a slightly diminished resonance, — pulmonary expansion, pure or mixed with rales, being always audible. But I have lately wit- nessed a case of empyema, in which, although great and universal dulness of the side existed, the phenomena were audible, and even perceptible to the patient in the postero-inferior and lateral por- tion of the chest. They may, then, coexist with extensive liquid effusion. This, however, must be considered as an exception to the general rule, that after the absorption of an empyema the friction sound coincides with clearness on percussion. " The duration of the friction phenomena, depending on the ab- sorption of the liquid and the rapidity of organisation, varies re- markably in different individuals: it is comparatively short in the GENERAL SYMPTOMS OF PLEURISY. 277 young and robust; while in the feeble and cachectic the phenomena may continue without changing for upwards of a month; thus, in a case of phthisis senilis, the friction sound continued for upwards of five weeks audible from the third to the seventh rib. When, however, it succeeds to the absorption of an effusion, it may con- tinue for a period varying from three days to as many weeks. In one case the phenomena continued unabated for this space of time, but on the patient being sent to the country, it at once subsided. The organisation went on rapidly on the improvement of the vital force. '• As might be expected the friction sound is generally more audi- ble over the central than either the upper or lower portions of the chest. I have never found it in the acromial or supra-spinous re- gions, but have observed it immediately below the clavicle. The case was one of aneurism of the innominata, with pleuritis of the upper portion : dissection verified the diagnosis. In a case of em- pyema, in progress of absorption, the friction phenomena existed posteriorly down to the very lowest boundary of the thorax. " The rarity of these signs in the upper portion is explicable by the less degree of motion of the pulmonary on the costal pleura. " When describing the phenomena of dilatation of the air-cells, I alluded to Laennec's opinion, that the murmur of ascent and descent proceeded from the friction of sub-pleural vesicles, and stated my reasons for agreeing with Meriadec Laennec in his dissent from this opinion ; and, without denying the possibility of its occurrence, I must observe that I never met with it in any case of Laennec's em- physema, and that in the instance recorded by Reynaud, in which the friction signs coincided with an emphysematous state of the lower lobe, in a phthisical patient, the facts are far from conclusive. " The rarity of the friction phenomena in pneumonia has been already noticed. In no case have I found them after hepatisation had formed ; and their coexistence with the crepitating rdle in the early stages is extremely rare." M. Reynaud points out another easily recognised sign of pleuritic effusion. It is the absence of vibrations of the parietes of the thorax, when the hand is placed on it, during the time in which the patient speaks. In a case in which pneumonia coexisted with pleuritic effusion, and in which, generally, the symptoms indicating paren- chymatous inflammation are generally wanting, one of these, crepi- tation, may be removed by causing the patient to lie on his face. At this time, also, the oegophony becomes bronchophony. General Symptoms. — For the most part pleurisy is accompanied by fever. In the first or acute stage, the skin is hot, and pulse is hard and frequent; indeed a tense pulse is one of the most charac- teristic symptoms of the disease. In a more advanced period, either from an abatement of the inflammation, or by the passage of the disease into a chronic state, the skin loses its heat, but the pulse re- tains its frequency with less resistance. Profuse sweating only comes on when tubercles are developed either in the pleura itself, or in the 24* 278 DISEASES OF THE RESPIRATORY APPARATUS. false membranes formed on it. When pleurisy becomes decidedly chronic, the pulse loses all its frequency, at the same time that the breathing becomes free and regular. Not, as M. Andral remarks, that the disease is cured, for the effusion still exists, as is proved both by percussion and auscultation ; but the circumstances are favourable for a cure ; showing, he adds, that the ancients were in error in supposing that fever was necessary to the resolution of chronic diseases. The blood taken from a vein, in pleurisy, is cupped, and almost always exhibits on cooling a coagulum covered with a thick buffy coat. Unless in cases of complication, such as bilious pleurisy, the digestive organs are not disordered. As happens in other phleg- masia? of the serous membranes, the secretion of urine is dimi- nished, and deviates from its natural properties. Nutrition is pro- foundly affected ; chronic pleurisy with effusion giving rise almost always to marasmus. M. Andral, to whose admirable descriptions I am so largely in- debted, in the disease now before us, as I was in pneumonia, sums up the leading features of the disease, in its different stages, under the head of progress, duration, and termination. Pain, commonly seated beneath one or other of the mamma?, pre- ceded or accompanied by fever, and a dry cough, dyspnoea, fever, and often a weaker than ordinary respiratory murmur on the side in which there is pain, are the first symptoms which indicate the invasion of pleurisy. If no effusion is formed, these disappear at the end of a few days, and the cure is complete. But if an effusion in the pleura is formed, the sound on percussion is dull and flat; the respiratory murmur, at first weak, ceases entirely, or is replaced by a bronchial breathing ; different varieties of cegophony are heard, and the parietes of the chest on the affected side offers a more or less obvious dilatation. Death may be the result of this state of things in a short period ; and it is more to be dreaded when the dyspnoea and fever are great. If these leading symptoms of py- rexia and laboured breathing are abated in violence, the disease is prolonged, and passes into a chronic state; in which case it may either end in death or restoration to health. Death is generally preceded by decay and marasmus, which are the consequence both of the imperfect hematosis, owing to the complete inertia of one of the lungs, and of the presence of inflammation with copious sup- puration and the production of accidental tissues. In other cases death takes place in consequence of the sudden return of pleurisy in an acute form, which, supervening on the chronic, proves speedily fatal. Finally, death sometimes occurs as the result of an opening between the cavity of the pleura and the external air, either by perforation through the bronchial cells or the walls of the thorax. But even under these alarming circumstances there may be a favourable issue. Critical discharges sometimes announce the ab- sorption of the effusion, such as metrorrhagia, copious sweats, or a bronchial flux. PROGNOSIS OF PLEURISY. 279 The varieties of pleurisy proceed eitherfrom the symptoms or the seat of the disease. There are pleurisies with, as there are those with- out effusion, and unaccompanied by pain, cough, dyspnoea or accel- erated pulse. There are others, again, that do not give rise to any dulness of sound, nor to any modifications of the respiratory mur- mur or of voice. Some, most, pleurisies are manifested by charac- teristic symptoms; some are latent. There are double or single, general or partial pleurisies. * When the pleurisy is interlobular, nothing is revealed by either percussion or auscultation ; although sometimes a collection of pus is found simulating pneumonic ab- scess. Dyspnoea may be evident, with slight pain; the fever is hectic, and death closes the scene. If the disease be mediaslinic, the sound is dull on striking the sternum. When it is diaphragmatic the pain is no longer referred to the thorax ; the breathing is purely costal; there is orthopnoea; the patient sits up in his bed, or leans forwards and presses on as if to support his hypochondria ; the dulness is extreme, with hiccup, nausea, and sympathetic-vomiting. If the pleurisy is on the right side there is jaundice, owing to trans- mitted irritation of the liver. This last form presents a very diffi- cult diagnosis, since it simulates hepatitis, partial peritonitis, in the hepatic region, gastritis, and finally rheumatism of the diaphragm. I had occasion, when a student in Virginia, to watch a case of this nature, in which, with all the symptoms of pleurisy, there were jaundice and irritable stomach. The subject was a young man, a farmer, of robust and strong constitution, but somewhat addicted to drinking ardent spirits. He recovered under the antiphlogistic course,— venesection, purging with calomel and appropriate adjuncts, anti- monials, and subsequently blisters. The most frequent complications with pleurisy are pneumonia, pericarditis, and pneumothorax; and, but less seldom, bronchitis, and even peritonitis. Laennec describes three varieties of the complication of pneumonia with pleurisy. The first is the ordi- nary one of pneumonia with slight dry pleuritis. In the second, inflammation of the compressed lung may occur, producing that variety of hepatization which he has denominated carnification: while in the third, severe inflammatory action affects both the pleura and lung. This, says Dr. Stokes, is by far the rarest case. Prognosis. — Pleurisy must always be regarded as a serious dis- ease ; the prognosis in which will vary, however, according to the nature and intensity of the causes, the extent of the pleuritic inflammation, and the presence or absence of effusion. Pleurisy induced by tuberculous irritation most always furnish a bad augury ; so does double pleurisy, even before effusion has taken place. The gravity of the disease will be heightened by its being seated in the diaphragmatic portion of the pleura, and, still more, by the extent of the effusion : if double, and of any extent, it is generally fatal. An effusion of pus is more sinister than one of serum ; but we have no evidence to show that blood effused gives rise to more alarming symptoms thaneitherof the fluids just mentioned. The per- 2S0 DISEASES OF THE RESPIRATORY APPARATUS. sistence of the fever and dyspnoea is always bad ; nor can we hope for absorption of the effused fluid until these two symptoms have been abated or have disappeared. Marasmus and profuse sweats must induce suspicion of tubercles in the inflamed pleura. Typhoid Pleuritis (Dr. Stokes). — A very close analogy exists between this affection and the typhoid pneumonia. Like that disease, it occurs in the debilitated or broken-down habit; or is secondary to typhus fever, or some other morbid constitutional state. Pursuing the analogy, we find that it is generally latent, and often pointed out more by sinking of the powers of life than by any new suffering; that, though forming suddenly, it is slow to be removed; that it is seldom uncomplicated, but rather one of many secondary lesions; that it is frequently combined with gastro-enteric disease; and that it does not admit of active antiphlogistic treatment. In the first part of this section 1 have enumerated the principal circumstances under which we meet with typhoid pleuritis. As a complication of essential typhus, this disease is rare. Louis (Recherches sur la Maladie connue sous les Noms de Gastro- Entente, etc., torn. ii. Paris, 1829,) found, out of fifty-seven cases, but one in which it occurred. I have seen but two well-marked examples of it. In both, the disease set in during a severe typhus, and was pointed out by sudden and unaccountable sinking. In the first case, the effusion occurred on the sixth day, and occupied a large portion of the left pleura; no .pain or distress of breathing accompanied the disease. The patient recovered from the fever, and the effusion was subsequently absorbed; his pulse, however, remained quick ; cough appeared ; and phthisis was apprehended. He was carried off by a sudden attack of encephalitis; and, on dissection, the lungs were found to contain miliary tubercle, while the left pleura was obliterated. In the second case, on the fourteenth day of a severe maculated fever, a sudden sinking was observed, and frottement discovered over the left side. On the next day, the patient, a young female, had the appearance of an individual in cholera ; she had sweated copiously, and was covered with miliary eruption; there was severe orthopncea, and she speedily sank. A double effusion had existed. The left pleura contained a large quantity of whey- coloured fluid; while in the right, the effusion was more sanguino- lent and serous. In both, lymph occurred in a reticulated form over the whole serous membrane; and also in the pericardium. Similar circumstances occur in puerperal fever. Dr. Lee men- tions three cases in which the symptoms, during life, were exceed- ingly obscure, yet where copious effusions occurred, and the pleura was covered with false membranes. In one, the pleura had given way by sloughing (Cyclopedia of Practical Medicine, article Puer- peral Fever). Similar appearances have been observed by other authors. But it is in these morbid states of the system, which may be denominated the pyogenic conditions, that we observe this disease TREATMENT OF PLEURISY. 281 most frequently. It is common in the erysipelatous diseases, par- ticularly of the low type; in purulent phlebitis, and in the diffuse inflammation. In these cases, purulent collections are commonly found in the pleura, although, during life, symptoms of pleurisy were either absent or very slightly marked. In a few instances, however, I have observed the invasion of the disease to be accom- panied by severe pain. There is an affection which may be termed typhoid arthritis, in which this secondary pleuritis is liable to occur. The late Dr. M'Dowel was, I believe, says Dr. Stokes, the first to describe this disease, of which the principal characters are, the rapid tumefaction and suppuration of many of the larger joints, accompanied with a typhoid fever, and followed by affections of the brain, lungs, heart, or digestive system. In such instances, I have more than once ob- served purulent collections in the pleura, lung, and perjcardium. On this subject, Dr. M'Dowel's important papers, in the third and fourth volumes of the Dublin Journal of Medical Science ought to be consulted. LECTURE LXXI. DR. BELL. Treatment of Pleurisy—Bloodletting by venesection the first and chief remedy —In feeble habits and in advanced stages, cupping or leeching—Calomel fol- lowed by saline purgatives—Tartar emetic—Opium in full doses after venesec- tion—Blister to the side—Purging most useful in complicated and epidemic pleurisies—Diuretics; nitre, digitalis, colchicum—Calomel with nitre and a little opium.— Treatment of Xub-acuto and Chronic Pleurisy (Dr. Stokes)— Confinement of the patient to bed—Leeches to the affected side—S.nail blis- ters—Diuretics—Iodine—Diet at first simple, afterwards more nourishing— Morbid action of the heart; remedies for—Country air—Deformity; remedies for —Operation for empyema.—Chronic Uncircumscribed Pleurisy with Effusion {Dr. Stokes)—Symptoms—Physical signs of great importance—Decubitus— Effects of changes of* position.—Contraction of the Chest—Recovery of natural size sometimes rapid—One of the first signs—Differential Diagnosis.—Pneu- mothorax—Causes, symptoms, and treatment.—Hydrothorax, its causes, symptoms, and treatment. Treatment. — Universal experience, I believe I may say, is in favour of early and large bleeding in sthenic or sporadic pleurisy. The sooner after the invasion of the disease we bleed, and the more copious the depletion, the greater will be the probability of early convalescence. It would avail little were I to pretend to specify the quantity of blood to be taken from a vein on this occasion. You must be regulated by the violence of the symptoms, and the relief afforded. The pulse, which is generally frequent, hard, and resist- ing, ought to be abated in these particulars, especially in the quality of hardness or tension, by the abstraction of blood ; but the state of the heart will cause modifications in this respect, and the pulse is less our guide than the dyspnoea and pain, in the freedom with which we are to bleed in pleurisy. As a general rule, the blood ought to be 2S2 DISEASES OF THE RESPIRATORY APPARATUS. allowed to flow until the patient can make a full inspiration without catch or pain. The repetition of venesection will be regulated by the renewal of the pain and dyspnoea, more than by the febrile symptoms. As regards mere frequency of pulse, it is of little mo- ment in the case before us; it can never alone indicate the pro- priety of depletion. Indeed, it will rather indicate a fear of this having been pushed too far. It is desirable that, within the first twenty-four hours, an abiding impression should be produced on the inflammation ; and hence, if the first symptoms return in even a few hours after the bloodletting, you should repeat the operation. As our object is not simply to weaken the heart's action, but to abstract a considerable amount of blood, and withdraw in this way the ma- terial of vascular excitement and engorgement, the patient need not be invited to sit up ; but he should be bled lying down, so that there will be less probability of the coming on of syncope to interfere with the free flow of blood. In weak habits of body, either from original constitution or excesses, although the phlogosis of the pleura be intense, and will, if not checked, be followed by the changes already described, yet we cannot continue to abstract the desired amount of blood, with- out weakening beyond measure the heart's action, and inducing a degree of prostration, which, if it do not actually endanger the patient's life, would prolong excessively the convalesence. We are fain, in such cases, to accomplish our end by free cupping or leech- ing over the seat of pain. In general you will not have the choice in the country, but must be content with cupping. After this is over, a large warm poultice should be applied and covered with flannel. Adjuvants to bloodletting.are indirect evacuants, such as purga- tives and diuretics. The former will consist of salines with anti- monials, so as to produce large evacuations, and thus diminish the quantity of the circulating fluid. Preceding these, a full dose of calomel will be of service, both as itself an evacuant, but still more, from its revulsive operation on the liver and gastro-intestinal folli- cles, and its decidedly sedative impression. Its continuance will be under the same belief, and not in reference to what the English writers persist in regarding its specific, that is, its sialogogue operation, or at any rate the production of a slight soreness and inflammation of the mucous membrane of the mouth and throat. Tartar emetic as a counter-stimulant does not stand as high in the estimation of British practitioners in pleurisy, as it does in pneumonia and bronchitis. My own experience leads me to a different opinion. I have, in some of the milder but yet well-marked cases of pleurisy, trusted almost entirely to tartar emetic, either mixed with cream of tartar in powder, or dissolved with it in water. Opium may be given with more freedom in pleurisy, as it may of phlegmasia of the serous or sero-fibrous membranes gene- rally, than in those of parenchymas and mucous membranes, with whose secretory function it is more apt to interfere unseasonably at this time. A full, or rather a large dose of opium, two to three TREATMENT OF PLEURISY. 283 grains, maybe given at once after a large bleeding, and the patient be left undisturbed by the administration of any other medicine for the next twelve hours. Pain or stitch in the side still remaining after the subsidence of fever will be met by leeches to the part; or if full venesection has been previously practised, a blister. More especially is this remedy useful when effusion is about to take place: it has been known to arrest this latter, and in other respects to exert a most salutary effect on the progress of the disease. The blister should be large, and allowed to remain on only until the skin be vesicated: with this view about eight hours will commonly suffice. It is not neces- sary that the cuticle be raised with serum to any extent; for if at all separated from the cuticle beneath, it will soon rise into large serous bags after the application of simple cerate or of basilicon ointment. Once discharging, this effect ought to be continued ; first by the dressings just mentioned, or if there be much cutaneous sensibility, by a large poultice of flaxseed meal, or of bread and milk, between two pieces of muslin, and afterwards by the occa- sional application of weak blistering or tartar emetic ointment. The latter is preferable, if the disease assume somewhat of a chronic form. Purging was thought by many of the older writers to be preju- dicial in pleurisy; nor was the opinion without foundation, for the necessary interruption to the respiratory movements during defeca- tion, the occasional straining at the time, must operate prejudicially. These objections, however, were derived chiefly from a belief that diarrhoea or natural purgation, when it occurred spontaneously, was injurious, and that intestinal evacuation interfered with the crisis by expectoration. In complicated pleurisy, or in that of an epidemic and, as it will be found generally, of a mixed character, purgatives, with calomel for their basis, are of unquestionable effi- cacy ,'and must often take the place of bloodletting. Diuretics have acquired more reputation in the cure of pleurisy than purgatives. The antiphlogistic action of many of them, apart from the amount of renal secretion, will go far to explain their superiority in this particular. Nitre may be mentioned as displaying these two effects in a notable degree. Its operation is made more efficient by free dilution ; in fact, by its being dissolved in the patient's drink. I have at other times generally added to it tartar emetic, as in the following prescription: — R. Nitrat. potass., Jiss. Potass, tart, antim., gr. i. Aqua fluvialis, "f iv. M. ft. solutio, et adde, Lin. sem. infus., "jfxii. M. Sum. seger, pro haustu. Of this half of a large teacupful, sweetened and flavoured with lemon- juice, if required, will be taken by the patient at intervals of an hour 2S4 DISEASES OF THE RESPIRATORY APPARATUS. or two through the day. If the inflammation run high, two or three grains of tartar emetic may be directed, and the quantity of the nitre increased to two drachms, or even half an ounce, in the twenty-four hours, suitably diluted in a mucilaginous vehicle. Mucilage or syrup of gum-arabic may be substituted for the flaxseed tea, in the pre- scription which I have just given you, if required by the palate of the patient. It is not uncommon for vomiting to follow the first dose or two of this mixture, but I have seen no disadvantage from this, although it is deprecated by many writers, and is made a ground of objection to the contraslimulant use of tartar emetic in pleurisy. Other diuretics of the sedative class will be had recourse to in pleurisy, more particularly when it assumes the subacute or chronic form. Of these, digitalis and colchicum are entitled to our chief confidence; the first in infusion or tincture; the second in vinous tincture of the seeds. Laennec speaks highly of the infusion of digitalis. Calomel in small doses is often one of our best diuretics, and the more so when combined with squills, and opium enough to make the combination sit well on the stomach. Treatment of Sub-acute and Chronic Pleurisy (Dr. Stokes).— Here, again, I shall be content with placing before you all the views and practice of Dr. Stokes, in his own language, on these forms of pleurisy, including empyema. The physician will be frequently consulted by patients labouring under empyema of some standing. There is but little constitutional distress; yet the pulse is quick; the breathing hurried ; and emaciation is going on. One side is found dull and dilated; the heart is displaced; and the respiration puerile in the opposite lung. In such cases, a cure may be effected by the following treatment: — The patient must be confined to bed, and there remain for several weeks; this is a most important condition. His diet, for the first fortnight or three weeks, must be of milk, farinaceous substances, and vegetables. The bowels having been freely evacuated, an accurate measurement of the chest, above and below the mamma, is to be recorded ; and the situation of the heart and extent of dul- ness carefully noted. Leeches are now to be applied to the affected side, even though the case be chronic, and no pain whatever exists. From six to eight will be sufficient at each application, which may be repeated every day or second day, for the first week; during which time mild mercurials are to be steadily exhibited, till a slight but decided ptyalism is induced. After the first week, we may begin with small blisters, which are to be covered with silver paper, and applied repeatedly over various portions of the affected side. At the end of a week or fortnight, we shall often find that the line of dulness is subsiding, and that the heart has returned to its natural position. In some cases, however, even after ptyalism, there is no change in the physical signs; but the patient, notwith- standing, feels a degree of relief which cannot be explained by the diminution of the effusion. TREATMENT OF PLEURISY. 285 We are now (if fever be absent, and the pulse quiet) to slightly improve the patient's diet: we may allow light broths, fresh eggs, or perhaps a little chicken ; and with this change in regimen, we are to resort to diuretics, the success of which seems wholly to de- pend on our having, by the early treatment, subdued all inflamma- tory action in the pleura. For diuretics, the infusions of juniper or pyrola umbellata, com- bined with acetate and nitrate of potassa; the preparations of digi- talis, and the spirit of nitrous ether may be employed. But, in this stage, the remedy on which I have the greatest reliance is iodine, employed internally and externally; a pint of Lugol's mineral water may be taken during the day, and from two drams to half an ounce of the ointment, rubbed daily over the side. The effect of this treatment in promoting absorption is sometimes singularly rapid. The medicine generally acts as a powerful diuretic, and is to be continued until all liquid is removed from the pleura, as shown by the returning clearness and the fric- tion signs. In a few cases the heart continues to act too strongly after the absorption. For this the best treatment will be the application of a blister and the exhibition of the medicinal hydrocyanic acid, or digitalis, followed by the application of a large belladonna plaster; and the patient, for some time, must avoid all unnecessary muscular exertions. After the absorption of the fluid, it will be always right that the patient should go to the country; or if there already, that he should change his air. Nothing so distinctly promotes the organisation of the false membranes as this. I have now seen twenty cases of complete and permanent re- covery from empyema by absorption. In two, the effusion was com- paratively recent, of not more than a few weeks'standing. In one recovery took place, apparently from the patient being sent to the country; but in the remaining twelve, paralysis of the intercostals had occurred, and, in the majority, the heart was greatly displaced. The treatment, as above, was pursued with scarcely any variation in them all, and with a success truly gratifying. In several of these cases the constitutions were decidedly scrofulous, and in these the convalescence was for a time doubtful. In such cases, I would always recommend the use of the issue, and that the patient should pass the winter in some mild and sheltered situation. In most of these cases the patients were under thirty years of age; in three, below ten. In one, which I saw along with my friend, Dr. Beatty, the disease occurred during pregnancy ; yet the lady bore the treatment well, and was delivered of a healthy child at the usual time, and has since remained well. Should deformity occur we may hope for its diminution by time. Carefully regulated gymnastic exercises might also be employed, and perhaps electricity, to restore the tone of the intercostal muscles. vol. n. — 25 286 DISEASES OF THE RESPIRATORY APPARATUS. From these facts we may safely conclude, in opposition to the experience of Willis, Broussais, and Laennec, that the probability of a cure and the efficacy of remedies is much greater than has been supposed. Willis, in his book De Empyemate, says: "In tali casu pharmacia haud multum opus erit, sed tantum corpore preparatur illuc ad lateris apertionem procedatur. Operation for Empyema. — The results of the operation in em- pyema are anything but encouraging. This can be understood when we reflect on the following circumstances: — First. From the nature of an important operation and the dread which it inspires it is neither proposed nor submitted to unless as a last resource; or, in other words, when there is the least chance of success. This is not giving surgery fair play; all other means have failed, and this very failure shows an unfit state of the consti- tution. The disease has lasted for a length of time, the lung is compressed, atrophied, or bound down by adhesions, so that it can- not again fill the chest, and, in consequence, the operation only substitutes a pneumothorax for an empyema. (Dr. Townsend's Essay, op. cit.) In the next place, and from the same circumstance of chronicity, there is, as we have seen, a probability that tubercle of the lung is forming, and the operation is often performed while phthisis is advancing. Thirdly. Gangrene of the pleura not unfrequently follows the operation: supposing that this arises from the introduction of air, M. Roux injects water, so as to nearly occupy the space of the fluid withdrawn. Fourthly, and lastly. It will be found that in a very large pro- portion of cases operated on, the sound of fluctuation ivas heard, proving that air, as well as fluid, existed in the cavity. These are not cases for operation ; for although there is the possibility of air and liquid coexisting without a pulmonary fistula, yet it is certain that this occurs in the vast majority of cases. The existence of the fistula, alone, is a powerful argument against operation, as it so materially interferes with the reexpansion of the lung; but when we reflect that this fistula implies disease of the lung, and that this, in almost every case, is tuberculous ulceration, we can easily under- stand the failure of the operation. But that, when performed with judgment, the operation has often succeeded, there can be no doubt. The cases which seem to de- mand it are those where a rapid acute effusion, threatening life, occurs; and next, chronic cases which resist treatment, such as I have described. But even in these cases, so long as life is not threatened, it seems much better not to operate, but rather give the patient the chance of the ultimate absorption of the fluid. That many of my cases would have been operated on by others, I have no doubt whatever. I shall not enter here into the history of the operation, but refer with pleasure to the learned and complete essay on this subject by my friend, Dr. Townsend, which gives the OPERATION FOR EMPYEMA. 287 accurate statement of our knowledge of the whole subject. See the Cyclopaedia of Practical Medicine, article Empyema ; also the Essay of Dr. Hastings, before quoted; and a note by the editors of the Cyclopaedia, with reference to the experience of Dr. Davies which is favourable to the operation. Dr. Williams's and Dr. Davies's works must also be referred to. I shall here merely remark, that I altogether agree with this ex- cellent observer in his views as to the place of election in operating. He advises that the incision should be made higher up than is re- commended — in the fifth rather than the seventh intercostal space. The lower situation was chosen by surgeons in order to facilitate the escape of the matter ; but this was, perhaps, an erroneous view, for there may be a favourable evacuation of the fluid from any part of the chest. In most of the cases of "empyema of necessity" which I have seen, the tumour formed in the third or fourth inter- costal space, near the sternum, and the operation was successful. I have seen a case with my friend, Dr. Houston, where the tumour formed immediately under the clavicle; the result was favourable. And in another instance, in the same gentleman's experience, the empyema opened above the clavicle; of this, several instances are recorded. Nature thus seems to point out, that the opening should be high up ; and when we reflect on the danger of wounding the diaphragm, as in the cases recorded by Laennec, La Motte, and Solingen, we must prefer the higher opening. In Laennec's case, although the incision was made between the fifth and sixth ribs, the diaphragm was transfixed. I have seen an instance of the same kind; the particulars are as follows: — In the case of empyema from gunshot wound, which I have already mentioned, the patient, from intense pain of the side, which never intermitted, kept himself constantly bent on the affected side ; in consequence, the side was contracted, although with acute empyema. The operation, however, was performed in the usual place, between the sixth and seventh ribs, but no fluid escaped. On the finger being introduced, the sensation of a bag of liquid was conveyed ; and it was obvious that the knife had penetrated below the diaphragm. A trocar was now thrust upwards, which perforated the diaphragm, when a little sero-purulent fluid escaped, without any relief; the patient soon afterwards sank. It was found, on dissection, that the kidney had been wounded deeply in its upper portion ; upwards of a pound of blood was effused into the surrounding cellular tissue; and the perforation of the diaphragm by the trocar was easily demonstrated. The orifice seemed to have been closed by the coagulable lymph. The mode of operation, by the repeated removal of small quan- tities of fluid, as recommended by Morand, should in all cases be preferred; but particularly in the chronic effusions, where the lung has been long compressed, and probably atrophied. Time must be given for its gradual development, for the restoration of its circula- tion and permeability, and for the return of innervation to the inter- 288 DISEASES OF THE RESPIRATORY APPARATUS. costals and diaphragm. The necessity for this mode of operation will be of course greater where the fluid is purulent than in the serous effusions. Indeed, in chronic cases I would recommend that not more than a few ounces of fluid should be withdrawn at each operation. See Morand, Memoires de VAcademic de Chirur- gie; also, Boyer, TraiU des Maladies Chirurgicales, who gives a case remarkably illustrative of the danger of complete evacuation. Chronic uncircumscribed Pleurisy, with Effusion (Dr. Stokes).— On this subject I shall let Dr. Stokes speak. To this condition, whether supervening on an acute and violent attack, or from the first with sub-acute symptoms, the name of empyema has been long given. And although the composition of the fluid effused is often different from that of pus, it being sometimes bloody or serous, yet the term is applied conventionally to these as well as to the purulent effusions. Chronic effusion, compressing the lung and displacing the medi- astinum, may exist with or without distressing constitutional symp- toms. In the first case, if we separate the physical signs, we find nothing characteristic in the symptoms alone ; hectic may or may not be present; and no characters of the cough, expectoration, re- spiration, decubitus, or with a single exception, the appearance of the patient, are sufficient to distinguish this from other diseases of the lung. The exception alluded to, is the dilatation of the side and intercostal spaces— a subject which we shall just now handle. But if, in addition to the symptoms of pulmonary irritation and obstruction, as shown by cough, dyspnoea, increased by exertion, and by lying on the healthy side, and a sense of fulness and oppression referred to one side, which is often oedematous, we find the physical signs of accumulation, compression, displacement, and paralysis of the thoracic muscles, we may safely diagnosticate the disease in question. In certain instances, however, the symptoms are all but wanting. I have repeatedly known, says Dr. Stokes, persons with copious effu- sions to look well; to be free from fever, pain, or any local distress; to lie equally well on both sides ; to have good appetites, which they could indulge without apparent injury ; and all this when the heart was pulsating to the right of the sternum. Thus it appears that, in both classes of cases, the physical signs are of the last importance. Indeed, in pleuritic effusion, physical signs have greater value than in any other thoracic disease. Most cases of bronchitis, of pneumonia, and of phthisis, can be at least re- cognised without these aids: but such is not the case in pleurisy; and it is fortunate that its physical signs are more simple, numer- ous, and striking, than those of any other of the uncomplicated dis- eases of the lung. In the failure of the attempt to found any differential diagnosis on the symptoms of chronic pleurisy, considered apart from phy- sical signs, we must study the latter with care, and the more so, as the statements on empyema contained in surgical books are exceed- CHRONIC PLEURISY, WITH EFFUSION. 289 ingly loose and insufficient. Before entering on the signs, however, we shall recur to the subject of decubitus on the affected side. As a symptom of copious effusion, we meet with it more fre- quently in the chronic cases; yet even here it is often absent. As a sign, it is anything but pathognomonic ; as a constant symptom, I have only observed it in extreme cases, and where the mediasti- num and diaphragm were extensively displaced. Facts are still wanting to clear up the cause of this symptom. Richerand, believ- ing that the mediastinum was a strongly resisting septum, denied the doctrine of Le Dran, that the difficulty of lying on the healthy side arose from the pressure of the superincumbent fluid, and attri- buted it solely to the obstruction to dilatation of the healthy side, in consequence of its being placed undermost. But the extensibility of the mediastinum cannot be denied. The fact, which I have often observed, of displacement of the heart be- fore that of the intercostals, or diaphragm, is sufficient. On this point, Dr. Townsend observes, that in cases of pneumothorax with empyema, we have direct proof of the influence of the weight of the fluid. " The patient can generally lie on the sound side so long as the effusion is principally gaseous; but as the proportion of ponderable fluid increases, decumbiture on the sound side becomes impossible. In like manner, in cases of empyema, the dyspnoea is in general greatly aggravated by lying on the sound side; but when the fluid is evacuated, the patient is immediately enabled to turn on the sound side, although the necessity for its free dilatation continues as great as before, the diseased being still in a state of perfect inac- tion. In the case of pneumothorax with empyema, related in the fifth volume of the Dublin Transactions, in which the operation of paracentesis was performed, the patient was enabled to lie on the sound side the night after the fluid was drawn off, though it was ascertained by auscultation that the side was then filled with air, and the necessity for the free dilatation of the sound side conse- quently as great as before the operation. " These observations render it probable that the difficulty of lying on the sound side arises from the load which is thereby thrown on the mediastinum, as well as from the obstruction which the muscles of inspiration experience when the side which they have to dilate is placed under the weight of the body. To avoid this inconvenience, patients labouring under effusion into the chest generally lie on the diseased side, or else on the back, with a slight inclination of the body towards that side. This latter position is the more general of the two, and is so very characteristic, as to lead, in some cases, to a suspicion of the disease, even before any further examination has been made. This position, however, is not so constantly observed, but that we meet with frequent devia- tions from it. When the fever has completely subsided, and the- thoracic viscera have become habituated to the pressure of the effu- 25* 290 DISEASES OF THE RESPIRATORY APPARATUS. sion, the patient can sometimes lie indifferently on his back, or on either side; and there are even some cases on record where the patient lay constantly on the sound side. J. F. Isenflamm relates a remarkable case of this kind, in which a patient, presenting all the usual symptoms of empyema, lay generally on the right side, which, for this reason, was supposed to be the seat of the disease; accordingly, the operation was performed, but no pus was found. (Versuche einer Praklischen Abhandlung ueber die Knochen. Er- langen, 1782.) The patient died; and on dissection it was disco- vered that the left side was the seat of the empyema. Morgagni relates a case of this kind, on the authority of Valsalva : and M. Baffos records another instance. (Dissertation Inaugurale sur VEmpyeme. Paris, 1814.) These, however, may be considered as exceptions to a general rule, and probably depend on some adhe- sions which confine the effusion, and prevent its gravitating to the) most dependent part of the chest. (See Dr. Townsend's Essay on Empyema, Cyclopaedia of Practical Medicine.) There seems, continues Dr. Stokes, reason for admitting both the explanations of Richerand and Le Dran, as adopted by Dr. Town- send ; for, although the decubitus on one side interferes less with respiration of the corresponding lung than we would, a priori, sup- pose, yet it has some effect; and, on the other hand, it is easy to conceive a case in which the fluid, by lying on the mediastinum, would, by its weight, oppress the heart and affected lung. In an extreme case, however, where the pleural sac was at its maxi- mum of distention, it seems possible, if the patient had become habituated to the new condition of the mediastinum, that decubitus on the healthy side would not cause so much distress as in cases with less effusion. But there is another cause as yet unnoticed, namely, the effect of change of position on the abdominal viscera. In a case with protrusion of either ala of the diaphragm, the turning on the healthy side would, by increasing the pressure on the abdominal viscera, impede the descent of the opposite portion of the muscle, and con- sequently produce distress of breathing. It would have the same effect as we see from accumulations in the bowels, or from exter- nal pressure, as accurately observed by Dr. Townsend, who, in testing the statements of Bichat and Roux, that pressure on the side of the abdomen corresponding to the effusion caused extreme dis- tress, by forcing up the fluid, and increasing its pressure on the lung, found that the very reverse was the fact; for, while no unea- siness was produced by pressing up the diaphragm on the side where the effusion existed, any attempt to stop the motion of the opposite ala of the muscle caused extreme and immediate distress. (Cyclopaedia of Practical Medicine, article Empyema; also, Profes- ser Chomel, Dictionnaire de Medecine, article Pleurisie.) This emi- nent and accurate observer's experience coincides with that of Dr. Townsend. PLEURISY —CONTRACTION OF THE CHEST. 291 Considering the great weight and mobility of the liver, we should expect that, in empyema of the right side, there would be greater distress from the cause now pointed out than in the opposite case. Contraction of the Chest. — I have known, says Dr. Stokes, for it is still he who addresses us, many cases of pleurisy to recover, without contraction of the side, or depression of the shoulder: these were cases of sub-acute inflammation, or where the effu- sion had been rapidly removed. In other instances the contrac- tion has been confined solely to the lower portion of the chest, while the shoulder was not depressed: and in several, where the disease occurred in young persons, the deformity was either re- moved in process of time, or so.much diminished as to be scarcely perceptible. I have had no experience as to the connection of this termination with the hemorrhagic pleurisy, on which Laennec has dwelt so strongly ; on the contrary, it appears to me, that the more violent the inflammation, the greater is the probability that contrac- tion will accompany the cure, and it seems likely that the paralysis of the intercostals and diaphragm, by interfering with the expan- sion of the side, has an immediate effect in producing this result. We must agree with Dr. Forbes, that this deformity is not the con- sequence of hemorrhagic pleurisy exclusively; but that it is a common termination after the removal of purulent effusions, whe- ther by absorption or operation. And if other evidence were want- ing, we have it in the analogous contraction in chronic pneumonia and phthisis. See his original cases for two instances of contracted chest. Dr. Forbes refers to Dr. Hastings' valuable paper on Em- pyema, Edinburgh Journal of Medical Science, No. 1 ; to cases by Baron Larrey, Journal Comp. de Sc. Med. 1820 ; and to Mr. Jowell's case, Med. Chir. Rev. 1826; in which, as I have observed, the contraction was partially removed in the progress of cure. The return of dilated side to its natural circumference is some- times exceedingly rapid. I have known a dilated side to lose as much as an inch and a half in eight days. In some, the contrac- tion is shown merely by the flattening of the anterior portion, causing visible deformity, yet with but little alteration of size. In others, the affected side becomes of a triangular form, the base of the triangle corresponding to the median line, and the apex to the centre of the ribs. Even this condition, when occurring in the young person, may be much improved by time. One of the first signs of the absorption, with contraction, is the increased prominence of the inferior angle of the scapula. I have known the dulness consequent on the cure of a former pleurisy to be mistaken for that of recent hepatisation. Fever, with slight bronchitis, had supervened. The dulness was dis- covered, and no farther examination, either into the history or accompanying signs, being made, the most improper treatment was pursued. But contraction of the chest, in connection with empyema, may occur under circumstances very different from those described by 292 DISEASES OF THE RESPIRATORY APPARATUS. Laennec and subsequent authors. It may coincide uith an in- creasing empyema, and occur at a very early period of the case. This interesting circumstance I have known to occur in two cases. In both, pleuritis with effusion followed on injury, and long after the effusion there was exquisite pain whenever the patient attempted to expand the side. In one case, the patient, up to the period of death, kept himself strongly bent on the affected side ; so that the case presented the singular combination of a vast empyema, with extreme contraction of the affected side. Differential Diagnosis.—The diseases with which a pleuritic effusion is commonly confounded, are the following: — 1st. Tubercle of the lung. 2d. Pneumonia, in the stage of hepatisation. 3d. Enlargement of the liver. Nothing is more common than the error of taking cases of pleu- ritic effusion for pulmonary tubercle. The patient may recover, or die of tubercle, consecutive to the absorption of the empyema. In the first case, the physician felicitates himself on the cure of a consumption ; in the next, on the accuracy of his diagnosis. In both instances he is mistaken. The cases generally mistaken for phthisis, are of two kinds: there is either a circumscribed and chronic effusion, which may exist without much eccentric displacement ; or there may be a copious sub-acute effusion compressing the lung, and occurring in the lymphatic subject. In the first case, we generally find that the health does not suffer in proportion to the extent of disease, as indicated by the stetho- scope. The dulness is complete, as is also the absence of rdle, and often of respiration; and when these signs occur in the lower por- tion of the chest, we have a group of circumstances quite unlike the phenomena of phthisis. I have seen several examples of the second case. A child, of a lymphatic temperament, is attacked with pain of the side, fever, and cough. Phthisis is apprehended, and, after a fortnight or three weeks, the whole side is discovered to be dull, and tubercle is dia- gnosticated with mistaken certainty. The following circumstances should correct this error: — 1st. The absence of the usual constitutional suffering, in cases of acute phthisis. 2d. The fact of complete dulness of the side occurring in so short a time. 3d. The lung being impermeable except, perhaps, in the upper portion, where a feeble murmur without rdle can be heard. 4th. The signs of mediastinal displacement. In the sub-acute cases, the signs of diaphragmatic or intercostal displacement are often wanting. Pneumothorax (from »-v«u,u*, a-roc fl»g*£), Air in the Pleura. — This morbid state may occur in three different ways:— 1. It may be the DIAGNOSIS OF PNEUMOTHORAX. 293 consequence of partial pleurisy, the effusion in which being absorbed leaves a void which is sometimes filled with air secreted by the membranes. This kind is very rare. 2. Pneumothorax of an idiopathic kind arises from the effusion or secretion of air into the sac of the pleura without perforation, in a manner analogous to the secretion of air from the peritoneum, constituting tympanitis. This is, also, an unusual occurrence. 3. The most common kind of pneumothorax is that caused by some unnatural communication between the pleural sac and the external air; and this may be by a perforation either of the external parietes or of the pulmo- nary pleura. The latter is the now usually recognised kind of •pneumothorax, and constitutes a great majority of the cases met with in practice. The perforation depends on the progress of ulceration, which is generally of a tuberculous character, and, but rarely, of gangrenous abscess, through the pleura. The causes of pneumothorax are detailed by M. Andral (op. cit.). Its idiopathic origin is rare. Most commonly (if we except trauma- tic pneumothorax, or that proceeding from a penetrating wound of the thorax and costal pleura) the cause is external to the cavity of the pleura, and consists in a pulmonary lesion. Sometimes it is owing to a fistula which opens a communication between a tuber- culous cavity and the pleura; sometimes an abscess, the conse- quence of pneumonia, opening in the pluera; pulmonary apoplexy destroying the lung and the pleura; a cancerous ulcer of the lungs, or, as M. Andral has twice seen it, a simultaneous rupture of some of the pulmonary vesicles and the pleura. Symptoms.— These consist in —1. A dyspnoea of greater or less severity, according to the quantity of gas, and the rapidity with which it is formed. 2. A convexity of the thorax ; but this is not a constant symptom. 3. An unusual sonorousness, on percussion, through the whole extent of the diseased side, or only at the upper region, for, lower down, a dull sound indicates a liquid effusion. 4. The absence of the respiratory sound, coinciding with the sono- rousness. 5. Sometimes an amphoric or cavernous respiration. 6. If there are air and liquid effused, a gurgling, at first not very sensible, but augmenting each day, in the inverse proportion of the amphoric respiration arid the sonorousness. 7. A metallic tinkling, the cause of which is not hitherto known. 8. If there be at the same time liquid effused, succussion causes a noise of displacement, or a splash of the liquid against the walls of the chest. The diagnosis is well summed up, in its main features, by Dr. Houghton (Cyclop, of Pract. Med.). 1. The sensation of something giving way in the chest, and of air entering the pleural cavity. Very variable, but often absent or unnoticed. 2. In a phthisical individual the sudden supervention of over- whelming dyspnoea and pain. Rarely absent, therefore very valuable ; still more so if succeeding last sign. 3. Comparison of auscultation and percussion. Nullity of respi- 294 DISEASES OF THE RESPIRATORY APPARATUS. ration over one side, together with tympanitic clearness of sound, which below terminates abruptly in complete dulness. If accurately established, amounting to positive certainty, but sometimes not easy to establish. CEgophony rare. 4. Fluctuation on succussion. Positive certainty, but should be unquestionably verified. 5. Metallic tinkling. Positive certainly, but should be unques- tionably verified. This metallic tinkling is audible during coughing, speaking, and sometimes during respiration, or, more correctly ex- pressed, after these movements. Besides this, adds Dr. Houghton, it is often heard independently of these, observing a certain perio- dicity, and finer in its tone. The duration of pneumothorax may be from a period of a few hours ending in death, or it may extend to several days, and even more than a month. Its termination may be favourable, and brought about by the absorption of the effused air; but most generally death is the result. The treatment of pneumothorax promises but little more than merely to palliate some of the worst symptoms, by the alleviation of pain, and making the respiration somewhat easier. Its first and sudden occurrence, causing, as it does often, great prostration and irritating cough, may require a full dose of opium combined with antimony or calomel. Subsequent reaction with fever will be treated by venesection, if the patient be not much reduced by long prior disease; and in other cases by leeches or cups to the chest. In fact, as perforation of the pleura and consequent pneumothorax are, in the larger number of cases, additions to a previously existing disease, such as phthisis, the treatment must necessarily be modified not a little by the stage of the chief and primary diseases, and the remedies which have been employed or were in use at the time. Blistering and other means of counter-irritation will generally be allowable in the emergency. The immediate indication, where, in consequence of the smallness of the perforation or its valvular condition, air accumulates in the chest and becomes a cause of oppressive dyspnoea,is, as Dr. Williams justly observes, to give vent to the. air by puncturing the chest. Temporary relief has been afforded in several instances by this means; but before this operation is performed, it should be con- sidered whether, as it can give only temporary relief, the condition of the patient be such as to make this likely to outweigh the pain and risk of the operation. These certainly are not great, but when added to the dubious view in which the friends of the patient may regard an operation which proves but imperfectly successful, they are enough to deter us from the responsibility of recommending it in many cases. The circumstances are different when the accident occurs before the consumptive disease has advanced far, when there is still much flesh and strength, and the physical signs have shown that there is a considerable quantity of sound lung. The TREATMENT OF PNEUMOTHORAX. 295 operation may be repeated if the air accumulate again. As it is impossible to avoid the continued introduction of air into the chest, the mode of performing the operation is a matter of much less con- sequence than in empyema. It is more desirable to puncture low down in the chest, to permit the discharge of the liquid as well as the air. The following case, recorded by Dr. Stokes in the work so often borrowed from in these lectures on the diseases of the respiratory apparatus, will be to you a good clinical lesson : — Gangrene of the lung, empyema, and pneumothorax—Paracentesis—Gangrenous destruction of the costal pleura—Passage of the fluid behind the peritoneum. A gentleman, aet. 36, generally very healthy, with a large, well- formed chest, had occasionally complained, for the last few months, of pain in the chest, at one period very severe ; he had been cupped and blistered, but without relief: at length hectic symptoms set in, with restless nights; soon after, he felt as if something gave way in his side, and immediately expectorated a horribly fetid matter. A similar attack occurred in a few days, with the same fetid dis- charge, but accompanied by prostration, lividity of the counte- nance, and dyspnoea. I saw the patient along with Dr. Marsh and Mr. Crampton. We found the chest to contain air and fluid; and in consultation made the diagnosis of gangrene of the lung, and advised paracentesis. The operation was performed between the seventh and eighth ribs, a little below and external to the right mamma; the withdrawing of the trochar gave issue to a quantity of fetid air; a probe was introduced, and met by an elastic resist- ing substance; this was apparently perforated, and about three quarts of dirty, gray-coloured, fetid fluid given exit to. Great relief followed the operation. The patient, however, passed a wretched night, with hectic paroxysms; no discharge occurred from the wound. 17th. The trochar and canula were introduced, and a quart of the same fetid matter came away—patient felt easier ; passed a bad night. 18th. A pint of fetid matter was taken away; spent a most un- easy night, with incessant cough and frothy expectoration; the act of coughing sending the fetid air and matter through the external opening in great quantities. 19th. Much exhausted ; said he felt as if there was a well in his chest; he was sensible of a constant dropping of fluid ; pulse 120 ; great weakness; heat and soreness in the side. 20th. Mr. Colles saw him, in consultation with the other attend- ants. Anodyne enemata and stimulants were ordered ; he passed a better night, but had great dysuria ; ordered mucilaginous drinks. 21st. Passed a bad night; pulse 144, and weak; during a fit of coughing, which brought on the usual discharge from the wound, about a cupful of blood gushed out. 22d. The introduction of a gum-elastic tube gave exit to no fluid, 296 DISEASES OF THE RESPIRATORY APPARATUS. but a great quantity escaped while the patient coughed ; the abdo- men became tense and tympanitic, with exacerbation of all the symptoms, and the patient died in about thirty-six hours. Dissection. — Externally the body presented some livid marks at the right side, and a slight fulness in the right inguinal region and side of the scrotum. The right pleural sac contained above a quart of fetid purulent fluid; the lung was of a dark greenish hue, smeared with a creamy substance; its lower and back part de- stroyed by gangrene, leaving a large greenish-coloured cavity, the size of the hand. The substance of the lung near this was easily broken down, and the vessels and bronchial tubes were seen pass- ing through it; the remainder was gorged with a frothy, dark sanies; the whole lung was reduced to half its size ; some adhesions united it to the mediastinum, almost forming a circumscribed cavity: the costal pleura was in some places highly vascular; in others, covered with lymphy secretion ; in some places very tena- cious. In one patch, destroyed by gangrene, the intercostal muscles were laid bare for the space of several inches, and were in one part sloughy, forming an opening at the inferior and posterior part, at which place nature had attempted an outlet for the flnid — the latter having made its way into the cellular tissue, beneath the skin, and between the peritoneum and abdominal muscles, down the side of the abdomen to the scrotum. The general cavity of the right side was much diminished by the liver having been displaced up- wards by the flatus of the intestines; the liver was in such close apposition with the lung, as to be in danger of being wounded by the trochar; thus accounting for the fluid not coming off by the canula in the first instance. Hydrothorax (from vSug, water, and fl*§*£, the chest), Water in the Chest. — We may restrict the term to serous effusions in the cavity of the pleurae. One among the manyevidences of an amended pathology deduced from morbid anato.ny is our better knowledge of the causes and real character of dropsies of the chest, including both hydrothorax and hydropericardium. No longer regarded as, in general, a primary disease, we see in these effusions, as indeed in all those of serous sacs, an effect, or symptom in fact, either of inflammation of their membranes or of impeded circulation. Recog- nising these two as the chief if not sole causes of hydrothorax, we see in the first variety, or that from inflammation of the pleurae, active hydrothorax, while the second variety, which may be called passive, is caused by interruption to the circulation, either by organic diseases of the heart or congestion of the lungs, and tumours at the root of these latter. Sometimes hydrothorax results from dis- eases of the kidneys, from a febrile state connected with the exan- themata?, particularly scarlet fever; and from a sudden suppression of cutaneous exhalation. In some of these cases it may be asso- ciated with cedema of the lungs, increasing greatly the distress and the danger. PHTHISIS PULMONALIS. 297 The treatment of hydrothorax will be regulated very much by a knowledge of its cause. If the effusion have ensued on inflam- mation of the pleura, either simple or combined with pneumonia, our remedies should be the same as those directed for sub-acute or chronic pleurisy and pneumonia. Accordingly, a few cups on the affected side, or a blister kept discharging, and calomel with squills and nitre, or if the bowels be irritable opium may be used with good effect both towards removing the morbid secretory action and promoting absorption. Hypertrophy of the heart and a full hard pulse is sometimes to be met by venesection, followed by calomel and nitre, and digitalis with colchicum. In cases of irre- gular circulation, with much oppression and symptoms of venous congestion, digitalis, with the alkalies and tonics, will constitute the outline of treatment. Active hydrogogue cathartics, which are well represented by the compound powder of jalap or gamboge with cream of tartar, often give great relief in hydrothorax. When in an enfeebled or cachectic state, efforts at spontaneous relief are made by expectoration, this should be encouraged by the use of polygala senega with carbonate of ammonia. When we have rea- son to believe that hydrothorax is caused by diseased kidneys, mercurial purgatives, the blue mass with some narcotic, and dia- phoretics, will be of most service. Counter-irritation must constitute a leading part of the treatment of hydrothorax. Blistering has been already mentioned, but \n order to be efficient the discharge must be kept up by the repeated application of some vesicatory substance. Setons have been highly recommended with similar intent. LECTURE LXXII. DR. BELL. Phthisis Pulmonalis. — Its causes and special pathology—The disease caused by tubercles in the lungs—Pathological Anatomy of Phthisis—Tubercles— their stages and characters—Granular or crude stage ; accompanied by con- solidation—Second stage, or that of elimination and softening—How brought about—Third stage, or that of ulceration—Vomica—Infiltrated tubercle— Order of change in tuberculous lungs—Description of vomicae—Associated lesions of other organs with tuberculous lungs—The mucous surface of the larynx and bronchia and that of the small and large intestine most commonly diseased by inflammation, ulceration, and formation of tubercle in phthisis pul- monalis. Phthisis Pulmonalis — Pulmonary Tubercle, or Tubercular Phthisis. — Dr. Stokes having declared his intention to confine himself solely to the diagnosis and treatment of phthisis, it remains for me to say something about the causes and special pathology of this formidable disease. Fortunately just now, the circumstances that make this task easier render at the same time its discharge a less imperative duty for me. The works of MM. Laennec and Louis and of Sir James Clark on phthisis, are of ready access to vol. 11. — 26 298 DISEASES OF THE RESPIRATORY APPARATUS. all, since they are all republished in the United States. From them is the lecturer most inclined to draw, in making up a summary description of the disease, if, indeed, he did not feel that this has been done to his hands by M. Andral in his, by me, so oft quoted work (Cours de Pathologie Interne). A very clear, connected, and good digest of the subject you will find, also, in the lectures of Dr. Williams, which it has been my good fortune to collect from the London Medical Gazette, and send forth to the American reader in a book form, in the Select Medical Library. Phthisis Pulmonalis, or Pulmonary Consumption, is now almost everywhere among medical men understood to designate a disease caused by the presence and development of tubercles in the lungs. The olden creed, that a wasting away of the body, a decline, may be caused by protracted irritation and inflammation of an organ, holds sway no longer; and few are found to speak even of a laryngeal and pulmonary, still less of a gastric, an hepatic, an in- testinal, a splenic, and a renal consumption. It is not to be denied that irritation or inflammation of any one of these organs, — pneu- monia, gastritis, &c, — may quicken consumption into fatal acti- vity ; but it is by their developing the growth of tubercles of the lungs. Pathological Anatomy of Phthisis, and first and chiefly as respects Tubercle. — On examining the lungs of persons who have died of consumption, we find them greatly changed from their natural con- dition, in their being consolidated into irregular masses; and on cutting into them they are generally also excavated in parts, which are either empty, or contain a thick liquid matter. A closer ex- amination reveals to us more precisely the morbid structural changes which thus present themselves as it were in mass. We discover, on pressing the softer part of the lung between the finger, a number of little hard bodies, and on cutting into it we see that they are roundish granules, of a light, semitransparent, reddish- drab, or skin colour, sometimes more grey or ash-coloured, more rarely devoid of colour, and quite transparent, of sizes varying from a pin's head to a hemp-seed. These bodies are tubercles, which, in their different sizes, appearances, intimate structure, and products, offer three distinct stages of growth; viz., 1, of incipient develop- ment or of crudity; 2, of elimination or softening; 3, a period of excavation or of cavity. The tubercles of the first period correspond with those already described when a soft part of the diseased lung is examined. They are hard, destitute of organization, and disseminated in masses of more or less size, or intimately combined with the pulmonary parenchyma which is in a state of infiltration; sometimes they occupy only some lobuli, or again a whole lobe, and even the entire lung itself. Their number is variable. Sometimes they are found singly, studding a tissue otherwise healthy; but more commonly they are in groups of several together, and then they are either clustered in branches like berries, or they form a considerable mass, with the interstitial tissue consolidated and indurated between STAGES OF TUBERCLE. 299 them. They are most commonly distinct in the inferior lobes; in the upper parts and near the root of the lung they are usually con- glomerated in masses. Their chief seat is at the summit of the lungs; and when they are met with at the same time in the inferior tubes, they are always at a less advanced stage than those of the upper lobes. Before describing the two stages of tuberculous growth and change consecutive to those in the first or crude stage, we may naturally pause and ask, what is the primitive state which, again, involves the question, What is the origin of tubercle 1 On this point I shall not detain you long. Laennec believed that tubercles began like small transparent grains, of a grey colour, but sometimes almost colourless, and of a size varying from a millet to a hemp-seed. These he denominates miliary granulations—grey tubercle. In the middle of some of these diaphanousand colourless bodies, Laennec describes, as visible, a slight opaline or greyish tint: if cut into, they exhibit in their centre a yellowish and opaque point, which indicates their transformation into yellow tubercles. According to this celebrated teacher, we can find, at times, yellow and opaque tubercles in the lungs as small as granulations, and they are sometimes softened too. One of them bruised between the fingers feels like cheese : this is tubercle proper. The lungs which are the seat of granulations exhibit, also, tubercles proper, or those of a more advanced growth, and, like them, the granulations are disseminated or agglomerated in other tissues and organs, and with the same variety of colour and transparence, — as in the pleura and peritoneum, and in the intestinal ulcerations of consumptive persons. M. Louis, whom I shall quote as I find his facts and views recorded both in his book, Pathological Researches into Phthisis, translated by Dr. Cowen, and in his article Phthisie (Diet, de Me- decine), adds the weight of his own observations to those of Laen- nec; and says, that he has seen almost always the granulations larger, more numerous, more yellow and more opaque in their centre in proportion as they approached the apex of the lungs, where tubercles most commonly have their seat. M. Andral, after expressing his dissent from the views which I have just presented to you of incipient tubercle, adds, that there is not that uniform co-existence, alleged by Laennec, between the miliary granulations and tubercle in other parts of the body than the lungs, since they are only seen together in the pulmonary tis- sue. M. Andral then proceeds to give his own views. He regards granulations not as accidental formation, but as the result of modi- fied nutrition, and made by indurated and hypertrophied pulmonary vesicles, constituting one of the anatomical forms of pneumonia (vesicular pneumonia). The granulations of serous membranes, he regards as nothing more than the rudiments of false membranes, and those in the mucous membranes as hypertrophied follicles. Constantly he has found these granulations to be red and soft be- fore they became grey and hard. Finally, the appearance of the 300 DISEASES OF THE RESPIRATORY APPARATUS. granulation is displayed artificially after the incision or laceration of pulmonary lobuli. . , Dr. Baron believed that tubercles at first consisted of cysts with transparent sides, from the interior of which was afterwards secreted the greyish-white matter. Although M. Dupuy at the veterinary school, at Alfort, often found cysts and tubercles existing simulta- neously in the same animal,yet this conjunction is not common in the human species, and, upon the whole, pathological inquiry does not fa- vourthis viewof Dr. Baron. MM.Cruveilhier and Magendiesuppose that tubercles were primarily fluid, and consisted of pus which gradu- ally becomes solidified by the absorption of the thinner portion. M. Andral adopts this opinion in a general, perhaps we might call it an abstract sense. It is ; that as all the component parts of our bodies are primarily liquid, tubercle must come under this general law. But this admitted, how comes the tubercle to pass from a liquid into a solid state? Dr. Carswell believes it to be a peculiar secretion which takes place from mucous membranes; but that it may accompany other secretions, such as that of inspissated mucus in the air vesi- cles, or of dense false membranes in the pleura or peritoneum. But if we examine the miliary bodies minutely, we fail to find inspissated mucus adequate to account for their hardness, which is in the texture itself, and not merely contained within cells. Dr. Williams presents the question of the formation of tubercle in a luminous point of view, by following out a series of patho- logical changes, from simple morbid secretion to that of tubercu- lous matter totally devoid of organic form, its particles even not being globular, but irregular, like that of mere dirt or clay, and it must remain where formed a dead, inert mass, until decomposed by chemical agency, or changed by the operation of the surround- ing tissues. But, for a better understanding of his argument we ought to have passsd in review the other stages of tuberculous growth. Let us, previously, with M. Andral inquire into the precise seat of tubercle. Observation shows that this matter may be equally produced at the surface of the pulmonary mucous mem- brane, either in the bronchia, or in the air-cells themselves; also in the cellular tissue interposed between the several parts of the lungs. M. Andral believes that tubercle may be formed in the lymphatic ganglions,— a favourite idea, by the way, of Broussais, who was disposed to regard this gland as the chief seat of tubercle conse- quent on irritation of the respiratory mucous membrane. As it is not yet decided that the miliary granulations are really nascent tubercles, we ought, before proceeding farther in describing stages, to have a clear idea of tuberculous matter as it undoubtedly presents itself before it has undergone much mutation or become softened. A common state of parts, often but not universally asso- ciated with the presence of miliary granulations, is consolidation, of no particular shape or consistence, ofien nearly as hard as these bodies, and possessing in degree their semitransparence and colour. Generally, this consolidated matter is of a darker hue, from the colour of the blood and the black pulmonary matter in it. In SECOND AND THIRD STAGES OF TUBERCLE. 301 spots of this matter we recognise opaque, yellowish-white masses of various form and size, generally somewhat rounded. Some of them are nearly as solid as the dark or semitransparent indura- tions, but they are much less tough; others have more or less of a cheesy consistence, and some are found in parts approaching to a state of grumous fluidity, but still retaining their light colour and opacity. These opaque masses are commonly found within the indurations, from which they appear to be formed, and they are just of the same character as the specks before described which occur in some of the single or agglomerated miliary granulations. It may be inferred that the clusters and nodules of granulations are, also, converted into this same opaque, friable, yellowish-white matter. This matter, continues Dr. Williams, whose version of this state of tuberculous growth I am now giving, is entitled indis- putably to be called tuberculous. It is occasionally found in other situations unaccompanied by any induration ; such as in the interior of dilated vesicles and bronchial tubes, in masses under the pulmo- nary pleura, and in the bronchial glands. In these instances it is commonly of a friable or cheesy consistence, and has not the hard- ness which it seems to retain for a while when it has originated in the indurated tissue. Second Stage of Tubercles. — This is the stage of elimination or softening, which succeeds that of development or crudity, in a period of more or less duration. Generally, the softening takes place in the centre and proceeds to the circumference. The tuberculous matter becoming softer and moister, assumes an unctuous and soft, cheesy appearance, and at last resembles pus, or a colourless liquid mixed with opaque shreds of tuberculous matter. Of the cause of the softening of the tubercles, pathologists entertain different opi- nions. Some, as Bayle and Laennec, believe that tubercles have an inherent power of softening, as they had primarily of developing themselves. Broussais and Bouillaud attribute the change to inflam- mation. M. Andral adopts the opinion of M. Lombard, and believes that tubercles acting as foreign bodies on the tissues to which they are adherent, or in which they are imbedded, irritate them and give rise to a secretion of pus which mechanically separates the tuber- culous matter. M. Louis thinks that the change is brought about by the new organization of vessels in the tubercles themselves. The process of softening having been gone through, other phenomena occur which constitute another stage. Third Stage, or that of Ulceration. — This is begun by changes analogous to those by which the skin in contact with an abscess is rendered thinner and is finally perforated. Around the liquefied tuberculous matter the pulmonary tissue is red and destroyed: the bronchial tubes soon participate in this destruction, and open a free passage by patulous orifices to the tuberculous matter, which is now expelled by expectoration. The cavity left in the lung after the process of evacuation and expulsion of the fluid matter of the tubercle is called vomica. 26* 302 DISEASES OF THE RESPIRATORY APPARATUS. Not unfrequently the tuberculous matter is found diffused through a considerable extent of the pulmonary tissue, constituting the in- filtrated tubercle of Laennec. In its earlier condition, the lung in this state closely resembles the last stage of hepatization, when the opacity, which precedes suppuration, shows itself. It is very much mottled or marbled ; for, besides the yellowish-white opacity which is seen in different degrees in its different parts, there is the black pulmonary matter giving it a grey or greenish colour; and there are, also, the whiter coats of vessels and interlobular septa, and spots of red tissue less affected. When the lung in this state is cut or torn, which it commonly may be with facility, its interior pre- sents a granular surface, like that of hepatization ; and except that its colour is more varied, and it has generally more of the light opacity of tuberculous matter, it resembles a hepatized lung more than anything else. But in it are seen what we rarely meet with in hepatized lungs, circumscribed abscesses or cavities, containing a fluid matter. These circumscribed cavities are vomicae. In summing up the changes in the lungs of a phthisical patient, we find them, says Dr. Williams, to occur under two heads: — 1. Consolidation, generally of an indurated kind, and either almost colourless and transparent, or of a pearly grey or reddish-drab, or of a dark red or more dingy colour. 2. An opaque, yellowish- white, parsnip-coloured, friable matter, of various degrees of con- sistency, being first hard and afterwards becoming soft, and form- ing vomicae: this lighter opaque matter, which is properly called tuberculous, is produced commonly within the consolidations just named, but sometimes elsewhere. To this description we may add a few words on the nature of the walls of the vomicae. These are formed by the agglomeration of small tubercles and the condensa- tion, in consequence, of the interposed pulmonary tissue and of an irregular coat of lymph, and in part also by the induration of pul- monary tissue, in consequence of the irritation excited by the tu- bercle in its stage of softening. When the vomica is first formed, by the expulsion of the tuberculous matter, its inner surface is soft and rugged ; after a time this becomes smoother, and something like a membrane forms on it, which occasionally pours out a puriform fluid, but which after awhile becomes hard and semi-cartilaginous. The walls of the cavities are supplied by their own vessels, and grow and secrete matter into their cavities by the aid of these vessels. When these cavities approach to the pleural surface of the lung, there is often a coating of lymph or false membrane on the pleura at the part, which either thickens it or unites it by adhesions to the costal pleura. Butff tfn:re be no such deposit or adhesion, and the pleura should give way and be perforated, then the contents of the cavity and the air from the bronchia pass into the pleural sac, constituting pneumothorax and pleuritic inflammation. The tuberculous cavities or vomicae are traversed by parenchyma- tous shreds and sometimes by bloodvessels, but which last are rarely eroded or destroyed. When they are suddenly opened in this way VOMICA — CICATRISATION OF TUBERCULOUS CAVITIES. 303 hemoptysis even of a fatal nature is sometimes the consequence. At other times again the vessels may be completely obliterated. The bronchial tubes open into the cavities generally by destructive ulcer- ation. The matter contained in the cavities consists of a mixture of pus, mucus, tuberculous matter, and serosity, tinged or mixed with blood; and even occasionally portions of the pulmonary paren- chyma, which at times may be brought up by expectoration. The situation of tuberculous cavities in the lungs, in a great ma- jority of cases, is at the summit or upper lobes, whence they invade gradually the lower ones as the disease advances. Their size varies greatly, from that of a pea to being large enough to contain a pint or more of fluid. Sometimes the whole of the upper lobe is converted into a cavity of this kind. I had intended to speak next of the causes of tuberculous forma- tion or of pulmonary consumption, but believe that you will be better able to appreciate the value of opinions on this subject after my having noticed the chief, I will not say all the accompanying lesions of tissue in other organs. You will perhaps inquire first, whether this peculiar morbid and so generally incurable structure can be removed, or, in other words, is consumption curable? The weight of observation is in favour of the affirmative answer to this question. Laennec has shown, as the result of personal observation, that cica- trisation or healing of a tubercle has taken place. M. Andral de- clares that he has seen several cases of this healing of tubercles; and adds, that it may take place in various degrees. The interior of a cavity being completely emptied of pus, its walls are lined by a cellulo-vascular membrane. Afler a while this cavity disappears, and we meet with nothing but a simple cellulo-fibrous line at which abut abruptly large bronchia ; or, there may be a larger mass of cellulo-fibrous or of calcareous or cartilaginous structure at which abut the bronchia. This is commonly the appearance of things at the apex of the lungs, which is shrunk, puckered, and adherent to the pleura costalis; and which, in its shrinking, leaves between it and the pleura a space that is afterwards occupied by a cartilaginous tissue of new formation. Such, says M. Andral, are the changes which take place in subjects who, after having exhibited all the symptoms of phthisis pulmonalis, have been cured, and afterwards died of some other disease. Dr. Carswell believes in the cura- bleness of tuberculous disease, and points to the indurated matter, like chalk or hard mortar, found in the bronchial glands, as proofs that the tuberculous growth and transformation going on in these parts have been arrested. Simultaneous with these is often the irritation and tuberculous transformation of lymphatic glands in the neck, in scrofula, which are evidently often arrested, and the patient is left for a term of years in tolerable health. He has seen chil- dren who had tabes mesentericaentirely recover,and when examined after a lapse of years, and some of them in an adult state, having died from other diseases, hard, dry, chalky masses were found in the me- senteric glands. Dr. Williams (op. cit.) mentions the healing, by con- traction in size, of tuberculous cavities ; but he adds, that they are 304 DISEASES OF THE RESPIRATORY APPARATUS. scarcely ever quite empty: they contain more or less of a pale- coloured, plaster-like matter, which consists chiefly of carbonate and phosphate of lime, and sometimes contains earthy concretions. " The contraction is evident from the puckering of the pulmonary tissue visible on the pleural surface near the cavity, and the adjoin- ing vesicles are generally dilated to fill up the space. The creta- ceous matter is probably secreted by the fibrous false membrane (which lined the cavity of the tubercle); but it may have been ori- ginally of the character of tubercle or pus, and being unable to escape, the animal part has been absorbed, and the earthy insoluble salts are left behind and accumulate from successive depositions." In some cases of tuberculous disease we see the patients cough up chalk-like concretions, which are an evidence of the chronic nature of the disease, and of the restoralive efforts of the parts to oppose farther degeneration. It is worthy of remark, that both the softening during the elimination of tubercle and its induration, in the process just mentioned, begin in the centre. Lesions in other Parts of the Respiratory Apparatus. —I omitted to indicate, when describing the changes which accompany pulmo- nary tubercle, the other alterations taking place in the lungs them- selves. These are emphysema and cedema of various extent and degree, and inflammation of the lung around the tubercles. This last may present the three degrees of acute pneumonia. Chronic pneumonia is quite common around the tubercles, either during their stage of crudity or that of softening. The question, to be answered presently, comes up in view of this conjunction of pneumonia with tubercle; is the inflammation of the lung the cause of this tubercle ? The larynx and trachea are quite frequently the seats of inflam- mation and ulceration in phthisis, a fact of which you are already apprised in my Lecture (IX.) on chronic laryngitis. It stated, that " of one hundred and two consumptive patients noted by Louis, the trachea was found to be ulcerated in thirty-one, the larynx in twenty-two, and the epiglottis in eighteen." The ulcera- tions of the larynx are chiefly seated at the insertion of the vocal cords, — in these latter themselves, especially at their posterior part, at the base of the arytenoid cartilages, upper part of the larynx, and interior of the ventricles. Sometimes one or more of the vocal chords is destroyed entirely. The epiglottis suffers from ulcerations, sometimes without any corresponding affection of the larynx or trachea. Their situation is generally at the laryngeal , surface of the epiglottis, and commonly at its inferior portion. The trachea is chiefly ulcerated at its lower and posterior part, and here, a|so, the redness of the mucous membrane is most mani- fest. Occasionally the cartilages are denuded and even destroyed by ulceration. Small, round, hard tumours are seen beneath the mucous membrane of the larynx and trachea, which have been called tubercles, and which, after a while, give rise to irritation and ulcerative inflammation. These are regarded by M. Andral as diseased follicles (Clinique Medicale). By M. Louis, as by Broussais before him, the inflammation and ulceration of the trachea LESIONS OF OTHER ORGANS IN PHTHISIS PULMONALIS. 305 are attributed to the irritation of pus and tuberculous matter, in its passage from the bronchia during expectoration. The pleura is diseased by adhesive inflammation in a vast majority of cases of pulmonary tubercle. Of 112 cases of this disease, examined by M. Louis himself, there was but one in which both lungs were free from adhesions. These are, generally speak- ing, in number and extent proportionate to the pulmonary disease. Pleurisy is common during the last period of existence in phthisical subjects; and terminates in the formation of false membrane, serous effusion, and even sometimes true pus. Tuberculous degeneration of the bronchial glands is common enough in pulmonary tubercles of children, but much less so in that of adults. In the latter there may be tubercles of these ganglions without a trace of pulmonary phthisis {Clinique Medicale). Associated disease of the circulating apparatus is every now and then met with in phthisis. The heart is rarely hypertrophied: the opposite state, or that of atrophy, is more common. Sometimes the heart is soft and flaccid; and at other times it is firmer than natural. When the ventricles are of diminished thickness, this is more commonly found in the left than in the right ventricle. The aorta, for the most part healthy, is sometimes found in a morbid state, which is manifested by a redness of varying intensity and extent. At its bifurcation we sometimes see cartilaginous la- minae, ulcerations, and osseous points. Often it is contracted in its diameter. The spleen was found, by M. Louis, to be augmented in size sixteen times and diminished fifteen times, and in its normal condi- tion fifty-nine times. It is often found tuberculous, especially in children. The variety of seats of disease associated with that going on in the lungs, is well summed up by Dr. Williams. " Tuberculous disease in the mesenteric and other lymphatic glands, spleen, liver, brain, ovaries, and other parts, and tubercle combined with indura- tion, or some low form of organized structure in the serous mem- branes, the pleura, peritoneum, membranes of the brain, &c.; inflammation and ulceration, probably proceeding from tuberculous deposits in various parts of the intestinal mucous membranes ; chronic inflammation of the joints, and brown softening of their synovial membranes; diseased nutrition of the interosseous liga- ments ; greasy degeneration of the liver; and general wasting of all the tissues." Most constant and remarkable of all the lesions of other remote organs, associated with tuberculous disease of the lungs, are those of.the digestive canal. M. Louis reaches the conclusion that they occur in four-fifths of phthisical subjects. The pharynx and esophagus, except sometimes a thinness and softening of the inferior portion of the latter, are healthy. The stomach is variously altered, in its being sometimes greatly augmented in volume, and more fre- quently in its mucous membranes being thinner than natural, soft- ened, and even destroyed, or, on the contrary, thicker than in health. 306 DISEASES OF THE RESPIRATORY APPARATUS. It may also be of a lively red colour, and the seat of ulceration. The common seat of softening is at the upper part of the great curvature. The change of tissue in this case may occupy nearly the whole surface of the stomach, or it may be displayed in the form of bands. Sometimes projecting bodies are seen on the mucous membranes, of a rounded form, one or two lines in diame- ter, resembling fleshy granulations or wounds. Ulcerations of the stomach were observed by M. Louis in a twelfth of the cases of consumption. M. Andral (op. cit.) records, as the result of his observations in the Chariti, that at least three-fifths of the persons who died from phthisis exhibited a well-marked morbid condition of the stomach. The duodenum was generally found by M. Louis to be in a nor- mal state. Out of sixty cases he only saw three of ulceration of this organ. Very different was the state of things in the small intestine proper, the mucous membrane of which was softened, thickened, and more or. less red, and exhibited in addition small abscesses, tubercles, and ulcerations. Tubercles in every stage of development are met with in the entire track of the small intestine, but much more frequently near the caecum. They were observed by M. Louis to be present in 36 out of 95 cases. Ulcerations were still more frequent, having been met with in 78 out of 95 subjects, and also most numerous and deep as we approach the caecum. The coat of the intestine has been found to be entirely perforated. In the largeintestine the morbid changes in the redness, softening, and thick- ening of its mucous membrane, and the frequency of ulcerations and tubercles are similar to those in the small intestine. Fistula in ano was hardly ever met with by M. Louis or by M. Andral. The mesenteric glands were found to be tuberculous and enlarged 23 times out of 102 subjects of phthisis. The meso-caecal, meso- colic, and lumbar glands, exhibited similar changes. In 8 of 80 cases, the lymphatic glands of the neck were tuberculous. The axillary glands have been almost always in a normal state. In the secreting apparatus, alterations of tissue have been met with in consumptive subjects. Thus, the cellular tissue sometimes exhibits tubercles; the arachnoid and pia mater show false mem- branes, serosity on the upper surface of the arachnoid, and redness, thickening, and injection of the pia mater. The peritoneum in a fifth part of the cases has a serous effusion, and occasionally false membranes, pus, and adhesions. Ascites is only met with when there is complication of heart disease with phthisis. The liver is morbidly affected by what is called fatty transfor- mation, which reaches the entire substance of the organ. M. Louis has met with this in 40 cases out of 120, or one in every three. The figure of the liver is normal, but its volume is almost always augmented, and especially at its great lobe. We find on these occasions that the liver covers almost entirely the anterior surface of the stomach, fills the epigastrium, goes beyond the false ribs, and reaches as far as the spleen and crista of the ilium. Its consist- CAUSES OF PHTHISIS PULMONALIS. 307 ence is commonly altered ; it is soft, and tears easily. This fatty transformation of the liver is confined almost entirely to phthisis pulmonalis; and it is found to be much more frequent among women than among men. It occurs when the disease is of short as it does when it is of long duration. Sometimes the liver is the seat also of tubercles, hydatids, cysts, &c. In general, the bile in subjects in whom this fatty transformation of the liver has taken place is of a dark colour and pitchy consistence. In one case only has M. Andral met with tuberculous formation in the gall-bladder and biliary ducts. The pancreas has always been found healthy. Seldom are the kidneys altered in phthisis. The same remark applies to the bladder. The muscles are generally atrophied in the phthisical; and the proportion of phosphate of lime in their bones is less. M. Dupuy has observed that cows affected with pulmonary tubercle secreted milk which contained an unusual quantity of this salt. After this summary view of the seats of tuberculous disease, we shall be prepared to accord in opinion with Dr. Williams, when he says: " If tubercle be, as we suppose, a degraded condition of the fibrin or nutrient principle of the blood, we may expect it to be de- posited wherever the nutrition or the secreting process is carried on — wherever lymph or pus is occasionally found — wherever, in short, bloodvessels run. Instead of being, as supposed by Dr. Cars- well, most commonly deposited on free mucous surfaces, its appear- ances on them is less usual, and bears the small proportion of the liability of these surfaces to plastic inflammations. Lymph is some- times, but rarely, secreted by mucous membranes; and it is about as common to find tuberculous matter, or a degenerated fibrin akin to it, in the]air-tubes or cells, when the coats of thgse are entire. It is more common on the serous membranes; but it is much more usually (but not as Lombard maintains, exclusively) deposited on the interstitial cellular texture of organs, especially those which are highly vascular, and in which blood is apt to stagnate and accu- mulate." LECTURE LXXIII. DR. BELL. Causes of Phthisis Pulmonalis.—External Causes—Climate—Difference of mortality in different countries—Consumption, a common disease in the Medi- terranean climates,—also in the West Indies, and in the islands of the Indian Ocean—Consumption varies in its rate of mortality in different periods—Close and impure air a common cause—Effects of dust given out in certain trades— Deficient or improper food—Internal causes of consumption—Age—Sex— Hereditary predisposition—Conformation of the chest—Influence of inflamma- tion of the respiratory organs—Tubercle may be formed without inflammation —Conditions for this—Consumption a constitutional disease—Progress, dura- tion, and termination of phthisis. Causes op Phthisis Pulmonalis. — These are external to the individual and internal. Of the former, climate is entitled to be 308 DISEASES OF THE RESPIRATORY APPARATUS. first considered. Within a few years a great many important facts have been collected on this subject, and opinion is undergoing a change respecting the sanative properties attributed to certain cli- mates in the cure of consumption. This disease is met with in every region of the earth ; but it is less common in extreme northern latitudes than elsewhere. The deaths from it in the region be- tween the fiftieth and sixtieth degree of north latitude, are only 53 in 1000 from other diseases. Between 45 and 50° N. the disease augments in frequency. Thus, in 1000 dea.hs, in Vienna, 114 are from consumption; in Munich, 107; in Berlin, 71; in London, 236. In Paris, a fifth of the deaths is from this disease. From 45 to 35° N. lat. the mortality is still considerable. In Marseilles, consumption carries off a fourth of those who die; in Nice, with its boasted climate for phthisical patients, a seventh; in Genoa, a sixth; at Naples, an eighth: in Milan and in Rome, so comparatively distant from each other and so differently situated, the deaths are a twentieth of the whole number. M. Journe, referred to by M. Louis, says that the Romanhospitalsfurnishas manycasesof tuberculous disease as those of Paris. In Philadelphia, the deaths from consumption are on an average of four years (1834, 1835, 1836, and 1838), in proportion to those from all diseases, as 1 to 7-60 : in Boston, the proportion is as 1 to 5§ in a period of twenty years (Shattuck — Vital Statis- tics of Boston); and in New York, 1 to 5-45. In this last men- tioned city the mortality from consumption is increased excessively by the deaths among the European part of the population; the pro- portionate mortality among whom, alone from consumption, is 1 in 3-25, which, if deducted from the whole in' New York, would leave for the native population a rate of 1 death in 7-66 deaths. (See Remarks on Bills of Mortality of New York, by Dr. Lee, Am. Journ. Med. Scien., vol. xxii.) The-mortality is greater among the coloured people, from this disease. Consumption is common enough at Madrid, Lisbon, Gibraltar, Malta, and the Levant; in fine, it commits no small ravages along the whole European shores of the Mediterranean, whereas, on the African side, it is represented, but how truly I know not, to be quite unknown. The climate of the Mediterranean and of Southern Europe gene- rally, does not merit the reputation which it has hitherto, or until recently, enjoyed for the cure of consumption. On the contrary, it excites with singular and alarming rapidity the tubercular diathe- sis into actual disease, by promoting the development and softening of tubercle. Dr. Sinclair, one of the surgeons to the British fleet in the Mediterranean, during the long war between France and England, bore strong testimony to this fact, as far as the crews of the vessels of his nation were concerned. Pursuing a course directly in contrast with what would have been thought advisa- ble by his professional brethren at home, he advised the speedy return of the sailors to England, as soon as the critical symptoms of consumption were manifest, as presenting the only prospect of CALSES OF PHTHISIS PULMONALIS. 309 saving the lives of these persons. It was found, on comparison of equal numbers in the fleet in the North Sea and in that in the Mediterranean during a winter, that there were fewer cases of con- sumption among the former, notwithstanding their exposure to a most inclement season, than among the latter with a so much more genial temperature. In Malta and Gibraltar the cases of consump- tion among the British troops in garrison, on an average of twenty years, are as numerous in proportion as they are in Great Britain among the same class of persons, viz., 6 per annum in every 1000 men. In the Ionian Islands the proportion is 5 in 1000 (Major Tulloch's Statistical Reports, ge, we can recognise it at an earlier period by accurate measurement of the antero-pos- terior diameter of the thorax, and in this way measurement is found amost important means of diagnosis in the earlier stages of phthisis. It should never be neglected. The best apparatus for making this measurement js a a pair of callipers moving on a graduated arc. By means of a spring callipers, one knob of which is fixed on the scapula, and the other below the clavicle, the comparative depths of the upper lobes can be at once determined, and the most minute difference detected. The circumference of the chest above the mamma, and the distance of the clavicle from the nipple, must also be observed. In the earlier stages, the difference varies from the eighth of an inch to half an inch, and there is no visible altera- tion, except a flattening or slight hollowing under the clavicle. But in the more chronic cases, distinct deformity takes place. The antero-superior region becomes extensively flattened or con- cave, the shoulder depressed, the clavicle flattened, and its lower edge everted, the ribs closely approximated or even overlapping, and the apex of the scapula tilted out, as in contraction from empyema. The heart ascends in the thorax, and in one extreme case I have found it to pulsate under the second rib. All these signs are more connected with the chronic solidity than the sup- puration of the lung, for the latter, by permitting some expansion to take place, may delay the process of contraction. This condition may exist with complete dulness of sound and bruit de potfele, but without the signs of cavities, or may coincide with gurgling and cavernous respiration in their different modi- fications. Signs from the State of the Circulating System.—Active orga- nic disease of the heart and aorta being among the rarest compli- cations in phthisis, it happens that we can seldom avail ourselves of signs drawn from the circulating system ; Louis found, out of a hundred and twelve cases, only three in which the heart was en- larged. It is more often diminished in volume, pale, and flabby, as if participating in the general muscular atrophy. This applies to the chronic cases, for in the acute I have often "found the heart red, and in no way altered from its natural condition. The slowness with which the pulmonary obstruction occurs in chronic cases, explains the rarity of morbus cordis; for, as Louis has remarked, fluids diminish with the obstruction. — Recherches sur le Phlhisie Pulmonaire. See also Broussais, Histoire des Phlegmasies Chro- niques, torn. i. SIGNS FROM THE STATE OF THE CIRCULATING SYSTEM. 33^ Notwithstanding the atrophied state of the heart in phthisis, its- action is occasionally violent and distressing. In most cases, indeed, its impulse is somewhat increased, and if there be emacia- tion, and much tubercle of the left lung, the impulse is distinctly double, the second stroke coinciding with the second sound. In a few chronic apyrexial cases, the heart's action is perfectly tranquil, while in a still rarer class the palpitations are violent and irregular, so as to lead to the belief of great organic disease. Of this, Dr. Townsend has recorded a case, in which the symptoms were almost precisely those of morbus cordis; there were violent palpitations on exertion; a rapid, full, and bounding pulse; tremu- lous motion of the jugulars; extreme dyspnoea and orthopnosa; lips and nails of a dark leaden colour; and the heart's action so tumultuous as to cause the whole anterior surface of the chest to vibrate. The heart was found perfectly well proportioned; the foramen ovale not completely closed ; both lungs were extensively tubercular with intercurrent pneumonia, which had been diagnos- ticated before death. —Transactions of the Association of the King and Queen's College of Physicians, vol. v. How far the open state of the foramen ovale may have influenced the symptoms in this case, is still to be determined. I have seen a case of tuberculisation of both lungs, where the inter-ventricular septum was deficient, the aorta arising from both ventricles; the cardiac symptoms were severe, but there was no permanent cyanosis. The particulars of this case were communicated by Dr. Graves to Dr. Houston ; the boy, aged three years, had had frequent attacks of bronchitis, and was admitted into hospital with signs of tubercular cavities and bronchitis; the heart's action was violent, the pulse feeble, and the skin cold. The face, hands, and feet, were of a dark, livid hue; but it appeared that this colour ivas not habitual, and only came on when he laboured under pectoral affections. On dissection, besides the usual appearances of phthisis, the heart was found malformed ; a well-defined opening, sufficiently large to admit the little finger, led from the right ventricle through the sep- tum into the upper part of the left; this passage was twice as wide as that leading into the pulmonary artery ; the left auricle was small, the right large; the left ventricle of the same size and thickness as the right; the aorta was unusually capacious; and the ductus arteriosus diminished in size, but not obliterated. — Pathological Observations, by John Houston, M.D. Dublin Hospital Reports, vol. v. But one of the most interesting signs connected with the circu- lating system, is an increased action, often accompanied with bruit de soiifjlet, which, when the upper lobe is diseased, may be occa- sionally observed in the corresponding subclavian artery, and which has not been noticed by any author. Two causes obviously exist for this increased action of the sub- clavian in phthisis ; viz., the falling in of the subclavicular region, 340 DISEASES OF THE RESPmATORY APPARATUS. and the consolidation of the lung; but I have little doubt that there is a third, namely, sympathetic irritation, something similar to the sympathy of contiguity of Hunter, for I have found that in certain cases if was distinctly remittent, its appearance coinciding with signs of pulmonary excitement and irritation ; I observed it to sub- side after a copious hemoptysis, and have repeatedly removed it by leeching the subclavicular or axillary regions; and the fact of its being often accompanied by the bellows murmur, inaudible in any other part of the circulatory system ; and, like the pulsa- tion, capable of being modified by the antiphlogistic treatment, leaves little doubt of the correctness of my view. Under these cir- cumstances, it occurs in cases with but little contraction or con- solidation ; and the bellows sound is often exceedingly sharp, though ceasing in the brachial artery, and altogether wanting in the heart, aorta, carotid, or opposite subclavian. Varieties of Phthisis. — Under this head we shall study the symptoms, in connection with- the physical signs of the more pro- minent varieties of the disease. The following cases may be enumerated:— 1st. Acute inflammatory tuberculisation of the lung without suppu- ration. 2d. Acute suppurative tuberculisation. 3d. Chronic progressive tubercle, with signs of local and general irritation; pulmonary ulceration. 4th. Chronic progressive ulceration succeeding to an unresolved pneumonia. 5th. Tuberculous ulceration succeeding to chronic bronchitis. 6th. Tubercle consequent on the absorption of an empyema. 7th. Chronic phthisis complicated with pneumothorax from fistula. 8th. Tubercle complicated with disease of the larynx. 9th. Latent progressive phthisis. 10th. Chronic latent but partial tuberculisation. 11th. Chronic general tuberculisation. 12th. Cicatrisation of cavities. Acute Inflammatory Tubercle without Suppuration. — All the cases of this which I have seen, occurred as sequela? or complica- tions of the fever of this country. In most, the symptoms super- vened after the fever, an interval existing between the crisis and the new attack. In others, the disease, commencing with the symptoms of the ordinary gastro-catarrhal fever, proceeded unin- terruptedly to its fatal termination. The symptoms are undistinguishable from the more violent forms of bronchitis. High inflammatory fever, with severe cough and extremely hurried respiration, sets in; the expectoration is scanty, viscid and often tinged with blood; the face is swollen and livid, and the nares dilate; the action of the heart is violent, and the mtipn^l!6"" / rapid ? there are shooti"g P^'ns in the side, and the patient has often copious sweatings and delirium. In some in- ACUTE INFLAMMATORY TUBERCLE, ETC. 341 stances, these symptoms are complicated with others referrible to the abdomen ; the tongue is dry and red, the abdomen swollen and tender, extreme thirst, drawing up of the knees, and diarrhoea. It is singular that in a case where these symptoms were best marked we found the gastro-intestinal tube healthy, while all the paren- chymatous organs were filled with granular and miliary tubercles. In another instance, peritonitis from numerous perforations had occurred, yet the abdominal were nearly masked by the thoracic symptoms. — See Transactions of the Association, &c, vol. iv.; also the Clinical Reports of the Meath Hospital, Dublin Hospital Reports, vol. v. In a second class, the symptoms are more pneumonic, while in a third, which may be termed the hemoptysical variety, the first symptom is a copious discharge of blood, followed by a rapid development of tubercle, but without the violent signs of irritation which occur in the two former instances.. In the two first cases the diagnosis is difficult, for the tubercle being often equably developed, comparison cannot be employed, and the want of the signs of ulceration adds to the difficulty. There is nothing characteristic in the symptoms, and the stetho- scopic signs, taken alone, or considered without reference to time, are insufficient. In the first variety we have the most intense sonorous, sibilous, and muco-crepitating rdles; every part of the bronchial system seems engaged. In the second, the musical rdles are comparatively wanting, while the crepitating and muco-crepi- tating are extensively audible ; yet, by successive observations, and considering the phenomena with reference to time, the diagnosis can be made. I published the first instance of this diagnosis as far back as 1828. The case was one of a young female who became attacked with violent symptoms of gastro-catarrhal fever, which resisted all means of relief. The stethoscopic signs were of intense bronchitis; yet we found that the chest became rapidly and extensively dull. This could only be explained on the supposition of an extensive crop of tubercle, which diagnosis was made at the time. On dissection, both lungs were found completely stuffed with small granular and miliary tubercles, in such quantity as to obscure the condition of the intervening tissue, but they were generally crepitating, and nowhere presented complete solidity. This progressive general though not complete dulness, conse- quent on the signs of bronchitis, has led me in many cases to announce the acute general development of tubercle. In the second or pneumonic variety, the patient, though not suf- fering so much from dyspnoea, is in equal danger. The musical rdles are either absent or very slight; but an intense and extensive crepitating rale is to be heard. As in the former case, dulness advances, and the phenomena are only distinguishable from those of ordinary pneumonia by the absence of the signs of hepatisation. The rdle continues to the end, and hronchial respiration is not observed. 342 DISEASES OF THE RESPIRATORY APPAR.4 The third or hemoptysical variety is never so rapidas m« iwu former, and hence we can often avail ourselves of the signs of ulceration. . „. • . A remarkable feature in the inflammatory cases is the resistance of the symptoms and signs to treatment evenof the most active and varied description. The disease seems to defy all medical treat- ment. We may now state the general principle of diagnosis. If in a case presenting the symptoms and signs of intense bronchitis, or if crepitating rdle has been present, yet persisting to the last, we find the chest becoming dull; if this dulness be extensive,yet incomplete, without bronchial respiration, the stetho- scope showing that the lung is- everywhere permeable, the solidity only occurring in points ; or if the crepitus be so slight as not to account for the dulness, we may make the diagnosis of the acute inflammatory development of tubercle. Acute Suppurative Phthisis. — In the preceding variety, the absence of suppuration is owing not to any inherent character of the disease, but arises simply from the rapidity of the asphyxia. The cases now under consideration are those described by Louis as the acute phthisis; one case only of the first variety is given by him. In this affection the symptoms set in as in the former case; they continue with great violence, and resist treatment. The expectora- tion soon becomes purulent; the fever is high, but after a time becomes a sort of mixture of the inflammatory and hectic forms. The stethoscopic signs of the earlier stages are the same as in the last variety, but the deep-toned rdles are not so often observed. After the tubercles suppurate, mucous rdles passing into gurgling are heard. The musical rdles, however, are not removed; a sibi- lous sound during inspiration and expiration is audible, and this, when the action of the heart is strong, is influenced by it so as to produce a distinct musical rhythm: of course, dulness rapidly advances. In the cases given by Louis, death occurred in three, four, five, six, and seven weeks. I have seen two cases in which no pulmo- nary symptoms existed before the occurrence of fever, yet in which death occurred within three weeks from the first invasion, and the lungs were found full of tuberculous anfractuosities. Louis rerriarks, that, notwithstanding its rapid development, this disease is accompanied by those secondary lesions which we see in the more chronic forms ; ulcerations of the epiglottis, trachea, esophagus, and small intestine, have been observed. In one case, he found the mucous membrane of the stomach softened and thinned; in another, the liver was fatty; and, in a third, the lymphatic glands of the neck and mesentery contained tuberculous matter. The diagnosis of this affection has been in part given by Louis. By combining his observations with mine, we may state it to be the tollowing: — CHRONIC PROGRESSIVE TUBERCLE, ETC. 343 If in a case which has presented violent and generally uncon- trollable symptoms and signs of bronchitis, or of pneumonia continuing in its first stage ; with a fever at first inflammatory, and afterwards passing into severe hectic, we find an extensive dulness to supervene, more partial, but more complete, than in the preceding form, accompanied with a large mucous rdle, and supervening in a few weeks from the first invasion of the dis- ease ; we may diagnosticate the acute suppurative phthisis. In the third or hemoptysical variety, the disease is not so rapid, nor are the signs of irritation at all so violent. There is sometimes an absence of rdle, although the dulness seems as it were to grow daily, and advance downwards. The hemoptysis seems to relieve the mucous irritation, but the tubercle advances. In this form I have observed the contraction of the chest at a very early period ; it \vould seem as if, the terminal tubes being plugged up by minute coagula, atrophy of the cells occurred long before ulceration. LECTURE LXXVI. Tubercle op the Lung (continued).—Chronic progressive tubercle—First stage; symptoms of irritation; expectoration scanty; pain of the side—Signs on per- cussion and auscultation—Second stage; symptoms decided; pulse quick; ema- ciation increases; sweatings more profuse; cough looser; expectoration puri- form, tubercular—Physical signs—Third stage; apyrexia ; perspirations cease ; voice lost or hollow; aphthae on the tongue—Chronic tuberculous ulceration— Tubercle consequent on chronic bronchitis—Long duration of this variety of phthisis—Tuberculisation consequent on absorption—Phthisis complicated with empyema and pneumothorax; with laryngeal disease—Chronic latent forms— Cicatrisation of cavities—Inquiries into the state of a patient Suspected of phthisis—Recapitulation of physical diagnosis.—[Fournet's views.] Chronic Progressive Tubercle, with Local and General Irri- tation, Pulmonary Ulceration.— This is the common form of con- sumption, properly so called. Its symptoms have been slated so often, that their description here would be unnecessary; we shall, however, take a brief view of the symptoms and signs conjointly, in three stages of the affection — it being always understood that their combinations and characters are capable of great modi- fication. We may divide the disease into three stages: in the first, the tubercle is developed, but not yet suppurated ; in the second, small ulcerations are formed ; and, in the third, we have vast caverns excavating great portions of the lung. Between these stages there is no exact line of demarcation, but, when established, they have each symptoms and signs which are somewhat peculiar. First stage. — The more prominent symptoms are those of irri- tation; cough, pain, and quickness of pulse, which in certain cases are preceded, but in the greater majority followed, by an unaccount- able emaciation; the cough is almost always dry during the first few weeks, unless where the tubercle has succeeded to catarrh ; it 3-14 DISEASES OF THE RESPIRATORY APPARATUS. may occur in every variety, but is most commonly a slight fre- quent, and irritating cough, referred by the patient to a tickling sensation in the trachea. The expectoration when occurring, is scanty, and consisting of a thready, greyish, and nearly transparent mucus, occasionally dotted with blood : a slight wheezing some- times accompanies the cough. With these symptoms the patient frequently complains of pain, which may be situated in any part of the side. In some instances it is only felt in the lower, while in others it occupies the upper part of the chest, shooting from the clavicle to the subscapular regions, and often occupying the articulation of the shoulder, when it is often mistaken for rheumatism or the pain of hepatic disease; it occurs with various intensities, is generally remittent, and often relieved by anodyne or slightly stimulating applications. I have known it to be regularly intermittent, coinciding with the paroxysms of hectic, so that the disease was taken for ague, and treated accord- ingly. The combination of pain in the shoulder with quickness of pulse should always excite alarm. This pain is commonly ac- companied with tenderness of the subclavicular region, and often with that irritation of the muscular fibres which causes their con- traction on percussion ; the respiration is slightly hurried, and the first approaches of hectic can be perceived. Under these circumstances, we may have one of two results from a physical examination; we shall either find that there is no sign of disease, or that some of the various phenomena of tuberculous irritation may be discovered. In the first case the absence of physical signs has no value, unless considered in relation to time : thus, if the duration of the symptoms be only a few weeks, the absence of commensurate signs would be rather an argument in favour of tubercle; while, if they had continued for months, and particularly if there existed any other local or constitutional cause of hectic, the absence of signs would so far justify the opinion that the disease was not pulmonary tubercle. But, in the second case, the existence of any of the following signs is almost enough to reveal the too fatal disease:— Comparative dulness of the clavicle, scapular ridge, or inter- scapular region. Feebleness of respiration, most valuable when occurring on the left side, and occurring with or without puerile breathing in the other portions of the lung. The interrupted respiration.* * [Prolonged expiratory murmur, first noticed by Dr. J. Jackson of Boston, is a valuable though not a diagnostic sign of crude or ulcerated tubercle. In a subsequent note, more distinct mention will be made of the value of the difference in intensity and duration between the sounds of inspiration and of expiration, in aiding us to form a correct diagnosis in pulmonary tubercle.—B.] CHRONIC PROGRESSIVE TUBERCLE, ETC. 345 The various rales combined with a feeble or puerile respiration, and confined to the upper portion of the lung. Increased resonance of the voice, most valuable on the left side. Loudness of the sounds of the heart in the upper portions, most valuable at the right side. The friction sound audible in the antero-superior portions. If we now compare the symptoms with the physical signs, we must be struck with their agreement in pointing out a progressive irritation and deposition, but without further destruction or any supersecretion from the part. Second stage. — This is characterised by the establishment of decided symptoms; the emaciation increases; the pulse continues quick ; the countenance becomes characteristic ; the sweatings are more profuse; the cough looser, the expectoration becoming puri- form, tubercular, and often bloody. The digestive system now begins to suffer; thirst, loss of appetite, and abdominal pains, tor- ment the patient, and the first indications of the wasting and per- sistent diarrhoea appear; the patient feels that he can lie better on one side than the other, and begins to feel pain in the opposite side of the chest — a sure sign that his terrible disease has invaded the remaining lung. Notwithstanding all this, it will commonly be found that this is the period at which the patient seems to feel the greatest relief, and shows the greatest confidence in recovery; two causes seem to concur towards this result: the first, that the gas- trointestinal disease acts as a revulsive, and relieves the pulmonary irritation to a certain degree, as in the case of fistula in ano, and we have a painless but yet revulsive discharge. In the next place, the pulmonary irritation is relieved to a certain degree by the secretion of pus from the ulcers and bronchial tubes; and thus, if no new inflammatory crop of tubercle is developing, a period of comparative ease is produced. But there is a third and mechanical cause to be noticed; accord- ing as the suppuration of the tubercles extends, and the excavations enlarge, the cough often becomes much less frequent and trouble- some ; it no longer occurs in fits, but singly, followed by the easy expectoration of a mass of muco-puriform and tuberculous matter; this is traceable to the free bronchial communication with the ulcer- ous cavities. The destruction of the lung causes a relief to the patient, and too often may we hear the voice of hope and confidence reverberating in the cavity which seals the patient's doom. The physical signs are the following:— Increase and extension downwards of the dulness on percussion. The respiratory murmur is feeble or changed into a semi-tracheal breathing, most audible in the erect position. This is often com- bined with deep-seated or superficial cavernous breathing; the bruit de soupape and cavernous rdles. When the ulcerations are small and numerous, the cavernous phenomena are indistinct; and dul- ness of sound, with a large mucous rdle, increased by coughing, and a semi-tracheal breathing, are the principal signs. vol. n. — 30 346 DISEASES OF THE RESPIRATORY APPARATUS. When the cavities are sufficiently large, some form of pectori- loquism may occur ; but most commonly there is nothing but an increased and undefined resonance of the voice. These signs are most distinct in the postero-superior portions. All varieties of the crepitating, mucous, and cavernous rdles occur, the size of the bubbles generally diminishing from above downwards; and in certain cases the rdles are modified by the action of the heart, or occasionally suspended by bronchial ob- struction. The respiration in the lower lobe, or opposite lung, is puerile; and we have the signs of atrophy evident, generally, in proportion to the chronicity of the case. Third stage. — In this condition the patient is often apyrexial, and the perspirations cease, particularly if the digestive system remains healthy; the pulse may be slow, though generally becom- ing again accelerated before death ; emaciation proceeds to the last extremity. The voice is sometimes lost, at others hollow and me- lancholy ; the cough is loose, the respiration tranquil, and expec- toration easy ; aphthae appear on the tongue, and spread over the cavity of the mouth; the limbs become cold ; the breath gets a heavy odour, and the appetite in general fails. Yet the painful tenacity of life continues for a length of time, as if the patient wanted strength to die. The physical signs of this condition are so graphically described by Dr. Clark, that I cannot do better than give them in his own words. " The chest, at this advanced period of the disease, is found to be remarkably changed in its form ; it is flat, instead of being round and prominent; the shoulders are round, and brought forward; and the clavicles are unusually prominent, leaving a deep hollow space between them and the upper ribs. The subclavicular regions are nearly immovable during respiration; and when the patient attempts to make a full inspiration, the upper part of the thorax, instead of expanding with the spontaneous ease peculiar to health, seems to be forcibly dragged upwards. Percussion gives a dull sound over the superior parts of the chest, although the caverns which partially occupy this part of the lungs, and the emaciated state of the parietes, may render the sound less dull than in the preceding stage. The stethoscope affords more certain signs ; the respiration is obscure, and in some places inaudible, while in others it is particularly clear, but has the character of the bronchial, or tracheal, or even cavernous respiration of Laennec. There is a mucous rhonchus; coughing gives rise to a gurgling sound (gar- gouillement); and pectoriloquism is generally more or less distinct, for the most part, on both sides, though more marked on one than the other. In this state the patient may still linger for weeks, or even months, reduced almost to a skeleton, and scarcely able to move, in consequence of debility and dyspnoea." (Treatise on Pul- monary Consumption. London, 1835.) To this succinct but lucid description there is but little to be CHRONIC TUBERCULOUS ULCERATION, ETC. 347 added. When the cavities are large, there is often an absence of pectoriloquism ; and the cavernous respiration, whether from the size of the cavern or the feebleness of breathing, becomes often in- distinct, and as it were distant. It is at this period that the metal- lic phenomena are generally audible, while the respiratory murmur, which had been puerile in the healthier portions of the lung, at length loses this character. Chronic Tuberculous Ulceration, succeeding to an unresolved Pneumonia. — In this case the progress of the tubercle is insidious; and, where the seat of pneumonia has been in the lower lube, it is reversed, beginning below and proceeding upwards. Tubercle may supervene in the sthenic or asthenic pneumonia, but much more frequently on the latter. Independent, however, of any constitu- tional tendencies, there are three cases in which this termination may be observed : the first, in which a sthenic pneumonia has been neglected, or exasperated in its early stage ; the second, a case in which auscultation has not been employed, and the disease only rendered latent by treatment; and the third, the typhoid variety, when the strength is profoundly injured. In such cases the lung remains solid, or we may observe attempts at resolution to occur more than once. A considerable portion of the lung may resolve, yet the process be arrested, and one part con- tinue dull on percussion. Under these circumstances the patient seems, for an indefinite period, in a state of imperfect convalescence ; his pulse may have become slow, but it begins to rise; he does not gain flesh ; some cough remains; obscure fever manifests itself; the breathing be- comes hurried, and by degrees the usual symptoms appear ; and he generally sinks in from three to six months from the first attack of pneumonia. When the lower lobe is engaged, the physical signs are the fol- lowing : — Hepatisation continuing for about a month, we find a mucous rattle generally near to the root of the lung; the respiration of the upper lobe, which had been puerile, gradually becomes feebler, from below upwards, either without rdle or with a few mucous or muco- crepitating bubbles ; every day we observe the dulness to advance ; the bubbles at the root of the lung become larger, and ultimately a cavity appears; then the ulcerative process stretches upwards, and new excavations appear in various portions. When the upper lobe has been engaged, the same circumstances occur; and vacillations in resolution may be observed even after ulcerations have formed. After middle age, the process is ex- tremely slow, and may coincide with a singularly tranquil state of the heart. Tubercle consequent on a Chronic Bronchitis. — This combina- tion is much more frequent than has been supposed; a great num- ber of cases, called bronchitis, occurring after the meridian of life, are of this nature. 34S DISEASES OF THE RESPIRATORY APP-' The cases may be divided into two classes, according, to the expectoration. In the first, it has been for years concoctec o muco-puriform; in the second, it consists of a scanty serous or sero-mucous fluid. Tubercle may supervene in both cases, but is more common in the first than in the second form. In the first case, a chronic catarrh, having existed for many months or years, passes insidiously into phthisis; or, what is more common, a peculiar change of symptoms marks the commencement of the tuberculous disease. A* patient shall have had "cough and expectoration for three or four years, yet preserving his flesh and appearance, and with a quiet pulse. He may then be attacked with hemoptysis; his pulse becomes quickened, and emaciation advances slowly, and he by slow degrees passes into phthisis; or a tubercular complication may supervene, without any apparent change in symptoms. The pulse may continue tranquil, and hectic be absent, and the disease be only detected by physical signs. It is in these cases, but particularly the last, that we observe the extreme chronicity of phthisis. It may be advancing from five to fourteen years, or even longer — a fact to be explained, in part at least, by the copious expectoration which acts as an issue, and the healthy state of the digestive system. To these must be added the important condition stated by Dr. Clark, of the absence of consti- tutional disposition, rendering the progress of disease slower. In some instances, the disease advances steadily and almost imper- ceptibly ; while in others there are frequent exacerbations with hemoptysis, and great increase of dyspnoea and expectoration. I have no observations to illustrate the early stages of the tran- sition from bronchitis to phthisis. In all cases which I have seen the disease was local, and comparison could be employed. We may then apply the diagnostics as in the third variety. Dulness and signs of anfractuosities are found, and the diagnosis will lie between dilated tubes and phthisical ulcerations. The progression of the signs, the rdle, and the absence of the bronchial respiration, and resonance of the voice as in dilated tubes, will in general suffice for diagnosis. Of these principles, the first is the most important. In some advanced cases, great deformity is produced by the con- traction of the chest. Tuberculisation of the Lung, consequent on the Absorption of an Empyema.—We may suspect this occurrence in all cases where, after the absorption of an empyema, the cough is renewed, and the pulse becomes permanently accelerated. In neglected cases, yet in which absorption occurs, independent, or nearly so, of treatment, it is a common termination. In a few instances, an interval of quiescence intervenes between the subsidence of the first and the commencement of the second disease; while, in others, the phthi- sical symptoms and signs supervene immediately on the removal of the effusion. Without possessing a sufficient number of cases to determine the point, I would say that the rapid absorptions are more likely to be followed by a fatal development of tubercle than PHTHISIS COMPLICATED WITH EMPYEMA, ETC. 349 those more chronic. And it may be inquired, whether the " doubt- ful convalescence" of Laennec is not often produced by the forma- tion and evacuation of a small quantity of this consecutive tubercle. I have often, in such instances, been kept in a state of great appre- hension, by the recurrence of rdle and feeble respiration several times in the upper portion of the lung. In two cases I found that, although tubercle existed in both lungs, it was in much greater quantity in the side opposite to thatwhere the pleurisy had occurred, as if the pressure had diminished the liability to tubercle. It is a curious fact, but not without analogies, that the occurrence of an empyema and pneumothorax from fistula suspends the progress of tubercle in a remarkable manner. The physical diagnosis is often difficult from our inability to apply comparison. The pleurisy has altered the symmetry of the chest, and has caused physical phenomena, depending on the con- traction ; hence, in the earlier periods, the dulness and feebleness of respiration may not be tubercular, and may even occur on the side where least tubercle exists. This I have more than once veri- fied ; but when, with the symptoms of a new pulmonary disease, with hectic, and a quickened pulse, we find the opposite clavicle or scapular ridge becoming dull, and with some of the active signs of irritation, we may diagnosticate tubercle. When the disease, how- ever, predominates in the affected lung, a curious change of phe- nomena is observed ; the dulness and feebleness of respiration, as it were, change seats, and, in place of existing inferiorly, are perceived in the upper portion, while the lower becomes not really clearer than it was, but comparatively so. But tubercle may supervene, even although the empyema is not absorbed. The opposite lung is then the seat of disease, which may pass into ulceration. In this way large cavities may exist in one lung, with an original empyema of the other. In some of these cases the puerile respiration of the tuberculous lung is beyond every- thing intense, so that a large cavity may exist, yet without our being able to detect either the cavernous respiration or gurgling. This must be borne in mind, in all examinations of the lung, previous to the operation for empyema. In more chronic cases, however, with great emaciation and less puerility of breathing, the progress of tubercle in the opposite lung can be easily recognised by the usual signs. Phthisis complicated with Empyema and Pneumothorax from Fistula. —'■ I shall not enter here into the history of this triple lesion, but remark, in the first place, on the interesting fact, that the proper symptoms of phthisis are in many cases arrested, and singularly modified by the occurrence of the new disease. I have often found that, after the first violent symptoms had subsided, the hectic ceased, the phthisical expression disappeared, the flesh and strength returned ; and in this way the patient has enjoyed many months of comfortable existeitce, and was only disturbed by dyspnoea and the sound of fluctuation on exercise. 30* 350 DISEASES OF THE RESPIRATORY APPARATUS. To explain this, we must recollect the compression exercised on the lung, which, by diminishing its vascular supply, causes its atrophy and arrests its disease. The pleuritis, too, may have a revulsive effect; and perhaps the increased action of the opposite lung, by preventing the obliteration of the minute tubes, may hinder the accumulation of tubercle. In chronic cases, where the lung is, as it were, anchored to the parietes of the chest by adhesions, the cavity from which the fistula has passed can be easily detected. With respect to the opposite lung, there is nothing to interfere with direct diagnosis, unless it be the puerility of respiration. Under the circumstances, however, any sign of irritation of the opposite lung is sufficient to point out tubercle. Phthisis complicated with Laryngeal Disease. — I have already stated the frequent combination of ulceration of the larynx with tubercle of the lung. (See, also, Dr. Bell's Lecture (LX.) on Chronic Laryngitis.) The common case of phthisis laryngea is in most instances pulmonary consumption, with ulcerations of the larynx, either preceding or following the tubercular disease. With respect to diagnosis, the early history must be examined, so as to discover whether pulmonary as well as laryngeal disease exists. If there have been cough, pain of the chest or shoulder, hemoptysis, difficulty of lying on one side, copious expectoration, any degree of emaciation, quickness of pulse, or hectic fever, before the laryngeal symptoms, there is the greatest probability of tubercle existing; or if these symptoms distinctly supervened on the laryn- geal affection, forming a new train of sufferings, the same conclu- sion may be come to. Many cases also will be found to have commenced by an influenza, a bronchitis, or pneumonia — in all of which the complication commonly exists. The physical diagnosis is in general easy, except in old persons, or when great stridor exists. A certain degree of stridor does not prevent a stethoscopic examination ; and when the obstruction is great (a rare case), we can use percussion and measurement. In most cases the tubercle predominates on one side, and comparison can be employed. Acute affections of the larynx are rare in phthisis. The follow- ing case presents symptoms which are somewhat difficult of ex- planation: — A gentleman in the last stage of chronic phthisis, with dulness of the upper lobe of the left lung, and the signs of a cavity under the clavicle, was suddenly seized with dreadful dyspnoea, followed by a slight convulsive fit. The respiration was tracheal, but the obstruction seemed to be low down. In this state he continued for twenty-four hours, with occasional slight remissions. The diffi- culty of breathing then increased so much that the opening of the trachea was contemplated as a means of temporary relief. The operation, however, was not performed. Next tnorning, the symp- toms being somewhat relieved by a blister and other treatment, I CHRONIC LATENT FORMS. 351 was enabled to make an examination. The right lung sounded everywhere clear, but respiration was unusually feeble; while the left, which before presented feeble respiration and the signs of a cavity, now gave the most intense puerile murmur, masking the cavernous signs. In fact, the phenomena of the chest were com- pletely reversed. By degrees the tracheal breathing subsided ; the signs of a cavity returned ; the right lung*expanded as before, but a general bronchial rdle preceded death for a few days. These phenomena can only be explained by the temporary ob- struction of the right bronchus. Chronic latent Forms — Cicatrisation of Cavities. — I shall not dwell at any length on the remaining varieties of phthisis. Like other diseases, pulmonary tubercle is occasionally a latent disease; but I have never known it latent when considered as to local symp- toms, general symptoms, and physical signs combined. The first may be wanting, the second absent or anomalous, and the physical signs obscure; but, by combining all the phenomena, the disease can be detected in almost every case. What has been already said is sufficient to guide the diagnosis (p. 331) in most cases of the senile phthisis. On the signs of cicatrisation I have nothing to add to what has been already stated by Laennec. A certain feebleness of respira- tion, a little dulness of sound, and a somewhat tracheal character of the vesicular murmur, are the phenomena commonly observed. In the examination of a patient supposed to be phthisical, the following points demand attention before proceeding to the physical signs: — 1st. The age, habit, and diathesis of the patient, and whether phthisis or scrofula have existed in his family. 2d. The exact date of his illness. 3d. Whether this has been the first attack, and how far he has been liable to bronchitis. 4th. Whether the disease commenced by laryngeal, tracheal, or bronchial irritation, or followed a pneumonia, a pleurisy, or a con- tinued fever. 5th. Whether there has been hemoptysis, and if so, its nature, repetitions, and whether it preceded or followed the other pulmo- nary symptoms. 6th. Whether the cough was at first dry, or followed by expec- toration. 7th. The nature and quantity of expectoration, and whether there has been a change from a mucous to a purulent character, coinciding with the symptoms of ulceration; whether any calculous matter has been expectorated. 8th. Whether there has been pain; if so, its seat and nature ; whether it has affected the shoulder, side, or calf of the leg. 9th. The existence of hectic, emaciation, and acceleration of breathing ; the state of the pulse, and decubitus. 10th. The condition of the digestive system. 352 DISEASES OF THE RESPIRATORY APPAR/ 11th. The state of the pharynx, larynx, and trachea. 12th. Whether there be any syphilitic taint, if so, examine: for periostitis of the chest. Secondary syphilis .simulate phth sis when the syphilitic hectic exists with the bronchial irritation which I have described. If, as is often the case, there be also periostitis of the ribs or sternum, the symptoms are almost identical. 13th. Whether the patient (if a female) be hysterical; the state of the uterine system. 14th. Whether, if there has been any external disease of a scrofulous nature, the symptoms have succeeded to its removal or diminution. The practitioner must not build too much on the complication with hysteria. Nothing is more common than to attribute the symp- toms of tubercle to this affection — an error injurious to the patient and to the reputation of the physician. The complication of the hysterical cough with fever should always excite alarm. In phthisis, if there be any cause for spasmodic cough, this character often con- tinues to the end. Thus, where tubercle succeeds to pertussis, the original character of cough may continue long after great cavities are formed. There is, however, a singular hysterical affection with violent cough and hemoptysis, excitementof the pulse and respiration, and copious sweatings. The respiration is intensely puerile ; but though the symptoms continue for months, defying all treatment, there are no signs of consolidation. With the information thus obtained, we may proceed to the phy- sical examination, which must be conducted in as delicate and rapid a mode as possible. It is almost never necessary to uncover the whole chest — the baring of the upper portion is sufficient. Before percussion, gentle pressure should be made on the sub-clavicular regions, to discover whether ai\y tenderness exists, which would render its use painful. Percussion must then be performed, the patient being in the erect position, and without the head being inclined to either side. It is always to be comparative and strictly so, and we get much better results by the most delicate than by forcible percussion. The best pleximeter is the index finger, the back of which is laid on the chest. In this way the clavicles, sub- clavicular regions, and ridges of the scapulae, are to be explored. If necessary, we may use percussion at the end of a forced inspi- ration, and compare the sound of the upper and lower portions. For the active signs the stethoscope is absolutely necessary, for the results of immediate auscultation are not sufficiently accurate; the respiration, cough, voice, and sounds of the heart, are to be explored rapidly; and an observation being made of the external appearance of the chest as to contraction, the examination is com- pleted. In the nervous female, and in cases in which there has been recent hemoptysis, the examination must be performed as expedi- tiously as possible ; and in the latter case, all fatigue to the patient, and forced inspirations, are to be avoided, lest a new hemorrhage should be induced. ° CHRONIC LATENT FORMS. 353 Before considering the treatment, we shall recapitulate the facts of the physical diagnosis. Of course many of these have been already observed by authors. 1st. That there are no physical signs peculiar to tubercle. 2d. That every known auscultatory sign, active or passive, may be met with in phthisis. 3d. That in the great majority of cases comparison can be used, in consequence of the predominance of disease in one portion of the lung. 4th. That where comparison cannot be employed, there is much greater difficulty of diagnosis. 5th. That the earliest and consequently most important signs, are, in the great majority of cases, those of irritation. 6th. That these may exist in any of the tissues of the lung. 7th. That the bronchitic signs derive their value principally from their localisation and combination with dulness on percussion. 8th. That the crepitating rdle of pneumonia is rarely observed in the portion of the lung first tuberculated. 9th. That when it occurs it is either recurrent or continued; and in the latter case it persists much longer than in ordinary pneu- monia. 10th. That feebleness of respiration is one of the most common physical signs. 11th. That although commonly combined with other signs, it may occur as the sole phenomenon. 12th. That the interrupted respiration receives its value solely from its localisation, and coexistence with other signs. 13th. That of the signs of irritation, those of the serous membrane are the rarest. 14th. That complete solidity of the lung is rare in phthisis. 15th. That in the early stages it can often only be ascertained by comparison; it proceeds from above downwards, and may exist with a feeble or puerile respiration. 16th. That perfect tracheal respiration is rare in phthisis. 17th. That when it exists it is most evident in the erect position. 18th. That one side is rarely observed to be equally dull. 19th. That the formation of cavities gives a tympanitic character to the sound on percussion. 20th. That in cases of solidity of the left lung, a somewhat simi- lar character is given by the distension of the stomach with air. 21st. That in the universal development of tubercle, the sound is generally, but not completely, dull. 22d. That a great quantity of tubercle, when equally diffused, may coincide with but little dulness on percussion. 23d. That in ordinary phthisis the greatest variety may exist as to dulness. 24th. That the signs of irritation, and of solidification in its early stages, may be modified or even removed by an antiphlogistic or revulsive treatment. 354 DISEASES OF THE RESPIRATORY APPARATUS. 25th. That in the early stages of the case, these phenomena only show that tubercle is about to form. aMflnt;u„ enrrppA 26th. That the signs of ulceration may imperceptibly succeed those of irritation, or appear at once. . anr.\:av 27th. That they rarely exist without the signs of the earlier stages of tubercle'in other parts of the lung. ... .. , 28th. That they may be temporarily obscured by obstruction ot their bronchial communications. t 29th. That they are not audible to any distance beyond their actual situation. 30th. That the action of the heart may produce an audible agi- tation of the fluid contents of a cavity. 31st. That the metallic phenomena are generally perceived when the cavity is large, but may occur from several small but inter- communicating ulcerations, and may be absent even in very large cavities. 32d. That atrophy of the lung causes contraction "of the chest at an early period, and independent of the formation of cavities. 33d. That in very chronic cases it may produce a deformity greater than what occurs from the cure of empyema. 34th. That the action of the heart seldom furnishes signs of value in phthisis. 35th, That in cases of tubercular deposit in the upper portion of the right lung, the sounds of the heart are often heard more loudly in this situation than under the left clavicle. 36th. That in certain cases the sounds of the heart and those produced by its impulses on the diseased lung cause a distinct rhythm. 37th. That in cases of extreme atrophy of the upper lobe of the lung, the heart ascends high in the thorax. 38th. That the subclavian artery corresponding to the affected side, occasionally presents an increased pulsation with bruit de souffiet (bellows sound), which can only be explained by some sym- pathetic irritation of the vessel. 39th. That the supervention of dulness, with the stethoscopic signs of bronchitis, indicates tubercle. 40th. That in this way we may discover tubercle in cases not localised, and consequently not admitting of comparison. 41st. That the crepitating rdle of acute phthisis is not succeeded by signs of hepatisation, as in pneumonia. 42d. That the dulness of the acute suppurative phthisis is greater than in the non-suppurative cases. 43d. That in the hemoptysical variety of acute phthisis, there is often a want of proportion between the signs of solidification and those of pulmonary irritation. The first being well marked, and the latter comparatively wanting. 44th. That in the ordinary progressive phthisis, the physical signs accurately correspond with the successive changes. 45th. That where tubercle succeeds to an unresolved pneumonia AUSCULTATION IN DISEASES OF THE LUNGS. 355 of the lower lobe, there are, coincident with the signs of softening in the unresolved portion, evidences of the spreading upwards of condensation. 46th. That the supervention of dulness in a case of chronic bronchitis, followed by the signs of anfractuosities, points out that tubercle is developed. 47th. That where the expectoration is scanty, and the disease very chronic, the occurrence of dilated cells may obscure the signs of tubercle. 48th. That where anfractuosities form, we may distinguish them from dilated tubes, by the dulness which has preceded them, by the signs of their extension, and by reference to time. Here it is necessary to observe, that in certain cases of bron- chitis, where the minute tubes are engaged, and with profuse puri- form expectoration, the lodgment of the secretion causes occasionally a dulness of sound. But this cannot be confounded with that of tubercle, for it almost always occurs in the lower portions, is con- stantly varying, and may be removed (for a time) by an emetic, or a blister. I have only seen one case in which this lodgment caused a temporary dulness of the upper lobe. It was evident in the morn- ing, but disappeared in a few hours, leaving the respiratory murmur natural. 49th. That the discovery of tubercle, in cases of absorbed em- pyema, is often difficult from the condition of the lungs having been altered. 50th. That where a great empyema exists, the intensity of the puerile respiration in the opposite lung may obscure the signs of disease of its substance. 51st. That in cases of empyema with pneumothorax, where adhesions prevent the collapse of the lung, the original cavity may be still detected. 52d. That in this complication, the signs of irritation of the op- posite lung are almost always indicative of tubercle. 53d. That in the laryngeal complication, the physical diagnosis is in general easy, unless where great stridor exists.* * [Some useful additions to auscultation in the different diseases of the lungs, including phthisis, have been made lately by M. Four- net (Recherchcs Cliniques sur VAuscultation des Organes Respi- ratoires et sur la Premiere Periode de la Phthisie Pulmonaire), a good summary of whose discoveries and causeless pretensions, for his work contains both, is given in the British and Foreign Medical Review, vol. ix. I shall draw on this latter for a few of the pro- minents traits in M. Fournet's work. A good means of self instruc- tion to the student in auscultation, is presented in the following paragraph: — If a perfectly dried sponge be alternately compressed, and allowed to dilate close to the ear, a sound, varying in delicacy with the 356 DISEASES OF THE RESPIRATORY APPARATUS. fineness of that substance, and distinctly conveying an impression of dryness, is perceived. If the sponge be then wetted, at first slightly, and then to a gradually increasing degree, a sensation of humidity is produced: " the humid character is at first homoge- neous, then divides into a number of unequal consecutive sounds; the latter separate from each other, become isolated, and finally produce the sensation of bubbles originating, being developed and bursting" The transition from the slightest to the greatest possible decree of humidity is marked by distinct phases in the audible phe- nomena produced. But the result may be varied by changing the liquid with which the sponge is imbibed; when water is the fluid employed, the sensation of humidity is simple, uncombined with a character of viscidity, and resembles the respiration of an oedema- tous lung. If water, slightly charged with blood or gummy matter, be employed, a sensation of viscousness, such as accompanies the sound audible in a lung affected with active sanguineous congestion, is perceived. If the quantity of such fluid be increased, the bubbling character is developed; but the complete evolution of the bubbles seems obstructed by the clamminess of the tissue of the sponge.— Again, if a very fine sponge, moderately soaked with pure water, be compressed at any particular point with the finger, and then allowed to expand, a crepitating sound follows, possessing the pre- cise characters of those puffs of crepitant rhonchus, coexisting more particularly with the inspiratory movement, in pneumonia. The perfection of the bubbling character, the duration of the sound, &c, are modified by the manner in which the finger is removed after effecting the pressure. If it be raised in a jerking manner, so as to ob- struct the free ingress of air into the tissue of the sponge,it appears to effect its entry by successive efforts, the bubbling character is incom- pletely developed, or a few scattered bubbles only are distinguished. Now here we have exactly the characters of the crepitating rhon- chus of pneumonia, when the entire mass of a lobe is, with ihe ex- ception of a few vesicles, impermeable to the air; the practical inference from this is, according to M. Fournet, perfectly clear — abundant puffs of crepitant rhonchus indicate a more favourable physiological condition of the lung, than a rhonchus consisting of a few scattered and ill-formed bubbles. To us it appears that the experiment merely illustrates the practical fact ascertainable by clinical observation. When, of the kind now referred to, the cre- pitation commonly occurs only at every second or third inspiration, and at the close of the movement, a condition which is known to accompany the period of transition from the first to the second stage of the disease. M. Fournet further avails himself of his experiments with sponge in illustrating the mode of production of the inspiratory and expi- ratory murmurs, and their relation to each other. The expansion after compression is accompanied, as we have seen, with a distinct sound ; unless a coarse sponge be employed, no appreciable noise is, on the contrary, produced by its compression. The sound AUSCULTATION IN DISEASES OF THE LUNGS. elicited in the former instance is analogous to the inspiratory mur- mur, because resulting from the rush of air into the material ex- perimented on ; its duration and intensity are in the direct ratio of the thickness of the part compressed, in other words, of the quantity of substance acted on. In the same way, according to M. Fournet, in the normal state of the lungs and of the moving powers of those organs — that is, the number of permeable vesicles, and the force of respiration continuing the same — the duration and intensity of the respiratory murmurs will be constant quantities, and may hence be expressed numerically; to this proposition we shall presently have occasion to return. But we may not any longer delay with these experimental inquiries, which are carried much further by the author, and may be varied by any one inclined for such investiga- tion. They certainly illustrate usefully the phenomena of healthy and abnormal respiration ; for that the application of these results to the pulmonary tissue is neither strained nor inadmissible seems proved by the fact, that experiments by M. Piorry, on pieces of lung imbibed with various fluids, gave rise to precisely similar sounds. There is excellent exercise for the young'auscultator, whose cli- nical opportunities are limited, with a piece of sponge, a basin of water, and a little gum. On the subject of the respiratory murmurs or sounds, and the difference between the inspiratory and the expiratory, M. Fournet, as will be seen by the remarks of the reviewer subjoined, furnishes new views: — Let us commence with the normal respiratory sounds in the vesicular section of the apparatus. Nothing is more common than to hear the inspiratory murmur of individuals characterized as " pure and vesicular," when it agrees with the adult type of health; but this expression, if meant to denote the character of the sound, to convey the notion of a successive dilatation of separate vesicles, is seriously erroneous. M. Fournet is perfectly correct in affirming that, if we look for such characters in healthy respiration, we shall search in vain for sound lungs. Far from this, the vesicular cha- racter, thus understood, is an abnormal phenomenon ; whilst the true healthy sound is a mellow, continuous, gradually developed, breezy murmur, unattended with a sensation either of dryness or humidity. The use of the term vesicular is only justifiable with reference to the presumed seat of the sound. If we add, with our author, that the healthy expiratory murmur possesses precisely the same acoustic constitution as the inspiratory — that it is as soft and breezy, as free from hardness and dryness, and differing therefrom solely in duration and intensity, we shall probably startle no few practised auscultators. At least the testimony of writers of repute is to a different effect. But the question is neither to be decided by authority, nor by an appeal to d priori notions on the physical play of an organ, of the intimate structure of which nothing is in reality known ; — it is a question of pure observation. Let the observer place his ear to VOL. n. — 31 353 DISEASES OF THE RESPIRATORY APPARAT the chest of healthy subjects, think neither of physics, nor of che- mistry, nor of written dogmas, but apply his mind to perceive his own sensations, and he will invariably find that (unless when as is not unfrequently the case, it is inappreciable by the senses) the expiratory murmur possesses all the softness, gentle breeziness and freedom from bronchial character, which belong to its predecessor in the rhythm of respiration. Above all, he will discover that the period elapsing between the termination of the inspiratory and the commencement of the expiratory sound is an almost indivisible moment; that, consequently, where the one ends the other begins — that if the former be seated in the vesicles, the latter originates there also. But, as we have already said, these murmurs do differ in two essential points, intensity and duration ; the inspiratory exceeds the expiratory in both. M. Fournet has ingeniously endeavoured to give a precise estimate of the degree of difference subsisting between them, by assigning a numerical value to each; and fixes on 10: 2 asthe ratio of their comparative intensity and duration in the healthy state. In describing the pharyngeal, buccal, and nasal murmurs, M. Fournet dwells on the error, occasionally committed, of mistaking those sounds for bronchial respiration produced in the region to which the ear or stethoscope is applied. Independently of the dif- ference of quality and of the seat of these sounds, which is easily recognised by an attentive and practised ear, there are two modes of correcting the illusion noticed by our author: the doubtful sound, if developed in the pharynx or mouth, may be altered in character by causing the patient to change the form of the openings of those parts, and vary the degree of rapidity with which the air penetrates ; and again, as in some instances the pharyngeal sounds are perceived not by the applied but by the free ear, closure of the meatus of the latter will correct the error, as true bronchial or vesicular respi- ration are never perceived by the distal ear. The laryngeal inspiratory and expiratory murmurs are, accord- ing to this observer, equal in intensity and duration, and may be represented by the number 20. The tendency to equalization of the two sounds increases, the higher the section of the respiratory pas- sages in which they are examined : an observation of very nearly the same kind was made four years since by Dr. Cowan. The diagnostic value of certain modifications of the respiratory murmurs is found to depend in a great measure on the existence of such modified character in one lung only or in corresponding parts of both organs: in other terms, certain states of respiration°derive their sole, others their chief value from comparison, a fact judi- ciously inculcated by Dr. Stokes. Now, for the employment of this principle with precision, the respective conditions of both lungs in health require to be pre-ascertained ; for a very trifling natural difference in the murmurs in each will obviously produce the same effect, as a certain amount of disease would on the supposition of AUSCULTATION IN DISEASES OF THE LUNGS. 359 their being naturally identical. Let us suppose, for example, tnat a practised auscultator detects a delicate shade of difference in the intensity of the inspiratory murmurs under the clavicles; he will have an important sign of commencing tuberculization on the stronger side, provided, in the healthy state, the intensity is equal on both. Auscultators have carefully examined, therefore, whether the murmurs are similar or dissimilar in the corresponding points of the two sides of the chest; but we regret that the delicacy of the question has already interfered, and is likely to continue to interfere very seriously with uniformity of opinion respecting it. Dr. Stokes dwells on the importance of his discovery, that " in many indi- viduals there is a natural difference between the intensity of the murmur in either lung, and in such cases, with scarcely an excep- tion, the murmur of the left is distinctly louder than that of the right lung. M. Fournet has, on the contrary, satisfied himself that, in persons presenting all the characteristics of healthy lungs, the sounds of inspiration and expiration are precisely identical in all corresponding points; in the few individuals in whom he detected a slightly greater development of the expiration under the right than the left clavicle, there were some motives for a dubitative opinion respecting the state of the lungs. The normal intensity and duration of the inspiratory sound being represented by 10, the extreme degrees of increase and de- crease mark 20 and 0; between the maximum point of elevation and that of total cessation, all intermediate grades are observed* A remarkable difference in the mode of production of increase and diminution is, according to M. Fournet, that the former change never springs directly from any physical alteration in the pulmonary structure, and is produced, not in diseased parts, but in circum- jacent healthy tissue; in a word, it announces the general fact, that a part of the lung supplies, by increased action, the^ functional incapacity of another, and characterizes supplementary respiration. On the contrary , the diminution of the murmur is the direct effect of some physical obstruction to the entry of the air, and represents the intensity of that obstruction. The importance of this modi- fication, which, in the great majority of cases, affects both the in- tensity and duration of the sound, is apparent from the fact, that there is scarcely an organic disease of the larynx, trachea, bronchi, pulmonary tissue, and pleura, which, as well as certain spasmodic affections, is not productive of it to a greater or less amount. In health, the inspiratory sound is uniform and continuous; this condition constitutes, according to M. Fournet, its normal rhythm. In cases of sharp pleurodynia, he states, this rhythm changes ; the murmur becomes abrupt, jerking, and divides into several successive J r and unequal parts. In incipient pleurisy, in the dry stage, a similar state is however observed; so that this observation throws no new light on the diagnosis of these two complaints. During the altera- tion of inspiratory rhythm, the expiratory remains unchanged ; a fact easily intelligible. 360 DISEASES OF THE RESPIRATORY APPARJ The expiratory murmur is subject to much greater increase in point of intensity and duration than the inspiratory . if ue credit M. Fournet, the maximum increase in these respects may be re- presented by the number 20, that already employed to designate the corresponding condition of the inspiratory sound. Now, as in the normal state, the former and the latter murmurs are made respectively equal to 2 and 10, it follows that while inspiration is only capable of acquiring double its healthy duration, expiration may attain ten times the natural proportion. And again, as it is elsewhere stated, that while the expiration undergoes this enormous rise, the inspiratory sound may fall to 1, it follows that instead of the expiration being only one-fifth as intense as the inspiration, it may be twenty times as intense as the latter ; and hence, that it may actually bear one hundred times a higher proportion to the inspi- ratory murmur than natural. We are almost persuaded there is exaggeration in this expiratory estimate; at least we have never, ourselves, observed a degree of prolongation in cases of vesicular emphysema (wherein the abnormal extension has to us appeared to reach its utmost limit) which could be rated at more than five or six times the natural amount. Augmented expiration may either coexist with a proportional increase in the inspiratory murmur, or the healthy ratio of the two phenomena may be destroyed by an accompanying fall in the inspi- ration. The former condition occurs in puerile or supplementary respiration ; the latter in the early stage of phthisis, and in emphy- sema: these are indeed the only affections in which the dispropor- tion exists to a very large amount, and hence its special value in their diagnosis. The diagnosis of the first stage of pulmonary tubercle has received accessions by the labours of M. Fournet. I must, in illustration of this fact, confine myself to the following synopsis prepared by the reviewer, to whom I am entirely indebted in this note. But the facility with which these signs may be ascertained, the constancy of their presence,, the regularity of their progress and catenation, form almost as important elements in judging of the confidence to which they are in practice entitled, as the actual reality of their existence. Upon some of these points, in so far as they are capable of being generalized on, M. Fournet speaks with just appreciation of the difficulties of clinical medicine. " The observer must, while investigating the local signs, carefully guard against being influenced by any preconceived opinions, ori- ginating in the external appearance, or in the commemorative or general symptoms of his patient. If dominated by an opinion, in great measure already formed, the very best auscultator is not un- likely to become so careless and inattentive in his examination, that the impressions received by the senses are, without his being aware of it, converted into so many confirmations of his preformed judgment. This is the more likely to happen, because the pheno- mena appreciated by the senses and the mind are very numerous, AUSCULTATION IN DISEASES OF THE LUNGS. 361 and only distinguishable by very delicate differences from others of wholly distinct diagnostic force. When a first examination has been made, under circumstances like these, we are sometimes astonished at the variation in the result of a second. First Phasis. A few small tubercles scat- tered through the lung. SeconI) Phasis. Infiltration of crude tubercles ■< in groups. Third Phasis (or of transition from first to second stage). Commencing softening. f Inspiration, dry, rough, fa '■'■*' intensity increases to 12. duration falls to 9, 8. quality, natural. Expiration, dry, rough. IwX i-e gradually to 8. quality, clear, ringing. Commencing bronchophony in rare cases.. Pulmonary crumpling sound. Dry crackling rhonchus. Sonorous, sibilant, rhonchi (symptomatic of bronchitis). Inspiration—intensity = 12, 14. duration = 9, 8. quality, clear, ringing. Expiration, intensity ? _« i n duration } = ' quality, blowing, rarely bronchial. Dryness and roughness of respiratory murmurs are now masked by change of quality. Slight bronchophony, frequently. Slight obscurity of sound on percussion. Diminished vocal fremitus. , Unnaturally distinct transmission of cardiac sounds. Humid crackling rhonchus. Sonorous sibilant rhonchi, as before. Pulmonary crumpling sound disappears. Inspiration — intensity = 15, 18 duration = 7, 6, 5. quality, blowing, or slightly bronchial. Expiration, intensity ) io i* iq on duration \ = 1<5' 1o> lb' M' quality, bronchial. Strong bronchophony, or imperfect pectoriloquy. Sound more obscure, or even dull. Vocal and tussive fremitus much diminished. Diminution of partial movements of ribs corresponding to indurated mass. Transverse retraction of corresponding part of the chest. Subclavicular flattening. " The physical signs are not, as might be believed, pathogno- monic of phthisis; for such signs alone merit that title as belong exclusively to a certain anatomical condition.....Some observers consider a prolonged expiratory murmur peculiar to phthisis, and almost all that has been written on the sound of expi- ration bears the impress of this idea ; the belief is a groundless one, for the expiratory murmur manifests itself in a multitude of differ- ent conditions. . . . But from mutual combination, from coex- 31* 362 DISEASES OF THE RESPIRATORY APPARATUS. istence with some signs, and from their appearance, »«dePf"^^7 of others, the phenomena described may lead to a precise diagnosis of tuberculization; their primitive or absolute value goes no further than pointing out the presence of induration or foreign bodies in the pulmonary tissue. ... . " At a very early age no inference could, I think, be drawn from the existence of the morbid characters of the respiratory murmur, which I have assigned to the first phasis, — in many instances even to those of the second." (p. 203, et seq.) Fully as we assent to the justness of these remarks generally, we would, nevertheless, point out a slight contradiction between one of them and the author's previous assertion, that the dry crackling rhonchus is peculiar to tuberculization, — if peculiar to, it must, when present, be pathognomonic of the disease. — B.] LECTURE LXXVII. Pulmonary Tubercle (continued).— Treatment of phthisis—To be considered under two heads; the curative and the palliative—The indications in both are to remove irritation of the lung and to improve the general health—Constitutional and accidental phthisis—Tubercle is preceded almost always by irritation—Cir- cumstances to guide the practitioner—Treatment of localised bronchitic variety; of the hemoptysical variety; of the pneumonic variety—Treatment after exca- vation has formed—Incurable consumption—Palliative treatment; of the more distressing symptoms, such as hectic, pain, cough, expectoration, hemoptysis, and diarrhoea. Treatment of Phthisis. — We may consider this treatment under two heads, viz., — the curative and the palliative: the first, the attempt to eradicate the disease by active treatment; the second, the relieving the various distressing symptoms of a hopeless con- sumption. And however differing in detail, the principle of both methods is the same, namely, the removal of irritation from the lung, and the improvement of the general health. It unfortunately happens that the palliative treatment is that which we must generally follow; but there can be no doubt that as medicine advances the cures of consumption will be much more frequent; its nature will be better understood, its first stages more commonly recognised, and the disease prevented from proceeding to incurable disorganisation. The first, the most important point in preparing ourselves for the successful treatment of phthisis, is to have clear notions as to its connection with irritation. Without adopting the opinion of Broussais, that phthisis is nothing but a chronic pneumonia (Histoire des Phlegmasies Chro- niques, vol. ii. See also his Commentaires sur les Propositions de Pathologie), but rather holding with Andral, Carswell, Forbes, and Clark, that the tubercular matter results from a lesion of secre- TREATMENT OF PHTHISIS. 363 tion, we must admit its connection with a state of irritation in most cases. There are some, indeed, where the matter seems deposited without any such action, but these are comparatively rare. Before entering on this subject, I shall state the division of cases of phthisis which I have generally followed with relation to treat- ment. They may be separated into two classes, the constitutional and accidental phthisis. In the first, tubercle supervene^ either with or without precursory irritation, in persons strongly predis- posed to it by hereditary disposition or original conformation. In these the disease is generally rapid, invades both lungs, and is com- plicated with lesions of other systems. The disease is constitutional, and the affection of the lung, though the first perceived, seems but a link in the chain of morbid actions. In the second, we meet the disease in persons not of the strumous diathesis, and who have no hereditary disposition to tubercle. The disease results from a distinct local pulmonary irritation, advances slowly, and the digestive and other systems show a great immunity from disease. In both cases we may effect a cure ; but this result will be more often obtained in the latter than in the former class. The value of early treatment is of course greater in the constitutional than the accidental case. In the early stages of the constitutional disease, recovery is only to be effected by treatment; in the advanced cases, when it does occur, it seems almost independent of treatment. In the accidental phthisis, the lesser tendency to abdominal and other complication, allows time for the vital powers to act; while in the constitutional variety, tubercle is commonly deposited through- out the body, and the patient dies rapidly in consequence of such extent of disease. But to return to the connection with irritation, we find it, in the great majority of cases, to precede, accompany, and accelerate the disease; and further, that within certain limits it is by removing irritation that we best succeed in effecting a cure. Without this principle we have no key to the treatment of phthisis. Tubercle is preceded by irritation. This is seen in the history of almost every case; an ordinary cold, an attack of influenza, a pneumonia, a pleurisy, the bronchial irritation of hooping-cough, or the exan- themata — these admitted conditions of irritation are commonly the first links in the chain of consumptive symptoms. How commonly in the strumous diathesis do we see individuals continuing free from phthisis for many years, till an attack of pulmonary irritation occurs, and then we can trace the first growth and progress of tuber- cle. And, if further evidence is necessary, let us recollect the effect of injuries of the chest, and the phenomena of the acute inflamma- tory tubercle. That tubercle is accompanied by irritation hardly demands proof. Fever, cough, excitement of the lung, and acute pain, declare the inward disease. Or if we turn to anatomy, we find actual inflam- mation of the tissues of the lung, redness, thickening, softening and 364 DISEASES OF THE RESPIRATORY APPARATUS. ulceration of the mucous membrane, puru ent secretion*, vermilion redness of the inter-tubercular tissue, solidification of the< lung, and lymph on the pleura. Finally, it is not uncommon to see the patient suddenly cut off by some violent inflammation, pneumonia, pleurisy, cerebritis, or enteritis. . , , . . . But tubercle is not only preceded and accompanied by irritation, but it is hastened by it. Every new attack of irritation is followed by increase of the tubercular symptoms, unless it be of the surface, when a revulsive action, proving the general proposition, is occa- sionally seen. Lastly, experience shows, that it is by means calculated to dimi- nish irritation of the lung at the least expense to the constitution, that we can best palliate or delay the progress of phthisis; and I trust to be able to show that the antiphlogistic treatment is the true mode of arresting the disease in its early periods. Thus the proposition is proved by the study of symptoms, by the results of anatomy, and by the experience of treatment. It is hardly necessary to repeat that there are cases of extensive tubercular formation, in which irritation is either absent, or but little marked. These are always incurable, happily they are rare. On being called to a case of phthisis, the practitioner has to decide whether to adopt the curative or palliative treatment. The following are the circumstances which may induce him to attempt the cure:— 1st. The absence of the strumous diathesis, or an hereditary dis- position. 2d. The fact of the disease being recent; for, where physical signs of tubercle exist, the chance of recovery is inversely as the duration of symptoms. 3d. The want of proportion between the extent of disease as indi- cated by physical signs, and the duration of symptoms. If the extent be slight, although symptoms have existed for months, it shows a power of resistance in the economy. 4th. The calmness of the pulse. 5lh. The absence, or slight degree of emaciation or hectic. 6th. The healthy state of the digestive system. In all the ex- tremely chronic cases which I have observed, the digestive system continued healthy, and I never heard of a recovery after diarrhoea had occurred. 7th. The fact of the disease having distinctly supervened on a pneumonia or bronchitis. 8th. The occurrence of free expectoration from the first period of the cough. An important character, as showing an early at- tempt to relieve the irritation by secretion. 9th. The healthy state of the larynx. Most important. The combination of even a small quantity of pulmonary tubercle, in laryngeal disease, is always fatal. 10th. The disease, as shown by physical signs, being confined to one lung, and to a small portion of that lung. LOCALISED BRONCHITIC VARIETY. 365 11th. The absence of the signs of cavities. This requires expla- nation. We know that recovery happens after the formation of cavities, but in most cases their existence implies that of tubercle in great quantity, occupying other portions of the lung. 12th. The absence of puerile respiration in the healthy portions of the lung. This character is of value, as showing that a small part of the lung is obliterated, and indicating a quiescent state of the other portions. 13th. The absence of the signs of atrophy. It is not meant that a case should present all these characters in order to justify our hopes and attempts of cure ; any of them are of value. Of course the more of them present the better ; and, excluding the first character, they may be all available in any case of phthisis, whether constitutional or not. Incipient curable phthisis is met with in one of three forms, which may be designated as the Localised Bronchitic, the Tracheal, the Hemoptysical, and the Pneumonic varieties. We shall discuss the treatment of these separately. Localised Bronchitic Variety. — This is shown by the existence of the signs of bronchial irritation already described. They occur in the upper portion, are combined with vesicular murmur, and with slight dulness. The pulse is quickened, the cough is gener- ally dry, but the hectic is not yet confirmed, nor is emaciation decided. At this stage the experience of a great number of cases enables me to say that a cure can be performed. This is the period for ex- ertion on the part of the physician, but that in which precious time is commonly lost. There is a local irritation to be subdued; tubercle may or may not have formed. In the first case its quantity is so small, that na- ture often is able to throw it off; in the second case, it is threatened, and every day, by promoting irritation, increases the chance of its deposition. The patient must be confined to his room, and all exertions of the lung forbidden. If he be of a robust habit, and the pulse is inflammatory, a single bleeding from the arm is to be performed; the bowels must be kept gently open, and the diet consist of milk, farinaceous snbstances, and light vegetables. Leeches are to be applied in small numbers, alternately, to the sub-clavicular and axillary regions of the affected side. This de- pletion is to be repeatedly performed, the cupping-glass being occa- sionally used over the bites. Under this treatment the rdle will be commonly removed, the vesicular murmur increased in strength, and the dulness diminished, and all this with corresponding relief to the symptoms. We are now to commence the use of blisters, which are to be continually applied under the clavicle and over the scapular ridge. Their size should not exceed that of a dollar, and they must in alf cases be covered with silver paper. A blister is to be applied about every three days. This counter-irritation is to be 366 DISEASES OF THE RESPIRATORY APPARATUS. persevered in for several weeks, when the blister under the clavicle may be converted into a superficial issue, by dressing the surface with a disc of felt, and a combination of mercurial and savin oint- ments. During this treatment the cough is to be allayed by mild sedatives. The following is the formula which I employ at this stage:—R. Mucilaginis Arab, vel Tragacanth. Jiii.; Syrup Limon. §ss.; Aq. purse, giiss.; Aq. Lauro-Cerasi, 3ss. — 5'- 5 Acetatis Mor- phias, gr. i. This can be permanently used without deranging the stomach. As soon as the issue is established, the regimen may be improved. The patient may now commence the friction with the turpentine liniment, and if necessary, use inhalations of the vapour of water impregnated with a narcotic extract. From twelve to fifteen grains of the extract of cicuta may be employed, at each time of inhala- tion. In mild weather, horse exercise should be taken, and the invalid, to perfect his recovery, should remove to a milder climate, and frequently change his situation. Such is the treatment of the most common form of incipient con- sumption. We owe the principle of local depletion to Broussais, and among the many boons which he has conferred on practical medicine, there is none greater than this. On this subject I shall quote two of his propositions: — " Les sangsues placees d la partie inferieure du cou, entre les insertions des muscles sterno-masto'idiens, enlevent le catarrJie bronchique et previennent laphthisie pulmonaire. "Les sangsues placies autour des clavicules et sous les aisselles arretent les progrls d'un catarrhe qui vient de s'introduire dans le lobe supirieur et qui aurait infailliblement produit la phthisie pulmonaire. Un son mat ou mains clair, tout recent, annonce que le catarrhe a penttre dans le parenchyme, et indique qu'il faut insister sur les saignies locales.—Examen des Doctrines Midicales, vol. i.; Propositions de Midecine, prop, cclxxiii. See also his Commentaires sur les Propositions de Pathologic Incipient Tracheal Irritation. — A person of a strumous habit some of the members of whose family have been cut off by phthisis, which set in with symptoms precisely similar to his, is attacked, after exposure to cold, with a loud ringing cough, occurring in dis- tressing and uncontrollable paroxysms. He has pain and soreness ot the windpipe, loses flesh, and is feverish at night. There is fre- quently pain of the chest and shoulder, and some acceleration of breathing. The pharynx is healthy, or only slightly vascular. On percussion both lungs sound well and equally, and the respiratory murmur is everywhere audible. The treatment in this case must be active and decided, for if ne- glected the disease runs into the miserable complication of pulmo- nary tubercle with laryngeal ulceration. The patient must be confined to bed, or to a warm room, and placed on a milk diet; all exertions of the voice are to be prohi- bited. Leeches are to be applied daily to the windpipe, beginning HEMOPTYSICAL VARIETY. 367 with from eight to ten, and diminishing the number for four or five days; blisters may then be applied to the nape of the neck and sternum. But these remedies, though successful in a few cases, may fail, unless we adopt the mercurial treatment first recommended by Mr. Porter in sub-acute laryngitis. By the use of mild but frequently repeated doses of the ordinary mercurials, in combination with opium, we are to affect the gums gently, but decidedly ; when it will commonly happen that all tracheal and pulmonary irritation shall subside. Thus by the use of mercury we prevent the development of tubercle. This brings us to the important subject of the mercurial treatment of incipient phthisis. Before entering on it, however, we shall notice the two remaining cases for treatment. Hemoptysical Variety. — An individual in perfect health, or labouring perhaps under a slight cold, is attacked with copious hemoptysis, accompanied with great excitement of the heart. The hemorrhage having nearly subsided, we find the breathing and circulation quick; cough continues, and there may be local pain. The upper portion of one side sounds dull, and here the respiration is decidedly feeble, although generally with little rdle. This interesting fact has been already alluded to. The absence of rdle probably proceeds from the obstruction of the minute tubes by coagula. In a case of pulmonary apoplexy, I found every tube that could be traced plugged up by a bloody coagulum. But in certain cases of the strongly marked strumous diathesis we see a rapid advance of tubercle without the stethoscopic signs of mucous irri- tation, particularly when repeated bleedings has been performed. In these cases the tubercular development is often astonishingly rapid, no interval occurring from the first invasion. In a few, however, there is an interval of calm between the cessation of the hemorrhage and the phthisical symptoms. For controlling the hemoptysis the best treatment is general, followed at once by local or revulsive bleeding. Guided by the stethoscope, we apply a great number of leeches over the affected part, and repeat this treatment frequently. In a few cases I have seen leeching the feet, followed by the pediluvium, to have an excellent effect; but it is decidedly inferior to local bleeding. It is always better to control the bleeding in this way than by direct astringents; if, however, we must have recourse to these remedies, we may employ the acetate of lead in full doses, combined with opium, and a little excess of acetic acid, or we may use the sul- phuric acid and alum. I have never applied cold to the chest. The patient is to be kept perfectly at rest, and all unnecessary examina- tions avoided. Dr. Cheyne has given the weight of his testimony strongly in favour of bleeding in the hemoptysical variety of phthisis, and, in cases of bronchial hemorrhage threatening consumption, he re- commends small bleedings at intervals of a week. He considers 368 DISEASES OF THE RESPIRATORY APPARATUS. bleeding to be justified during hemoptysis, or any symptom or sign of inflammation. In such cases he exhibits tartar emetic in nau- seating doses, or the combination of one-fourth of a grain of tartar emetic, with ten or fifteen grains of nitre, a combination in which he places great confidence. {A Utter on Hemoptysis, tyc, Dublin Hospital Reports, vol. v.) In such cases I have not used emetics, from a dread of their increasing hemorrhage. I have seen death to occur in a case of hemoptysis, in consequence of an enormous eruption of blood after vomiting, induced by a very small portion of tartar emetic. The hemorrhage being controlled, the indication is to restore the lung to health as speedily as possible. All the means pointed out in the treatment of the first variety are to be used, but with greater activity. I shall presently notice a case in which mercury was employed. " The treatment," says Dr. Cheyne, " which I would recommend in incipient phthisis may be stated in a few lines. Journeying, if practicable, or what is better still, in fine weather, going from shore to shore in the steamers j short residences at Mallow, or the Cove of Cork, or some favourite spot in England, or, during the summer in Scotland. Diet as generous as the state of the lungs will permit; in some cases a glass or two of claret, and small bleedings. Sponging the chest and arms with very dilute nitro-muriatic acid, or with five parts of Mindererus's spirit, and one of spirit of rosemary; an issue over the most suspected portion of the lungs, or a succession of blisters, after each bleeding, each not much larger than a dollar; a light bitter two or three times a day, with twenty or thirty drops of laurel water, or the nitro-muriatic acid internally, or perhaps some preparation of iron. If I had time I would explain my reasons for rarely sending patients, in any stage of consumption, to the continent of Europe."— Op. cit, p. 364.) Pneumonic Variety. — This has been already alluded to when describing the succession of tubercle to an unresolved pneumonia. But the case of pneumonia occurring in a strumous habit, and particularly when engaging the upper lobe, may be arranged under the same head. In this case the disease may be primary, or occur in the secondary form. The treatment is to consist in repealed local bleeding with the cupping-glass, continued counter-irritation, the use of the seton, and the employment of mercury and sarsapa- rilla, as in the case of chronic pneumonia. Mercurial Treatment of Incipient Phthisis. — The idea of ar- resting the progress of scrofulous inflammation of the lung by mercury occurred about the same Jime, and without any mutual communication, to my friends, Drs. Graves and Marsh, and to my- self, and for the last few years these gentlemen and 1 have treated with mercury several cases of incipient pulmonary disease, which would in all probability have ended in phthisis. This subject is alluded to in Dr. Graves's Clinical Lectures. The facts stated in Dr. O'Beirne's valuable paper on the use of mercury in diseases of MERCURIAL TREATMENT OF INCIPDZNT PHTHISIS. 369 the cartilages (Dublin Medical Journal, vol. v.), first led to the hope that by similar treatment a strumous inflammation of the lung might be arrested. But a great number of observations must still be made in order to establish the actual value of this practice, and it must be recollected, that in the cases thus treated other and active means were employed to remove the local disease. Independent of the case of tracheal irritation, I have observed the action of mercury in some instances where the lung was de- cidedly engaged ; in two, permanent recovery followed; in one, the disease was arrested for some months, after which it returned with its former symptoms, and the patient died tuberculous; and in one, although mercury was thrice employed, no good effect whatever followed ; and on its last exhibition the remedy manifestly disagreed. I shall briefly notice these cases. A gentleman, aged twenty-four, was attacked with violent he- moptysis ; in a week afterwards he presented the following symp- toms: the respiration was hurried, the cough troublesome, with a scanty, mucous, and bloody expectoration ; the pulse quick, and the action of the heart strong; fever of a remittent character, with a tendency to perspiration, existed ; the patient lost flesh, looked pale and haggard, and complained of pain in the upper portion of the left side. The antero-superior portion of the left side sounded compara- tively dull; the respiration was here very feeble, with an obscure rdle evident on deep inspiration ; clearness of sound and puerile respiration existed over the remaining portion of the chest. No doubt could be entertained that if the symptoms and signs were not removed, a rapid consumption would ensue. The patient was confined to bed ; bleeding, both general and local, was re- peatedly performed, and mild mercurials exhibited at short intervals of time. The constitutional symptoms were much relieved, but the local signs continued unchanged, and the system resisted the mercurial action; calomel was now exhibited, and ptyalism at last produced, when a marked amendment took place, the sound became much less dull, and the respiration louder. The remedy was now omitted, and a large open blister established, and the patient was removed to the country. His convalescence was slow, but satis- factory ; the pulse was kept in check by prussic acid; and in the course of a year his health was restored. During this time several slight relapses took place, but they yielded to local depletion and counter-irritation over the affected part. A slight degree of atrophy of the sub-clavicular region occurred. A gentleman, aged thirty, was affected for several months with severe dry cough, which was frequently aggravated by exposure to cold and fatigue; he became pale, his pulse w-as quickened, and he presented all the appearances of approaching consumption. The right clavicle and scapular ridge sounded slightly, but decidedly dull; the respiration in the upper portion of this lung was feeble, and mixed with an obscure mucous rdle; no signs of bronchitis vol. n. — 32 370 DISEASES OF THE RESPIRATORY APPARATUS. existed in any other portion of the lung. These circumstances and the fact of the patient having lost two brothers m consumption, excited the greatest alarm. . The trachea was repeatedly leeched, and mercury, first in the form of blue pill, and afterwards in that of calomel, exhibited ; after a considerable time, full ptyalism was produced, when all the symp. toms subsided, the chest regained its sonoriety, and the rdles alto- gether disappeared; the patient regained his flesh and strength; several months are now elapsed, and he remains in the enjoyment of perfect health. A middle-aged female was admitted into the Meath Hospital with acute phthisis, under which she speedily sank ; the lungs were found tuberculated. It appeared that about three months before her final attack she had been seized with symptoms precisely similar to those which ushered in her last illness; these were subdued by mercury, and during the interval of the two attacks she had remained free from all pectoral symptoms. A woman was admitted into the Meath Hospital, labouring under violent symptoms of pneumonia, principally affecting the upper portion of the left lung, which resisted repeated bleedings, both general and local, and the use of tartar emetic; the disease ex- tended to the left lung, without, however, passing into hepatisation in the right; mercury was now exhibited, and the mouth made sore, but without any alleviation of symptoms ; copious expectora- tion came on, and the patient died in about three weeks in great agony. Both lungs contained numerous small, transparent tuber- cles, the intervening tissue was of a grayish-white colour, and the lung infiltrated with an enormous quantity of a white serous fluid. A gentleman was attacked with hemoptysis, followed by violent and distressing cough ; under the supposition that the liver was diseased, mercury was exhibited, but without improvement; he then came to town. He had cough, hoarseness, emaciation, and a quickened pulse, and the right clavicle presented a slight degree of dulness. It was determined to again employ mercury, but the medi- cine distinctly disagreed, no ptyalism was induced, the tubercular symptoms rapidly advanced, and the remedy was of course omitted. A gentleman, residing in France, was attacked with severe cough, with pain in the chest and tendency to hectic. A syphilitic affec- tion had previously existed, but, in its primary form at least, had been removed. The symptoms continuing, he came to Dublin. He was emaciated, had incessant tracheal cough, with great irri- tability of the nervous system. The fits of coughing were most distressing. In addition to these, he had severe pain in the upper sternal and right sub-clavicular regions, which seemed to proceed from periostitis, a diagnosis rendered more probable from the fact of his having distinct periostitis of the scalp, accompanied by mad- dening headaches. From the violence of the cough, an accurate stethoscopic examination could be scarcely made. A mild mercurial course completely removed all these symptoms. TREATMENT AFTER EXCAVATION HAS FORMED. 371 The patient felt for several weeks restored to a state of health to which he had been long a stranger. He regained his flesh, strength, and appearance, his pulse became perfectly quiet, and he returned to the continent. In little more than two months he died of pul- monary tubercle. I have now stated my experience of this matter. As to the general employment of mercury in incipient phthisis, I am any- thing but sanguine; yet that by its assistance in removing irritation from the mucous membrane and parenchyma, we may occasion- ally arrest the development or progress of tubercle, seems more than probable; for there can be little doubt that, in the scrofulous habit, there is more danger of tubercle from the persistence of irritation of the lung, than from the action of mercury on the system; but the remedy is a two-edged sword, and its exhibition must not be lightly attempted. Extensive numerical investigations must be made be- fore the treatment can be considered as in any way established. The subject is one of the greatest importance. In all cases, it must be remembered, that under treatment physical signs will dis- appear, or become less evident; and that this proceeds from the removal, not of tubercle, but of intercurrent irritation of the lung. We must, therefore, use the greatest caution in prognosis, and in all investigations bearing on the point, the subsequent history of the patient, for months or years, must be, if possible, ascertained. After the early stages of treatment, if an arrest of symptoms be happily produced, an issue or seton should be established ; and the patient should travel, and choose for the next season a temperate winter residence. 'Treatment after Excavation has Formed. — In a few cases, even after excavation has formed, I have seen a recovery.* In these cases * [Curablexess of Consumption. — Doctor Stokes, it will have been seen, considers phthisis to be curable. I might have extended my remarks on this point in a preceding lecture by references to the additional experience of other writers than those there cited, in favour of the curableness of consumption. Dr. S. G. Morton, in his valuable "Illustrations of Pulmonary Consumption^ distinctly ex- presses hisconviction,not merely of the cicatrisation of open tubercles but of their entire removal by absorption. Butthemostextended inves- tigation of the subject yet made is by M. Rogee (Sur la Curability de la Phthisie Pulmonaire, fyc). His observations were made in a careful port mortem examination of more than two hundred sub- jects. Of this number there were a hundred old women, upwards of sixty years of age. M. Rogee noticed more particularly two kinds of lesion at the apex of the lungs, which seemed to him of peculiar interest, viz., cretaceous or calcareous concretions, and cicatrices of the pulmonary tissue. The concretions were found by M. Rogee in fifty cases out of a hundred ; their situation corresponding precisely with that of tuber- 372 DISEASES OF THE RESPIRATORY APPARATUS. there was no evidence of the advance of tubercle, and the larynx and digestive system escaped disease. In other instances, treatment has distinctly prolonged life for many years. The principal remedy employed was the seton, with frequent changes of air, or sea- voyaging. In some cases the patients confines themselves to a milk and farinaceous diet, while in others they lived freely, indulged in wine, and entered into all the enjoyments of society. In one case, where a large cavity existed, the symptoms subsided on the occur- cles as commonly seen in the lungs, viz., at the summit of the lung thirty-nine times; equally distributed through the lung six times; in several parts of the lung, but not at the apex, six times. The relative frequency of the concretions in the two lungs were as follows: — In both lungs, simultaneously . . 24 times. In the right lung . . . 17 „ In the left lung . . . . 10 „ 51 Very frequently when there were concretions in the lungs there were also some in the bronchial glands. In size they were equal to a grain of hemp or a pea ; sometimes equal to a hazlenut; and, again, often as small as a millet-seed. They were found in dis- tinctly tuberculous lungs as well as those otherwise healthy. M. Rogee does not hesitate to regard these cretaceous and cal- careous concretions asthe result of the transformation of tubercles; in fact, of tubercles which were healed. An additional argument in favour of his opinion is adduced by him, in the fact of concre- tions being sometimes found in the lymphatic ganglions, which are also occasionally the seat of tubercles. Cicatrices are next noticed by M. Rogee. He divides them into four species: — 1. Cicatrices with the cavity still preserved. 2. Cicatrices with cretaceous or calcareous matter filling the cavity. 3. Fibro-cartilaginous cicatrices. 4. Cellular cicatrices. He details cases of persons at very advanced age, one of a woman eighty-four years old at the time of her death, in whose right lung were found two caverns perfectly cicatrised ; a third less advanced containing tuberculous matter, which had passed into the creta- ceous form. In the left lung there was a calcareous concretion. In two other cases of women, each seventy-four years of age at the time of death, cicatrised excavations were found, which had no communication with the bronchia. The whole paper of M. Rogee, which is published in three consecutive numbers of the Archives Generales de Midecine, 1839, merits an attentive perusal. He cer- tainly must obtain credit for establishing the position with which he set out, that pulmonary consumption is curable. — B.] TREATMENT AFTER EXCAVATION HAS FORMED. 373 rence of fistula in ano. The individual is now in robust health- Two of his brothers died of phthisis. In a case with cavity, yet in which the symptoms and signs are not progressive, the patient's best chance I believe to be the use of the seton, and travelling. If he does not recover, his life will be probably prolonged. He should take as little medicine as possible ; he should adopt all strengthening means, and use such a regimen as experience points out as the best. Heated rooms, cough mix- tures, acid draughts, inhalations, narcotics, " repeated counter-irri- tation," and all the varied and harassing treatment which ignorance supposes to be curative — these are not the means of recovery. So long as a drain from the chest does not weaken, it is clearly useful, and all the other means should be calculated to give enjoyment to the mind and to strengthen the body. See Dr. Forbes's notes to the translation of Laennec's Works, article Phthisis Pulmonalis. It is no little gratification to me to find my views of treatment of con- firmed phthisis coinciding so closely with those of this distinguished physician, to whose exertions British medicine owes so deep and lasting a debt. Our experience of the use of issues is different; but only so far, that in a certain number of cases, very limited, indeed, I have known recovery, or great prolongation of life, to occur after their employment. In the vast majority of cases, however, they seem worse than useless. The patient's winter residence should be, if possible, in a temperate climate ; but his occupation in summer and autumn months should be travelling. The temperate and even colder countries maybe visited with advantage. For winter resi- dences in this country, the patient may choose, in Ireland, the Cove of Cork,and also Mallow ; and in England,the various coast-towns of Devonshire and Cornwall. Of the latter, I have the most favour- able experience of Torquay. Dr. Forbes speaks favourably of Penzance. See his Observations on the Climate of Penzance. In the essential point of equability of temperature, the Cove of Cork is surpassed by few places. Recent observations have shown that the mean difference of temperature of the days and nights rarely exceeds four or five degrees, and often in the winter months does not exceed one degree. The town is completely sheltered from the north wind, and, from its southern exposure, receives the full influence of the sun and the southern breeze. It is only within the last few years that Cove has attained its celebrity. It is now the resort of many invalids. Of course, as in all places of the kind, the good effects of the climate are seen more in the temporary improvement in the health of patients than in their final or permanent cure. Such, however, is the penalty which all places of the sort must pay for their celebrity. Patients in the advanced stages of disease are continually arriving, and the favoured climate is expected to effect impossibilities. I shall not enter further into the subject of climate, but refer with pleasure to the works of Dr. Clark ; works which must ever be the 32* 374 DISEASES OF THE RESPIRATORY APPARAT guides of the consumptive, and the text books of the student of con- sumption* I have not alluded to iodine, because I believe that as * [In the United States the climate of East Florida has been highly lauded by many invalids, and more than one professional writer on the subject. Dr. Forry (op.cit.) in particular, is warm in his eulogies of a region which seems to have become in a sort endeared to him by the very hardships which, as one of the cam- paigners in the Indian war, he necessarily encountered. He de- scribes the peninsula of Florida as " possessing an insular tempera- ture not less equable and salubrious in winter than that afforded by the south of Europe." The comparison meant to be advantageous for Florida is not, however, you will have learned from the facts and tenor of my lecture on the "Causes of Consumption," (LXXIII.,) over flattering in fact. If the science of statistics, or, as it is the fashion of the day to call it, "the numeral method," were applied to an investigation into the proportion of cases of, I will not say cure, but of real relief and prolongation of life, I am afraid that much of the favourable opinion now entertained in favour of the countries bordering on the Mediterranean would be dispelled. The reputa- tion of the West India Islands, for the sanative influence of their climate is very much on the same deceptive basis — maugre the praises of St. Croix and certain parts of Cuba sounded by both invalids and physicians. The southern portion of the island of Cuba, the one as yet hardly spoken of, is that, however, on which our hopes must rest for a winter residence for the consumptive. I would not advocatethe other view of the subject taken by the late Dr. Parrish.to "rough it" in nearly all weathers (North Amer. Med. and Surg. Journ., vol. viii.); disregarding, at any rate, the winter's piercing cold, or Boreas's rude blast; but I believe that the strongest examples of suspension of phthisis, perhaps of cure, in its incipient stages, have been furnished by those who have been most intent oil change of air and scene, by almost continual travel,—now south, then north—one year in the far east, another roaming west. Next to this extended travel will be that course better adapted to the pecuniary resources as well as the feeling of the majority of phthisical invalids. It is to travel for weeks, it may be months entire, on horseback. Even at their own homes this kind of exercise can be taken daily; and who has not seen, by a persistence in this plan, invalids ap- parently in the last stage of decline battle it out for many months with the grim tyrant. Notwithstanding the prejudice, for I believe the adverse opinion amounts to this, against rooms artificially warmed, I should prefer for myself to reside in a house with equable temperature and moisture kept up during the winter and spring months, with adequate ventila- tion, and the privilege of sallying out for a short walk, or preferably still, a ride on horseback, whenever a genial sunshine and a southern air would allow of exit from the house. These, with the comforts of PALLIATIVE TREATMENT. 375 yet no case has been made out in favour of its exhibition. That its employment is generally adopted on the grounds of false analogy, and in ignorance of the pathology and pathological anatomy of tubercle, cannot be denied, and the consequence is what we might expect, that it is the favourite remedy of the harpies of medicine. Many cases may we see in which precious time is lost in the ad- ministration of the supposed specific ; many cases of injury of the digestive system, and of acute irritation of the lung, occur from its use, whether it be exhibited by the stomach, or brought to the lung by direct inhalation. The sufferings of a phthisical patient are suf- ficiently severe, without being aggravated by the interference of the empiric, who, ignorant of disease, as well as of the better feel- lings of our nature, prescribes for his own profit; supports his trade by mendacity, and increases his torturing exertions in proportion as his miserable patient approaches the couch of everlasting rest. Palliative Treatment. — I shall here shortly allude to some of the more distressing symptoms, such as hectic, pain, cough, expect toration, hemoptysis, and diarrhoea. The hectic is more a measure of the irritation than the suppu- ration of the lung. It will be often relieved or suspended by local depletion, by an hemoptysis, or by the adoption of a less stimulat- ing regimen. When the hectic is severe in the early and middle stages the patient should stay as little as possible in bed. He should not sit during the day in his sleeping-room, which should be a large airy apartment. The chest should be sponged with tepid vinegar and water ; frequent changes of linen are to be pro- vided, a fresh garment being put on when the sweating commences ; his diet must be of the least stimulating kind, and the digestive system carefully regulated. In a few cases, some of the prepara- tions of bark answer well, particularly where the fever assumes an intermittent character; but we cannot persist long in their use. We cannot too strongly denounce the attempt to moderate the hectic sweating by medicines merely, without attention to other circumstances. If the season be mild, the patient should go out every day. The pains are best relieved by a few leeches, or, what is as good, a small blister over the affected part, which may afterwards be dressed with the ointment of morphia. The application of turpen- tine, sprinkled on a hot cloth, will often succeed ; and in many cases, the belladonna, or other anodyne liniments, will remove the pain. When, however, the pain is accompanied with the friction signs, the best treatment will be a few leeches or a blister. There is a certain neuralgic affection of young females, which simulates the pain of phthisis. The patient complains of severe pain of one clavicle, generally the right; the pain is remittent or home, the prompt remedy for removing inflammation or any compli- cation of the disease by one's own physician, and the solace of friends, will give the invalid advantages which neither Nice, nor Pisa, nor Rome, nor St. Augustine, nor Cuba, can procure for him___B.] 376 DISEASES OF THE RESPIRATORY APPARATUS. intermittent and accompanied with exquisite tenderness; the dia- gnosiT^^awn'fr^mThnbsence of the stethoscopm signs, of pul- monary or pleural irritation, the clearness on P^u^ absence of constitutional symptoms. The value of these diagnostics is of course directly as the chronicity of the case. In the course of a single case we must have recourse to various remedies to allay the cough. All the different forms of demulcen s and opiates may be employed; of the latter, the most preferable are the different preparations of opium, hyosciamus, cicuta, and- belladonna. Inhalations of the vapour of water, containing a nar- cotic extract, are often useful. Where the cough resists these means, a few leeches applied to the trachea, on the principle advocated by Broussais, and more lately adopted by Dr. Osborne, will often give relief; and in some chronic cases, where even all these means fail, I have often found that the common antispasmodic mixture of camphor, valerian, opium, ammonia, and ether, gave the greatest relief. But the greatest caution must be used in adopting measures to check expectoration, for it is the natural relief of the lung, and unless its quantity is so great as to run down the patient's strength, it should not be interfered with. Its arrest too often lights up new irritation in the lung, or produces the enteric complication. I have seen the most dreadful consequences from the use of stimulating inhalations, carelessly or too long employed. Those of which I have had much personal experience are the inhalations of iodine, chlorine, and tar. They all act in arresting the secretion of the lung, and are, consequently, hazardous. They have no specific action on tubercle, but, by arresting purulent secretion, they cause a more rapid development of the disease. I have seen the chlorine inhalations used in a number of cases, and always with bad effects ; fresh irritations of the lung, pains of the side, tightness of the chest, sudden anorexia, diarrhoea, and sopor, have followed its use. If there be any means likely to diminish the chance of injury from inhalation, it is the combining it with decided and extensive counter-irritation. The experience of Meriadec Laennec, and of Dr. Forbes, is op- posed to the use of chlorine. Why is it that medicine is still to be disgraced by publications similar to those in which we find this treatment recommended ? publications, to use the words of Dr. Forbes, "alike unworthy of the notice of the honest pathologist and the philosophical physician."* When hemoptysis occurs, its treatment must vary according to the accompanying circumstances. In the active variety, or that accompanied with much fever or excitement of the heart, our best treatment will be small general and local bleedings, the application of leeches to the feet, the internal use of ice, and the different * [Iodine by inhalation, from which more benefit has been con- fidently expected, is scarcely more efficient. — B.] DISEASES OF THE HEART. 377 astringents, particularly sulphuric acid, alum, and the acetate of lead, in free doses. The diarrhoea, proceeding, as it almost always does, from an enteritis, is best treated by attending carefully to regimen ; in the early stages, it can be generallycommanded by the ordinary creta- ceous and opiate medicines, but these soon lose their effect. We must then use the metallic astringents, combined with opium, and have recourse to small anodyne enemata; when even these fail, I have often seen the most marked advantage from the application of a blister to the abdomen. In many cases, the diarrhoea was per- manently arrested, and the comfort of the patient materially improved. DISEASES OF THE HEART. LECTURE LXXVIII. DR. BELL. Diseases of the Heart.—Position and structure of the heart—its valvular me- chanism—Beat or impulse of the heart; when felt—Percussion—Various tones according1 to the part of the sternum struck—Auscultation—Two sounds of the heart; the first caused by the systole of its ventricles; the second by the resistance and sudden tightening of the semilunar valves—Different organic affections of the heart—Functional disorders—Simple carditis, a rare disease—Sequences of—Softening—varieties and causes of—Diagnosis not easy—Treatment, similar to that of pericarditis—Perforative ulceration and rupture—Recorded cases of and complications with.—Aneurism, ventri- cular—Thurrnan's summary of—Its precise seat and complications.—Aneu- rism of the auricles. I cannot offer you more than a mere outline of the subject of the morbid states and the disorders of the heart; and even from attetnpting this within the limits of two or three lectures, I feel almost deterred when I look over the works of Laennec, Bouillaud, and Hope, the lectures by Dr. C. J. B. Williams, and the elaborate articles in the different Medical Dictionaries, both French and English, as well as the contribution of Dr. Joy in the Library of Practical Medicine, now before me. But a comparatively short period has elapsed since Corvisart, the favourite physician of Napo- leon, was the only, as he was the earliest authority, entitled to any consideration on the diseases of the heart. After him came Bertin in France, and Testa in Italy, and connecting him with those who in our own day have done so much to make the pathology of the heart a part of demonstrative science. For correct diagnosis of the diseases of the heart, we must be familiar first with its position in health in the chest, and then its healthy structure. The heart is placed in the anterior mediastinum, rather to the left of the mesial bone, and so oblique that the apex points forwards and downwards to the left, while the base lies back nearer the posterior centre, the spine. It, therefore, lies with its 378 DISEASES OF THE RESPIRATORY APPARATUS. point forwards on the diaphragm, underneath which are the live and stomach ; and it is bounded on other sides by the lung, except a small space of about two inches, where, enveloped in its cover- ings, it is in contact with the walls of the chest. Its base is directed upwards, backwards, and to the right side, looking to- wards the fifth, sixth, and seventh dorsal vertebras, the esophagus and descending aorta intervening; and its point consequently downwards, forwards and to the left, answering in the erect pos- ture, and in a medium state of distention, and the heart in the act of systole, to the fifth intercostal space, that is, in a middle-aged individual, to a point about two inches below, and one to the inside of the nipple; or two and a half from the base of the xiphoid car- tilage. About one-third of the heart, consisting principally of the right auricle and the upper and right side of the base of the cor- responding ventricle, lies behind the sternum. The orifice of the pulmonary artery and its valves, and consequently those of the aorta likewise, which lie posteriorly, but nearly in the same line, are placed immediately behind the upper edge of the sterno-costal articulation of the left side. A moderately-sized stethoscope, ap- plied over the origin of the pulmonary artery, will cover also the aortic orifice and its valves, as well as a very considerable portion, nearly half of each of the auriculo-ventricular openings. The posi- tion of the heart is affected in a sensible degree by gravitation, and consequently by posture. In structure the heart is known to you to be a compound hollow muscular organ, consisting of four compartments or cavities, lined with serous membrane and invested by a fibrous capsule, external to which is a serous membrane, that forms by reduplication the pericardium or heart-sac. The contraction of the heart and the direction in which it chiefly contracts will be understood after knowing the origin and insertion of its fibres. The greater number of these, or fleshy bundles, arise from and are inserted into the strong fibrous rings which form the auriculo-ventricular openings, or into tendinous prolongations from them. The contraction of all these muscular fibres is towards the auricular and arterial orifices, which are the most fixed parts of the organ, and the effect of the con- traction must be to press the contents of the cavities towards these openings. Attached by the vessels at its base, and with its apex free, it is drawn together towards these vessels at each contrac- tion ; and the anterior surface being more convex, from the fibres being much longer than those behind, their contraction is greater, and the apex is, also, drawn forwards as well as upwards. The valvular mechanism of the heart, so important for the dis- charge of the function of this organ, must be understood in order that we may appreciate the nature of its deranged and irregular con* tractions. The office of the semilunar valves is obvious enough, from their mere mechanical structure — attached by the whole of their convex ventricular margins, they fall loose and unresisting against the sides of the arteries at each gush from the ventricles; but no sooner does the gush cease, and the distended arterial PHYSICAL EXAMINATION IN DISEASES OF THE HEART. 379 column press backwards, than their loose arterial margins are caught by the first turn of the refluent current, and they are dis- tended into three sacs, the free sides of which being in close con- tact completely intercept the passage of blood back into the ven- tricles. This action is merely mechanical, and can be produced in the dead body; it will be more perfect in proportion as the back- ward pressure from the arteries is greater. The auriculo-ventricular valves on the other hand, will not act well after death: their office depends on the vital contraction of the fleshy columns, to which their cords are attached, as well as on the mechanical spread of their laminae. On the right side we see the irregular triangular curtains of the tricuspid valve, which are drawn in succession, one somewhat behind its neighbour. When the right ventricle is much distended, these curtains do not entirely reach across the orifice; and regurgitation takes place. This seems to be a provision against an excess of pressure on the pulmonary vessels, and induced Mr. Adams of Dublin first to call this valve a safety-valve. The heart in action, communicates its beat or impulse percep- tibly to the person making an examination, when his hand is applied to a particular part of the chest, viz., to the left front between the fourth and sixth ribs, and about two inches below and in front of the left nipple in males; but they vary remarkably, both in strength and extent, according to the stage of the respiratory act and the posture of the body, as well as from differences in their own strength. Modifications will also occur from tumours and effusions of liquid or air into the pleura, and even from abdominal tumours and a distended stomach. The greater thickness and strength of the left ventricle make its motions more forcible and extensive than those of the right; and it is perhaps, as Dr. Williams, whose description I am now transferring for your behoof, suggests, that for this reason this ventricle is placed to act chiefly on the soft cushion of the lung, which offers no unpleasant resistance to it. Percussion is the next means of examining the region of the heart. It is performed by striking on the back of one or two fingers firmly applied on the chest, with three fingers of the other hand slightly bent, either on the ribs, which is better, or the inter- costal spaces if necessary. This is the plan adopted for the last seven or eight years of his life by Dr. Hope. It is scarcely neces- sary, he adds, to say that percussion over a solid, as the heart, where it is in contact with the walls of the chest, elicits a dead sound ; while that over a body containing air, as the lungs, stomach, &c, produces a hollow sound. It is less generally known, that a solid beneath a body containing air, as the liver beneath the edge of the lung, the outline of the heart beneath the lung that overlaps it, &c, may be recognised by a sound intermediate between hol- low and dead. Having tried the experiment before several indi- viduals placed at remote parts of a spacious room, Dr. Hope found that they readily distinguished the full hollow tone of the middle lobe of the lung, the duller intonation of the lung overlapping the heart or liver, and the dead sound of the precordial region, where 380 DISEASES OF THE RESPIRATORY APPARATUS. the heart is in contact with the walls of the chest. In a well con- stituted chest of a person who was fat, there is commonly some dulness on percussion from the left margin of the sternum to the extent of between one and two square inches towards where the impulse is felt; but this dulness is remarkably diminished, if not quite removed, by a leaning back or supine posture, and by taking a full inspiration; and it is as notably increased by leaning for- wards and. to the left and by a forced expiration. If variations in these respects are not observed we have at once probable evi- dence of some morbid condition of the heart either by adhesions or pericardic effusion. When the heart is enlarged, as by hyper- trophy, dilatation, fat, or even temporarily by congestion, the de- scent of the lungs being impeded, the dull portion increases, and may attain the diameter of three, four, or, in extreme enlargement, even five inches. The centre of the dulness generally lies between the cartilages of the fifth and sixth ribs ; but in great enlargement it lies lower, as between the sixth and seventh ribs. In copious hydropericardium, Dr. Hope has known (he dulness ascend under the sternum, in the conical form of the sac as large as the level of the second rib; and he has repeatedly traced the gradual descent of the dulness in proportion as the fluid was absorbed. The next evidence of the degree and kind of the heart's action is procured by the sense of hearing — or by auscultation. By listening either with the stethoscope, or with the ear alone applied to the region of the heart, you hear at each pulse two sounds fol- lowing each other in quick but regular succession, and succeeded by an interval of silence until the next pulsation. The first is a long, rather dull sound ; the second a short, abrupt flap; they are compared by Dr. Williams to the articulate sounds lubb dup. After many and varied experiments, and much discussion not always conducted with philosophic coolness, it is now decidedly as- certained that the first sound accompanies the whole duration of the systole of the ventricles, which also causes the impulse felt on the walls of the chest; and itisalso rendered equally clear that the second or flapping sound occurs at the first moment of the diastole. The motion of the auricles is accompanied by a slightly perceptible sound, according to Dr. Pennock and Moore (Experiments on the Heart, fyc). Various opinions have been held respecting the causes of these sounds. The first sound is attributed by Dr. Hope to muscular extension, by which he means a loud, smart sound, produced by the abstract art of sudden jerking extension of the already braced muscular walls of the ventricle, at the moment when the auricular valves close; 2, to muscular or rotatory mus- cular sound — bruit musculaire ou rotatoire — the dull rumbling sound of muscular contraction ; 3, the sound of valvular extension the most important of all. Dr. Williams refers the first sound or ventricular systole to a vigorous and rapid motion suddenly resisted by the mass of blood to be urged forwards by the contraction. In other instances abrupt and forcible contraction produces a sound like the first sound of the heart. If the end of a flexible tube be DIFFERENT DISEASES OF THE HEART. 381 applied at the abdominal muscles, and these be started into sudden vigorous action, one can hear sounds quite as loud as those of the ventricles, and very like them in character. By varying the mode of muscular contraction different kinds of sounds may be obtained. The second sound is believed by Dr. Hope, and by Drs. Pennock and Moore (Hope on the Heart, edited by Dr. Pennock), to be pro- duced by the closure of the sigmoid valves exclusively; by Dr. Williams, to be owing to the sudden tightening of the semilunar valves at the mouths of the arteries (aorta and pulmonary artery). The first sound, the impulse and the ventricular systole are syn- chronous. The second sound is synchronous with the diastole of the ventricle. The auricular systole, as we learn from Drs. Pen- nock and Moore (op. cit.), is attended by a slight intrinsic sound which is absorbed in or masked by that of the louder sound of the ventricular contraction. With this preliminary knowledge of the normal situation and action of the heart, we are better prepared to investigate the morbid changes, numerous and diversified as they are, of this organ. Those which first engage attention, both on account of their frequency and the new products to which they give rise, causing thereby additional complication and more diversified sympathetic disturbances, are inflammations. The inflammatory affections of the heart are arranged according to the tissues and organic structures affected. Inflammation of the muscular sub- stance and intermediate cellular tissue of the heart is Carditis; that of its lining membrane Endocarditis, of its investing mem- brane Pericarditis. Carditis may give rise to softening, indura- tion, and dilatation of the heart's substance. Hypertrophy may be the result of a slow inflammation, as chronic pericarditis; but still more common from this last cause are serous effusions,hydropericar- dium, and sometimes secretion of coagulable lymph and even pus. Consentaneous with endocarditis, and sometimes occurring sepa- rately, are different structural changes in the valves; as inflamma- tion, thickening, contraction, ossification, ulceration, and vege- tations. Other diseases of the heart disturbing its function without any notable change in the organ itself, are designated by the rather vague term nervous. The chief of these are neuralgia, palpitation commonly of a secondary nature, and spasms. Palpitation occurs under two different states; the one of increased, and the other de- ficient action of the heart. The latter often accompanies syncope. The remote disorders of function from organic disease of the heart's are both numerous and important, and interest all the other primary organs of the body, viz., the brain by apoplexy; the lungs by asthma, hydrothorax, &c.; the liver by congestion and enlargement; the aorta and its chief branches by abnormal pulsations; the veins by retarding the return of blood in them, and causing anasarca at one time, ascites at another. vol. n. — 33 382 DISEASES OF THE HEART. The heart is not always the active cause or originator of func tional disorders: it is not seldom the recipient of irritation from other organs to which it responds, often with extreme vivacity In fevers its disturbed function is one of the chief characters of these diseases, and for a long time was supposed to constitute the greater part of fever itself; but an amended pathology has shown us that cardiac disease is, in general, no more than a symptom, a very important one indeed, but still a symptom. Less alarming but exceedingly harassing disorders of the heart, responsive to those of primary origin in some other organ, are continually met with in practice; the violence of which, however, is often compounded of the lesion of the remote organ and the original or constitutional susceptibility of the individual, by which at every hour, on the slightest exciting cause, more than the common routine of life, the heart throbs with violence and beats against the sides of the chest, producing by itself so much distress as to mask in part and some- times entirely the original lesion or irritation in the remote and primarily offending organ. The observing physician sees continual examples of this combination of disorders in certain forms of dyspep- sia and hypochondriasis, as well as in chlorosis and anaemia, which, by the hasty and superficial inquirer, might be supposed to indicate some fixed organic disease of the heart; or if the latter be of the sentimental school, he may regard them as evidences of a mind ill at ease, whose refined sensibilities the rough world is unfitted to under- stand and appreciate. But, as neither time nor room is allowed for discursiveness, even on affairs of heart, as they come before the lecturer on medicine, I must pass on to the fulfilment of my purpose, which is, to make a few practical remarks, resting on a patholo- gical basis, respecting the chief organic and some of the functional diseases of this organ, mentioned in the kind of syllabus which I sketched for you a few minutes ago. Carditis, once used as a term indicative of all the diseases of the heart of an inflammatory nature, without specification of part or appendage, is now properly restricted to phlogosis of the muscular and cellular tissues of the substance of the organ. True carditis is a rare disease; its existence even has been denied by Laennec. This is too extreme an opinion. Cases, though few, are sufficiently attested, as in that one by Dr. Latham, in which the whole heart was deeply tinged with dark-coloured blood and its substance softened; and here and there, upon the section of both ventricles, innumerable small points of pus oozed from among the muscular fasciculi. Corvisart, who never met with a case of car- ditis in an uncomplicated form, gave, in addition to three cases of his own, six from Meckel, Storck, and Hildanus, in all of which pericarditis existed at the same time. Partial inflammation, cha- racterized by abscess or ulceration, is of occasional occurrence. Abscesses are more rare than ulcers. The latter occur both on the internal and external surfaces of the heart, and are consequent on inflammation of their respective membranes. The diagnosis of DIAGNOSIS OF SOFTENING OF THE HEART. 383 simple carditis cannot well be made. As generally seen, the dis- ease is complicated with disease of the heart's membranes, and its treatment will be the same as that of the latter. M. Bouillaud arranges the cases of carditis under the three fol- lowing heads: those terminating in softening (ramollissement), or suppuration; 2, those terminating in ulceration, perforation, and rupture of the walls of the heart, or of the columnar carneas, tendons, or valves ; those ending in ulceration, with the consequent formation of aneurism ; 4, those leading to induration in various degrees up to a fibro-cartilaginous or cartilaginous consistence, or even to perfect ossification, as in Burn's remarkable case. Softening is described by Dr. Hope (op. cit.) as presenting itself under the colours of red, yellow, and whitish; each of which may be inflam- matory or not. In the case already referred to and recorded by Dr. Latham, the whole substance of the heart was softened. But both red and white softening have been met with by Dr. Hope, where there was a retardation of the venous circulation through the muscular substance, as in dilatation with attenuation, great ob- struction of the mitral, and occasionally of the tricuspid valve. This condition, softening with redness, sometimes met with in typhous fever, has been by Bouillaud attributed to inflammation. Laennec refers it to the alteration or putrescence of the fluids, an opinion in which he is joined by Dr. Hope. M. Louis has met with it in typhus; and it is described by Dr. Stokes as occasionally existing in this fever, and, as constituting a condition of the organ which requires stimulation, as the administration of wine, &c. Yellow softening is represented by Dr. Hope to be more common than either the red or the white; it may pervade the whole or portions only of the heart, and may coexist with hypertrophy, dila- tation, or other lesions of the muscular substance. This like the red may be inflammatory, or may occur independently of inflam- mation. The diagnosis of softening of the heart is not easy. Suspicion of its existence will be entertained when the impulse is more or less reduced in strength, the beats intermittent and irregular, and of unequal force ; the pulse being of the same nature at the time. It is true that the same character of pulse with that just described accom- panies disease of the mitral valve. The distinction between the two is thus described by Dr. Hope:—" If after an exploration suit- ably conducted, no murmur be found to attend either sound of the heart, the irregularity of the pulse may be ascribed to softening, provided it be not referrible to temporary nervousness, to a parox- ysm of dyspnoea, or to ebbing of the vital powers on the approach of dissolution — all of which circumstances are capable of produc- ing transitory weakness and irregularity of the pulse, even in a healihy heart." p. 328-9. Hypertrophy, which complicates the diagnosis, is no uncommon accompaniment of softening of the heart; and in two of the three cases introduced by Dr. Hope in his work there was at the same time pulmonary apoplexy. 3S4 DISEASES OF THE HEART. The treatment of softening when accompanied by acute inflam- mation is conducted on the same principles as those which would govern us in pericarditis. When a result of chronic disease, it demands the same remedies as the primary affection ; and these are often of a tonic nature, such as iron, quinia, nutritious animal diet, and good air. Complete cessation of palpitation is not to be expected till anaemia is removed, for this alone is capable of main- taining the symptom ; nor, adds Dr. Hope, is a diminution of co- existent inflammation to be looked for till a restoration of the tone of the general muscular system and a decrease of the physical signs of softening denote that the heart has recovered somewhat of its natural tone and elasticity. To the existence of softening of the heart in typhous fever, I have already referred ; and also of its furnishing an indication for the use of various stimulants, and, I may now add, of quinia. Coincident, at times, though not necessarily so, with inflamma- tory softening of the heart, is perforative ulceration and rupture of the organ, which last, happily a rare termination, is a fatal one. Signs of abscesses and ulcers vary in different subjects, and are not distinguishable from those of other affections. Ulceration is the most frequent cause of rupture of the heart, which may take place, however, in consequence of softening of the muscular tissue. These forms of disease with rupture are much more frequent on the left than on the right side of the heart; and, as M. Breschet asserts, more on the apex of the left ventricle than elsewhere ; but M. Rey- naud found, in opposition to this view, that in seven out of thirteen cases analysed by him the disease did not occupy the apex. The exciting causes of rupture are, generally, considerable efforts, parox- ysms of passion, external violence, falls, &c. Corvisart was the first who noticed and described cases of rup- ture of the fleshy columns and tendinous cords of the heart. Laen- nec and Bertin have each met with an instance of the same. Violent efforts, as coughing, were the cause. The symptoms were, sudden and very suffocating dyspnoea, with overwhelming faintness, paleness and coldness, followed by all the general phenomena of disease of the heart. Rupture of the heart or great vessels into the pericardium, is not always immediately fatal, as a solid coagulum or a fibrinous condition has in several instances been known to arrest the hemorrhage for a few hours. Of ten cases mentioned by Bayle eight died spontaneously, one in about two hours, and another in fourteen. Dr. Pennock, the intelligent editor of Dr. Hope's work on the heart, refers to a communication by Dr. Hallowell (Am. Jour. Med. Scien., 1835) on rupture of the heart, in which he (Dr. H.) reports two cases occurring under his own observation in the Salpetriere at Paris. The number of well-attested cases of rupture of the heart amounts perhaps, by Dr. Hallowell's computa- tion, to sixty. Of these he has given an analysis of thirty-four, in which it is stated, that the patients had been affected for a greater or less length of time with palpitations, and had experienced frequent ANEURISM OF THE HEART. 385 » attacks of lipothymia, or complained of pain beneath the sternum, and tightness and weight across the chest. Usually the accident has occurred to persons advanced in life. Sixteen of the thirty- four individuals were males, and eighteen were females. Aneurism is another sequence of inflammation of the heart, by this last causing either ulceration or softening and yieldingness of the muscular tissue. The best summary on this head is by Mr. Thur- man (Medico-Chirurgical Transactions, vol. xxi., 1838), who is largely quoted by Dr. Hope. Mr. Thurman has collected together seventy-four cases. Lateral aneurism of the left ventricle is repre- sented by this gentleman to be met with under two principal forms, viz., 1, unattended by any external deformity of the heart, and confined altogether to the ventricular walls : or, 2, it may present itself in the form of a tumour growing from the exterior of the organ, and in size varying from that of a nut to that of the heart itself. In sixty-seven aneurisms, occurring in the fifty-eight cases, thirty-four were attended by tumour; in nineteen there was no tumour; and in the remaining thirteen, it is doubtful whether tumour existed or not; although, from the small size of the sacs in these latter cases, it is probable that the disease scarcely extended beyond the surface of the ventricles. With respect to the tissues of the heart engaged in the formation of the aneurismal sac, a careful analysis of the cases would seem to show that, in fifteen, the sacs were formed by the muscular fibres and pericardium ; in four, by the endocardium and pericardium only ; in twenty-five, in all the structures entering into the composition of the walls of the heart; whilst, in twenty-three cases.the disease was either too far advanced, or the data are insufficient to enable us to assign them to their proper places. The parts of the left ventricle most affected with aneurism are the thinnest parts of its walls or the apex, and the highest part of the base. Lateral aneurism of the heart should, Mr. Thurman thinks, be regarded as the effects of inflammation, but not in any one tissue exclusively. The number of cases in which the heart is not stated to have been the seat of some lesion (hyper- trophy, dilatation, &c.) in addition to the aneurism, does not exceed ten ; and in three only is it positively stated to have been otherwise healthy. As respects the influence of sex, in forty cases, in which. this is recorded, thirty occurred in males and ten*in females. The proportion thus met with in the female is much greater than is found to be the case in arterial aneurisms, which, according to Hodgson, occur eight, and, according to Lisfranc, eleven times oftcner in the male lhan the female. There can scarcely be a doubt, Mr. Thurman thinks, that, as in the case of other organic diseases of the heart, so it is of aneurism, acute rheumatism affecting this organ, either in the form of endocarditis or of pericarditis, is to be regarded as closely connected with the production, if not as the efficient cause of this lesion. If this view should prove to be cor- rect, we shall have no difficulty in explaining the greater frequency of arterial aneurism during early lile; as it is well known that 33* 386 DISEASES OF THE HEART. the progress of acute rheumatism, the inflammatory affections of the heart which have been alluded to, occur much oftenei at this than at any other period. „ . r . . „ .___ The symptomatology and diagnosis of aneurism of the heart are not by any means clear. In a great majority of cases, the disease would seem to have a very insidious origin, and to have been only very gradually announced by symptoms. There are after a while undoubted symptoms of diseased heart; but in the specification of the precise part diseased, and the kind of disease, consists the diffi- culty stated by Mr. Thurman, and admitted by M. Bouillaud as well as by Dr. Hope. Aneurism of the Auricles. — In all the cases which have come to Mr. Thurman's knowledge, whether in the sinus or appendage of the auricle, and which are nine in number, the disease was con- nected with, and appears to have been dependent upon, an extreme contraction of the mitral orifice, producing a difficult transmission of blood from the left auricle. The number of cases of aneurismal dilatation which are recorded as having occurred in the left auricle, is much less than that which we have seen to be the case in the ventricle. LECTURE LXXIX. DR. BELL. Hypertrophy of the Heart.—Divisions of hypertrophy—Average dimensions of a healthy heart—Dr. Clendinning's and JV1. Bizot's measurements—Anato- mical characters and volume of a hypertrophous heart—Exciting causes—Dif- ferent forms and complications of hypertrophy—Connexion between hypertrophy and cerebral disease, particularly apoplexy—Ossification of the cerebral arte- ries—Capillary congestion of the mucous membranes and liver—Serous infil- trations and congestions; disease of the kidneys in hypertrophy of the heart— Palpitation—Impulse heard through the stethoscope—Hypertrophy with dila- tation—Sounds of the heart and state of the pulse in hypertrophy—Arterial pulse; its cause and characters; modifications by hypertrophy—Causes com- monly affecting the pulse—Signs of hypertrophy of the right ventricle.—Treat- ment of hypertrophy—Abstraction of blood short of producinganaemia—Moderate and frequent abstractions to be preferred.—Purgatives and diuretics—Dropsy, its organic causes and consequent pathology—Treatment of—Perseverance in treatment of hypertrophy all important. Hypertrophy. — Bertin was the first writer who entertained clear ideas of the varieties of hypertrophy of the heart, which, with Dr. Hope, we may define to be an augmentation of the muscular sub- stance of the heart, resulting from increased nutrition. The varie- ties indicated by the French writer are laid down by Dr. Hope, as follows :— 1. Simple hypertrophy, in which the walls are thickened, the cavity retaining its natural dimensions. — 2. Hypertrophy ivith Dilatation. This (the eccentric or aneurismal hypertrophy of Bertin) presents two sub-varieties, viz. — A. With the walls thick- ened, and the cavity dilated. B. With the walls of natural thick- HYPERTROPHY OF THE HEART. 387 ness, and the cavity dilated ; i. e., hypertrophy by increased extent of the walls. — 3. Hypertrophy with Contraction. In this (the concentric hypertrophy of Bertin) the walls are thickened, and the cavity is diminished. Before speaking of the morbid growth of the heart, in which, of course, we meet with abnormal dimensions and weight, we ought to have a standard of health for the purposes of comparison. Of late years weights and measurements have been made by M. Bouillaud (op. cit.), by Dr. Clendinning (Brit. Med. Almanac, and his Croonian Lectures for 1838), and with still more minuteness and variety of specification by M. Bizot (Mem. de la SociUi Medicale d?Observation de Paris, 1837). Dr. Clendinning has " attempted to obtain averages accommodated to the advancing development of the organ." He estimates the average weight of the heart to be — Males. Females. 15 to 30 years . 8* oz. . 8| oz. 30 to 50 „ . 8£ „ . 8£ „ 50 to 70 „ . 9§ „ . 8 „ 70 and upwards . 9| „ . 8 „ In his lectures, Dr. Clendinning says: the normal heart maybe assumed to average for the whole life, above puberty, about 9 ounces in absolute weight, and lh ounces, or a little more in bulk, for the female ; and to bear after death to the person, for the male, the rate of about 1 to 160; and for the female, of 1 to 150. This statement is the result of an examination and weighing of nearly 400 hearts. Sex, as you have learned from the preceding calculations, has a decided influence upon the size of the heart. Under all cir- cumstances, as remarked by M. Bizot, the size of the female heart is found to be less than that of the male. The heart, unlike the muscles of animal life, unlike, also, the greater part of the other organs, which become atrophied with age, continues to grow and increase. Old age, continues M. Bizot, is the epoch in which the heart has the largest volume. It is, positively speaking, not only more voluminous at that period, but it is absolutely greater in rela- tion to the size of the body generally. Stature modifies the volume of the heart, which is rather less in tall persons of either sex than in short ones. The proportions of the relative capacity of the ven- tricles in all ages are relatively the same. The capacity of the ventricles increases with age, and the thickness of the walls of the left ventricle increases in the same ratio or that of age, while those of the right ventricle remain very nearly stationary. In the foetus the thickness of the two ventricles is nearly the same; at birth the left is a little thicker; and with the advance of age the disparity between the two ventricles increases. Hence, as M. Bizot very truly remarks, we cannot but see, that, to take the thickness of the wall of the right ventricle as a term of comparison, as has been generally done, in order to estimate the proportional thickness of 388 DISEASES OF THE HEART. the wall of the left ventricle, is the most defective mean,' P^ible The two following tables give the thickness of the walls of the two ventricles: — 1 to 4 5 to 9 10 to 15 16 to 29 30 to 49 50 to 79 MALES. Lines. Base. Middle. Apex. 3 3* 02 A37 '2-9- *To 3| i-9- 1 1 9 24 3£ qi 3 4,V FEMALES. Lines. Base. Mi.ldle. Apex. 2 A- 21 2j_ 50 to 89 'is- 4f 4i Ah 3t'o 311 2T3H 35J* q 6 33 Medium from 16 to 79 4,6^ 5-^ 3^ 16 to 89~ t5 44 »** MALES. FEMALES. Ages. Base. Middle. Apex. Base. Middle. Apex 1 to 4 & 6 _5_ 10 10 h% ' 13 8 53 5 to 9 14 5 5 (5" "6" h% 1 J. 10 to 15 1J 4 * l-7-x20 l-\ 9 'J* TO 16 to 29 1|| h\ liV 1 4 l£ 2S 30 to 49 1A| 1 7 45 TT "5 6" 1 l9 1~22 1.1 3 2 .« *S a 27 50 to 79 2J? 1 53 4-!- H H 1 Medium from 16 to 79 I!*! l^9-]^. 15 tO 59 If 1«$J$* The anatomical character of hypertrophy consists in the mus- cular substance of the heart being usually firmer and redder than natural. But in anaemic subjects we may expect to meet with flabbiness and paleness of texture — the states which prevail in the muscular system generally. Firmness existing in a great degree constitutes induration, a distinct affection, dependent not so much on increased as on altered nutrition of the part, the elementary particles being denser than natural. It is generally attended with hypertrophy. This morbid condition, or hypertrophy, may be con- fined to a single cavity, or may simultaneously affect several, or even the whole. Sometimes one cavity is thickened, while another is attenuated. When all the cavities are hypertrophous, and at the same time dilated, the heart attains a volume, two, three, and occa- sionally even four times greater than natural; and its weight, pro- perly eight or nine times, may be thrice as much. A case, con- tinues Dr. Hope, was met with lately at St. George's, in which it was two pounds and a half. The left ventricle, being more prone to thickening and not less to dilatation than the right, sometimes attains a volume seldom or never acquired by the right; and when its enlargement is very great it occupies not only the left peri- cardial region, but extends far under the sternum, where its impulse and sound may be.mistaken for those of the right ventricle. The situation of the greatest thickening is usually a little above ihe middle of the ventricle, where the columnce earner are inserted. The cavity of the hypertrophous left ventricle is sometimes dilated * See Dr. Pennock's valuable note, in his edition of Hope. CAUSES OF HYPERTROPHY OF THE HEART. 339 to such a degree as to admit the largest orange, or the fist of an adult. I have twice, says Dr. Hope, during the last six months, seen it exceed even these dimensions. On the contrary, in hyper- trophy with contraction, the cavity may be reduced to the size of a small walnut or a pigeon's egg; in Bouillaud's case it could scarcely contain the finger. The cavity of the right ventricle, naturally a little larger than a hen's egg, may be dilated to the size of a goose's egg or more; or it may be contracted to less than a pigeon's egg. In Bouillaud's case 65, it could scarcely contain the thumb; and in case 123 the columnar carnea was so thickened and adherent that there was scarcely any cavity left, and the blood could only filter through the narrow spaces between them. Hypertrophy may be not only confined to a single ven- tricle, whether the right or the left, but it may be confined to par- ticular parts only, as the base, the septum, the apex, the columnar earner, or the external walls, the remainder of the cavity being either natural or attenuated. The hypertrophy of the auricles is almost invariably of the second species, or that with dilatation. The exciting causes of hypertrophy are either of a nervous or of a mechanical nature. Under the first head are included all moral affections, and all derangements of the nervous functions that excite long continued palpitation. The second embraces all those causes which can either accelerate or obstruct the circula- tion, and thus occasion a preternatural pressure of the blood upon the heart; such are violent and sustained corporeal efforts of every description. These violent exercises may even occasion rupture and inflammation of the valves and aorta, issuing in incurable organic disease. It is protracted efforts that are, in Dr. Hope's opinion, always the most pernicious. Malformation of the chest, either congenital or occasioned by curvature of the spine, encroach- ment of the diaphragm on the cavity of the chest from the pressure of the gravid uterus, of ovarian dropsy, of other abdominal tumours, but perhaps above all, continues Dr. Hope, of long, stiff, stay bones, or wooden busks, which, by fixing the abdomen, prevent the descent of the diaphragm, are so many causes of hypertrophy of the heart. Mechanical obstacles to the passage of the blood from the aorta, as valvular disease or extreme smalhiess of this canal, are also, occa- sional causes. Inflammation of a contiguous serous membrane, as of the pericardium or pleura, is also a not unfrequent cause ; al- though not to the extent asserted by Bouillaud, who tells us that it is almost always complicated with chronic pericarditis or endocardi- tis, or their consequences. Dr. Clendinning tells us, that in upwards of five hundred autopsies made by him of patients dead of various diseases, above one hundred and seventy, or above a third of the whole number, proved to have had heart disease in some form or other. Five-sixths of these were, he says, cases of hypertrophy uncomplicated with other diseases of the heart, such as peri- carditis, endocarditis, or valvular disease. In about thirty cases only, or in about one-sixth of the whole, was well-marked valvular 390 DISEASES OF THE HEART. disease detected; in all these last cases, with but one exception, hypertrophy existed. , .. r. The frequency of the various forms and complications of hyper- trophy and dilaiation is expressed in the following scale by Dr. Hope: — . 1. Hypertrophy with dilatation of the left ventricle, and a less degree of the same in the right. 2. Hypertrophy with dilatation of the left ventricle, with simple dilatation of the right. 3. Simple dilatation of both ventricles. 4. Simple hypertrophy of the left. 5. Dilatation with attenuation of the left. 6. Hypertrophy with contraction of the left. 7. Hypertrophy with contraction of the right. The effects of hypertrophy merit serious consideration. Among the first of these are capillary congestion, by the increased force and activity of the circulation, and serous infiltration. The sensi- bility of the organs will be exalted, and they will be rendered more liable to inflammation, serous effusion, and hemorrhage. Hence apo- plexy and phrenitis, epistaxis, ophthalmia, and other inflammatory affections of the parts of the body, have been traced to this form of disease of the heart. The connexion between hypertrophy of the left ventricle and apoplexy is clearly made out by Bouillaud, Hope, Bricheteau, and others. Of fifty-four cases of hypertrophy detailed by M. Bouillaud, eleven, that is about one-fifth, present the coin- cidence of cerebral hemorrhage or softening of the brain; and this in individuals of various ages, from twenty-five up to seventy-nine. Dr._Hope's cases of apoplexy, thirty-nine in number, at the St. Mary-Ie-bone Infirmary, between December 12th, 1832, and the same date 1834, exhibit a coincidence in twenty-seven of hyper- trophy of the heart; or 9-13, nearly three-fourths of the whole. The ages at which these conjoined diseases proved fatal are not such as might dpriori have been anticipated. Dr. Hope presents the following estimate on this score : —" Between birth and forty years, disease of the heart was not found in any of the four fatal cases that occurred within these dates. Between forty and fifty, it occurred in eight out of nine! — a remarkable increase. Between fifty and sixty, it occurred in four out of five — a decrease. Be- tween sixty and seventy, it occurred in three out of seven — a further decrease ; and between seventy and eighty, it occurred in ten out of eleven ! — another remarkable increase. It would thus appear that the periods of life during which fatal apoplexy is most prevalent are precisely those in which concomitant disease of the heart is of most frequent occurrence; namely, between forty and fifty, and between seventy and eighty." M. Bricheteau (Journ. Complem. duDict. des Scien. Med., J818,) relates twenty cases of the coincidence between apoplexy and hypertrophy of the left ventricle, and draws the same conclusion with Dr. Hope respecting the ages at which death from this con- EFFECTS OF HYPERTROPHY. 391 junction of cardiac and cerebral disease are most liable to occur. Lallemand (Recherches Anatomico-Pathologiques sur VEncephale et ses Dependences) gives several cases in which the two diseases were conjoined with fatal effect. In his Lettre lre, Observation XII., in a note, he points out a very important circumstance in the pathology of ventricular hypertrophy, viz., the contraction of the semilunar valves, which, he thinks, is the most common cause of cardiac hypertrophy, or aneurism, as he terms it. If this obstruc- * tion exist, distressing effects indicated by appropriate symptoms follow; but apoplexy or cerebral oppression is not among the number. The fact in a more modified shape is admitted by Dr. Hope (p. 261). We have a bluish colour of the lips and cheeks, infiltration in the cellular tissue of the limbs, symptoms indicating a venous congestion, which are wanting for the most part in hyper- trophy without any valvular obstruction. It has been suggested (Med. Gaz., 1835,) that "the true expla- nation of the hemorrhage in the brain is to be found in the diseased state of the cerebral arteries;" but this is assuming an occasional complication, it may be cause, for a fixed and determining one. We shall be obliged either to deny its force, or else to be able to detect a morbid state of the arteries in other organs, as in the lungs, for example, in which hemorrhage is an occasional effect of cardiac hypertrophy. But the coincidence between apoplexy and a dis- eased state of the arteries of the brain,particularly those at the base of this organ, has not been overlooked. Dr. Hope pointed it out in the first edition of his work. Still, we must admit, that ossification of the cerebral arteries, which is sometimes met with in extreme old age, is not incompatible with life and the possession of the mental faculties. It has been already stated that the brain is diseased in various ways by persistent hypertrophy of the heart. The history of indi- viduals affected with it, not unfrequently presents a striking narra- tive of violent headaches, brain fevers, various inflammatory com- plaints, and states of great nervous irritability and excitement. This remark, adds Dr. Hope, has been corroborated by the recent researches of Dr. Clendinning, his successor at the St. Mary-le- bone Infirmary. As the ophthalmic artery is derived from the carotid within the cranium, the eye participates with the brain in the effects of hypertrophy, and is vascular, brilliant, and prone to ophthalmia. The wasting away of the eye which Professor Testa (Malattie del Cuore, fyc.) has remarked as one of the effects of disease of the heart, is with good reason supposed by MM. Bertin and Bouillaud to be connected with ossification of the ophthalmic arteries. Capillary congestion of the air-passages is a common effect of cardiac disease, whether it be hypertrophy, or dilatation without hypertrophy. The mucous membrane is injected and reddened; and consequent upon this organic change are functional embarrass- ment, as hurried breathing, catarrhal and bronchitic disorders, with cough and dyspnoea. Sometimes blood is mixed with the sputa, 392 DISEASES OF THE HEART. and even a pulmonary apoplexy may supervene —a result already described to you as not uncommon, when I was speaking of hemo- ptysis or bronchial hemorrhage (Lect LXVI., p. 222-223). 1 may take this occasion to point out for correction a contradiction to this view, in my attributing pulmonary apoplexy to hypertrophy of the right side of the heart. The evidence, except in that adduced by M. Louis soon to be mentioned, is all in favour of the left being the offending and suffering side of the heart. The lungs in general are implicated with cardiac disease, manifested either by serous infil- tration or cedema. Emphysema of the lungs is also one of the most noticeable lesions which accompany diseases of the heart. Gene- rally, anterior to the latter, it is however sometimes consecutive, as when it is the result of prolonged efforts made for the inhalation of air. Congestion of the digestive mucous membrane, also, is distinctly indicated by M. Andral as a common sequence to diseases of the heart. Commonly it is mere obstruction, but at times it is con- verted into real inflammation. The liver is very frequently much congested, especially when the disease occupies the right cavities of the heart. With greatly augmented size we find the liver of a deep red and gorged with blood, which flows out freely on the slightest pressure. During life the enlargement of the organ is quite mani- fest, descending as it often does below the false ribs. A copious bloodletting, or other sanguineous evacuation, will sometimes suffice completely to remove this swelling. The spleen, sometimes more voluminous and engorged with blood than natural in heart disease, is. however, more generally small, denser, and even harder than in its normal state. Serous congestions and infiltrations from cardiac disease are met with in the cellular tissue and the serous cavities. The first appear- ance is a slight puffiness about the ankles, which gradually extends upwards, until a dropsical effusion occupies the whole sub-cutane- ous cellular tissue. The face is early swelled ; sometimes the hands and arms are swelled at the same time with the ankles; but the infiltration of the upper extremities is less seldom met with than that of the lower ones. Of the serous membranes, the peritoneum is that which is most frequently filled with effused serum in organic affection of the heart. Ascites only shows itself, however, afler infiltration of the cellular tissue of the lower limbs. Serosity in the pleura and pericardium is much less frequent; and in the arach- noid it has not been seen at all. It is worthy of remark, that both serous congestions and anasarca sometimes disappear in a short period; but they return somewhat later in the disease. The strong and sustained contraction of the ventricle, by sending more blood, and with additional impetus, to the different tissues, may so far modify their nutrition as to cause an augmented growth. Proof of this change is met with in the kidneys, which in cardiac hypertrophy of long standing are generally found enlarged and otherwise diseased, and often presenting the granular change of HYPERTROPHY WITH DUATATION. 393 structure and albuminous deposit in the urine described by Dr. Bright, and on which I have, on a former occasion, adequately en- larged (Lect. LII. and LIII.). In thus describing effects, I have indicated some of the chief secondary or functional and general symptoms of hypertrophy of the heart. The direct organic or local and physicial ones are now to be designated; and under this head I shall include those which are the immediate evidences of the morbidly excited action of the heart, such as palpitation, pulse, &c. The chief of these are, according to M. Bouillaud, the disordered actions of the heart itself, viz., an augmentation of .the force and extent of its pulsations, and of the intensity of its double sound. If to these we add increase in the extent to which dulness is perceptible on percussion in the pre- cordial region, and occasionally a notable prominence in the same part, he thinks we have enumerated its proper signs. The whole mass of the heart, instead of the mere point, seems to come into contact with the side of the chest at each beat. This summary of symptomatology requires examination. The energy of action of a hypertrophous heart, even when not subjected to the excitement either of exercise or of emotion, is such as to make it border on palpitation, and the patient has the annoy- ing consciousness of his heart beating at almost all times. He is annoyed at its thus beating, and it palpitates the more because he is annoyed. The distress is increased by stimulants of any descrip- tion, and sometimes by a full meal, however simple the kind of food. In noting now the impulse of the heart in hypertrophy we must be understood to refer to this morbid condition without valvular or vascular disease. It is better ascertained by the ear applied to the stethoscope than by the hand applied to the chest. A strong, slowly heaving impulse is the principal sign of simple hypertrophy; and the affection may be known to be greater when the impulse is followed by a diastolic impulse, as Dr. Hope calls it; by the first, the head of the observer applied to the stethoscope over the heart is distinctly raised, and he sometimes feels a shock disagreeable to the ear ; by the latter there is a sinking back in a sudden manner of the heart, terminating in a jog or shock. In simple hypertrophy, and in that with contraction, the impulse is seldom perceptible much beyond the precordial region, except during attacks of palpitation. The impulse in this, as indeed in every other form of disease, is the more perceptible the thinner are the walls of the chest. Thus, it is the most distinct in the emaciated, and in children; whereas, in very stout and muscular subjects, it may be barely susceptible. In hypertrophy with dilatation the signs are a compound of those of hypertrophy and those of dilatation. The contraction of the ventricles can easily be felt by the hand applied to the pre- cordial region, and we find during palpitation smart violent shocks which sometimes repel the hand. In extreme cases, Dr. Hope has known the extent almost equal to that of the expanded hand. If we attentively examine the patient when most calm, we see that vol. n. — 34 394 DISEASES OF THE HEART. not only his whole chest and the pit of his stomach, but his head, his bowels, and even the bed-clothes are strongly shaken at each contraction of the heart. The pulsations of the carotids, the radials, and the other superficial arteries, are often visible. The impulse of the heart can sometimes be distinctly felt as high as the clavicle in the left side of the thorax, and sometimes even on the left side of the back, especially in meagre subjects and children. The beats of the heart in hypertrophy, and hypertrophy with dilatation, free from valvular disease, are, even during palpitation, seldom irregular in the early stages of the disease, while the patient's general strength continues little impaired. But in the latter stage, preceding dissolu- tion, the pulse intermits, and the dyspnoea is sometimes excessive. As the impulse of the heart is diminished by loss of blood, diarrhoea, or any exhausting disease, rigid and long-continued abstinence, and in general all the causes capable of producing debility, we must be aware of the temporary diminution or cessation even of impulse, in an actually hypertrophied heart during the operation of these causes. The impulse of the heart is moreover masked by the existence of pulmonary emphysema over the precordial region, and it occasionally ceases entirely, or becomes a mere oppressed struggle, when some affection of the lungs supervenes. The sounds of the heart in hypertrophy are less than in health, or deadened. In simple hypertrophy the first sound, or that pro- duced by the ventricular contraction, is duller and more prolonged than natural, in proportion as the hypertrophy is more considerable. The second sound, viz., that produced by the sigmoid valves during the ventricular diastole, is very feeble. The interval is shorter, owing to the first sound being longer. Both sounds are propor- tionately weaker in hypertrophy with contraction. Each sound of the heart, though essentially one, consists of the sounds of the two sides united ; and hence it is only in hypertrophy of both ventricles that we must expect to find the sounds confined within very narrow limits. In hypertrophy with dilatation the sounds are increased to their maximum, being louder than in any other disease of the heart, especially during palpitation. It is therefore to this variety that the remark of Bouillaud respecting augmented intensity of sound applies. In hypertrophy with a predominance of dilatation, the first sound is not so loud as in the preceding variety, nor has it a prolonged termination, but is short and smart like the second. Resonance of the precordial region on percussion is deficient in simple hypertrophy, if the heart be considerably enlarged ; but as hypertrophy with dilatation is the disease in which the organ attains the greatest volume, it is that in which resonance is most frequently and most extensively deficient. The line of dulness where the heart comes in contact with the walls, may be traced with great precision; and it often forms a circle of two, three, and occasionally four inches in diameter. Prominence of the precordial region has been already noticed as one of the signs of hypertrophy. Closely connected with the state of contraction of the left ven- tricle, whether in health or in disease, is the beat of the pulse at the ARTERIAL PULSE. 395 wrist. The pulse in hypertrophy of the left ventricle undergoes, from valvular and other lesions, a variety of modifications which disguise its real nature. It must, therefore, be studied in cases totally exempt from complication. In such, it is almost invariably regular, and bears strict relations in strength and size to the thick- ness and capacity of the left ventricle. Thus, in simple hyper- trophy, it is stronger, fuller, and more tense than natural; it swells gradually and powerfully, expands largely, dwells longer under the finger, and in anaemic subjects, (but no others,) continues Dr. Hope, it is sometimes accompanied with a thrill or vibration. These characters are still more marked in hypertrophy with dilatation, so long as the hypertrophy is predominant; but when the dilatation has proceeded so far as to diminish the contractile power of the muscular fibres, the pulse, though still full and sustained, is soft and compressible. In hypertrophy with contraction of the cavity, it is tense, but small, expanding little under the finger; and if the con traction be great, it loses its tension and becomes weak as well as small, from the insufficient quantity of blood propelled into the arteries. I use here Dr. Hope's own language, as abbreviation would only obscure. He adds: The strength, largeness, and tense prolongation of the pulse of hypertrophy with dilatation, are often so remarkable, that, from this sign alone the practitioner may often make a successful conjecture at the nature of the disease; the in- flammation only can impart similar strength, and comatose affec- tions similar prolongation. Depression or exhaustion of the nervous system will of course modify the pulse of hypertrophy, and of hypertrophy with dilatation. Arterial Pulse.— In order to render the arterial pulse a guide in the diagnosis of cardiac disease, we ought to have been well apprised of its signification in health. The beat of the artery at the wrist, that which for convenience sake we generally select, is the expression of the functional activity of the left ventricle, to whose contractions it regularly responds. When the ventricle contracts forcibly, the pulse is strong and resisting; when the ventricle contracts feebly, the pulse is weak and smaller. An oversight of the real physiolo- gical relations of the pulse has induced many, shall we say most practitioners, until of late years when organology is in the as- cendant, to attribute to it various significations, and a mysterious import of the condition of the general system quite unwarranted by the real state of things. The pulse, then, whether in health or in disease, with the modifications to be immediately mentioned, is an index of the dynamic state of the ventricles, except when the valves interposed between the ventricle and the aorta or great artery are structurally affected. The changes in the pulse, in the different states of the system during the diurnal cycle, in health as well as in disease, indicate similar changes in the ventricle. The circumstances which modify this latter are of course various; the quantity and quality of the blood, the state of the respiratory organs, and modifications in innervation being the principal ones. There is yet another modifying cause of difference in the pulse, and 396 DISEASES OF THE HEART. of course in the contraction of the ventricle as regards frequency, which depends on posture of the body. The number of pulsations when the body is in an erect position, wil be from ten to fifteen more than when it is recumbent. So, also, between lying and sitting, and between this and standing, there are notable differences in the frequency of the pulse. The immediate cause is the mus- cular exertion and strain, by which the ventricle is tasked to greater effort to distribute the blood through the body. The hydrostatic pressure is inconsiderable, for if the muscular effort required for standing be removed by giving the body a fitting support, as by means of a revolving board to which it is strapped, so that the weight is transferred from the ground to the new support against which the body rests, the pulse is very little more accelerated than when the person is in a recumbent posture. The difference in the pulse in the different postures is called the differential pulse. It was noticed by Dr. Bryan Robinson, but more fully considered and explained by Drs. Graves, Knox, and Guy. It is most noticeable in the early part of the day, reaches its maximum about noon, and its minimum towards midnight. Contrary to what is generally believed on this subject, the excitability and frequency of the pulse in health are greater in the morning than in the evening. In the common forms of indisposition, attended with febrile nervous dis- turbances, the differential pulse is greater than in health; but in advanced stages of hypertrophy and dilatation of the heart, Dr. Graves has found very little change in this particular, or, in other words, that the pulse is very generally unaffected by posture. He suggests that this fixed character of pulse may be a useful sign in our diagnosis of hypertrophy of the heart or of organic disease, by which we can distinguish it from functional disease of this organ. The quality of the pulse as regards volition and resistance will be not a little modified by the artery itself. Thus, when it has a thin yielding coat and large diameter, its beat will be relatively full and soft; when small, the pulse will be small and weak. At other times, again, as in old age, the coats of the artery become mor- bidly resisting and indurated, sometimes osseous, and then of course the pulse will feel hard if not strong. External causes, and par- ticularly heat and cold, produce an effect on the pulse by modifying the state of the arteries. Moderate heat or warmth tends to ex- pand the artery, and in this way to diminish the resistance which it makes to the blood impelled into it by ventricular contraction. Cold, on the other hand, as we learn from daily observation, even without reference to the direct experiments of Schwann, Miiller, Hastings, and Williams, causes a contraction of the arteries, and consequently renders the pulse smaller. Dr. Williams, in experi- ments carried on in 1835 to ascertain the causes of the sounds of the heart, repeatedly observed that when the aorta of an ass, recently killed, was plunged into cold water, it contracted, so as not to permit the introduction even of the little finger, and its coats acquired an increased thickness and rigidity ; the pulmonary artery did not contract so much. SIGNS OF HYPERTROPHY. 397 In stating, as I did a few minutes ago, that the pulse at the most represents the physiological condition of the left ventricle, and re- presents also its dynamic condition, we are not to infer that in all the morbid states of the cavity it is equally and distinctly respon- sive. In the main there is, however, greater accordance between the two than might at first appear; as when the pulse is feeble owing to the transmitted ventricular impulses hardly reaching the radial artery, and yet when we listen to the heart we hear pulsa- tions of some loudness, seemingly indicative even of violent efforts. But we soon learn that with all this seeming violence there is really a deficiency of power in the heart to propel the blood through the system. Commonly in these cases there is feebleness in the mus- cular parietes of the ventricle; but sometimes, and herein much tact in discriminating the difference is required, the ventricle is oppressed by the excessive quantity of blood sent to it, and relief is in the latter case procured by diminishing the quantity of the blood, and the pulse rises in consequence. But whatever may be the cause of these apparent contrasts between the force of the ventricle and the arterial pulse, you must take the proper steps to determine the actual condition of each; and to do this with effect you will follow the advice of Dr. Williams; and with your ear at the heart, and your finger at the same time on the radial pulse, make a careful survey of the circulation. The proportion of the number of beats of the artery to a respira- tion in health, four and a half of the former to one of the latter, is a standard, mutable indeed, but still of value to aid us in our diagno- sis of both pulmonary and cardiac as well as febrile diseases. Increase of respirations disproportionately to acceleration of pulse will indicate some disorder of the air-passages or lungs. In some forms of fever, again, as in typhus, the disproportion is on the side of the pulse, the beats of which are so frequent, while respiration is both relatively and even actually slower. I proceed now after this, I hope not unreasonable, digression on the pulse, to finish an enumeration of the symptoms of hypertrophy. The complexion is generally of a higher colour; in many it is florid when hypertrophy is present in its first period. But after a while this sanguine hue of apparently full health is exchanged for " a purplish patch" on the cheeks, and a purple or violet colour of the nose and lips, the intermediate skin becoming pale and sallow. In those again who are naturally devoid of colour, when the hyper- trophy is a little advanced,and the capillaries become obstructed, an universal cadaverous paleness and sallowness, extending sometimes even to the lips, overspread their face. The signs of hypertrophy of the right ventricle, in addition to the physical or increased impulse and dulness on percussion under the lower portion of the sternum, are, 1, absence of the strong, lar